Kimberley Smith
9 Dec 2020 · Coroner Anna Crawford · Surrey
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. informal patient absconding without supervision
“is no clear written policy/procedure on the following: - The carrying out of risk assessments when informal patients request to leave the unit; - The relevance of an informal patient being on intermittent observations when they request to leave the unit; - The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit; - The risk management plans to put in place when informal patients do leave the unit; - The recording of assessments and decisions relation”
2. delayed police reporting of missing detained patient
“is no clear written policy/procedure on the following: - The timeframe for reporting detained patients to the police as missing persons if they fail to return at the agreed time.”
3. incomplete alcohol detoxification protocol
“Consideration should be given to implementing the recommendation arising from the Serious Incident investigation to develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
Later report
“There was no missing person plan in place with timeframe and steps of escalation for [the deceased]'s leave.”
Closely relatedConfidence 0.80 · moderate
This report
“The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
Later report
“staff were aware that he had not returned from 18:45 onwards. The court found that thereafter there was a delay of approximately two hours in instituting the missing persons protocol”
Responses
2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted.pdf ↗· Surrey and Borders Partnership NHS Foundation Trust
Stated action
“The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients.”
Stated action
“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”
Stated action
“Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.”
Stated action
“The Trust has now completed its guidance regarding”
Stated action
“A retrospective baseline audit is also underway, looking back over a three month period between 1.8.2019 - 31.10.2019 to consider whether the Working Age Adult division identified and managed alcohol dependence appropriately. Once the improvements have been embedded, a second audit will be completed to check for improvements in our practices.”