Mansoor Zaman

“The failure of nurses on the ward to instigate an authorisation under S.5(4) MHA 1983 when Mr [name redacted] returned to the ward after absconding on the afternoon of 8th December 2024.”

“The failure of nursing staff on the ward to adequately document observations and care decisions.”

“The failure of Trust staff to reappraise the level of risk presented by Mr [name redacted] to himself and others in light of his erratic behaviour on 8th December 2024, specifically, a. His escape from the ward by violently kicking the fire exit door. b. His aggression toward the duty doctor during assessment. c. His assault upon a member of ward staff.”

“His second escape from the ward in identical circumstances to the first. The failure of Trust staff to re-assess the frequency and quality of observations that Mr [name redacted] should be subject to during the afternoon of 8th December 2024.”

“The failure of the duty doctor to act decisively and impose an authorisation under S.5 (2) MHA 1983 having been presented with an agitated patient who had minutes before escaped from the ward.”

“The dilatory response of staff on the ward to report Mr [name redacted] as a missing person to the police, an action that did not happen for almost three hours after it was known that he had absconded.”

“The categorisation of the risk presented by Mr [name redacted] as of a medium level by the nurse in charge when considering action to be taken after he absconded.”

“The use of the police 101 number as opposed to the required emergency 999 number to make the report.”

“The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff, nor communicated the findings of the report to the same staff.”