William Hafele
24 Nov 2014 · Coroner Martin Fleming · Surrey
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of training on missing person procedures
“Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions”
2. omission of critical risk assessment information
“Critical information required to make an informed risk assessment as to whether was missing or absent was omitted”
3. failure to communicate reclassification
“The decision to re classify from missing to absent was not communicated to the hospital”
4. insufficient training on response agreements
“Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place”
5. lack of mental health risk assessment training
“specific training with regards to risk assessments for mental health patients was lacking”
6. poor communication between agencies
“Ineffective communications between Police and Elgar Ward”
Linked reports
Closely relatedConfidence 0.87 · high
This report
“- Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.”
Later report
“The court heard evidence from some members of staff who gave evidence that they were not aware of a particular timeframe for instigating the missing persons protocol in relation to informal patients, and as such I consider there is a risk of future delays in reporting informal patients as missing persons to police, which presents a risk of future deaths.”
Closely relatedConfidence 0.90 · high
This report
“- In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking”
Later report
“(1) Cogent information about Ms [name redacted] declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to”
Responses
2014-0511-Response-by-Surrey-Borders-Partnership-NHS.pdf ↗· Surrey and Borders Partnership NHS Foundation Trust
Stated action · end of February 2015
“We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.”
2014-0511-Response-by-Surrey-Police.pdf ↗· Surrey Police
Stated action · January 2015
“The Force's Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility: e the risk assessment process to identify whether people missing from mental health and medical care establishments should be categorised as being low, medium or high risk as identified by certain criteria; and e the responsibility for identified enq”