Khuong Lam

1. 1. lack of guidance on review or revocation of Section 17 leave on transfer

   “The issue of Section 17 leave is covered in the Guidance issued in 2016. There is no section in this guidance covering the issue of review or revocation of Section 17 leave on transfer to another ward or to the PICU. It is the concern of the coroner that such guidance should be given across Wales in the next edition of the guidance.”

2. 2. failure to inform responsible clinician of transfer and review Section 17 leave

   “the RC told the inquest that if he had been made aware of [the deceased]'s transfer to PICU he could have reviewed him and decided whether Section 17 leave was still appropriate. The Coroner is concerned that the good practice now adopted by Cardiff Health Board should be replicated across Wales i.e. that the RC be informed of any transfer between wards; that Section 17 leave is reviewed on a transfer (and especially to PICU); and to consider further the number of escorts required for any Section 17”

3. 3. insufficient escort numbers for Section 17 leave

   “The inquest heard evidence that two escorts can provide a deterrent effect against absconsion, and are better able to deal with absconsions. Cardiff and Vale Health Board have now concluded a two month study of the efficacy of having two escorts to a patient on Section 17 leave and the lessons of this study should be applied across Wales.”

No published response was found on judiciary.uk.