William Savory
15 Jun 2022 · Coroner Anna Crawford · Surrey
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. delay in reporting missing patient
“The court heard evidence that Mr [name redacted] did not return at the agreed time of 18:35 on 26 January 2020 and that staff were aware that he had not returned from 18:45 onwards”
Linked reports
Closely relatedConfidence 0.87 · high
Earlier 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.”
This 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 0.80 · moderate
Earlier report
“The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
This 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
No published response was found on judiciary.uk.