Heather Findlay
12 Jun 2023 · Coroner Mary Hassell · Inner North London
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. patient absconding without escort response
“When Ms [name redacted] ran off, the HCA escorting her was so panicked that she did not even think of following”
2. absence of guidance for staff following absconded patients
“no ELFT policy for what those instructions should be or even what they could include”
3. police may not respond to mental health emergencies
“clinician calling the police in what the clinician perceived to be an emergency situation might not be assisted by the police”
4. police non-response to patient absconding calls
“the police would not necessarily attend, even if called direct by a hospital staff member in the street following a patient about whom they are worried”
5. inconsistent mental health emergency protocols across police forces
“Right Care Right Person (RCRP) is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health”
6. inconsistent risk grading and information sharing between trust and police
“the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The social work team leader dealing with the case was of the view that the police were the best placed to initiate emergency procedures under the Mental Health Act.”
This report
“I was left with the impression that a clinician calling the police in what the clinician perceived to be an emergency situation might not be assisted by the police.”
Closely relatedConfidence 0.90 · high
Earlier report
“C&l ward staff did not have a proper understanding of what action the MPS would take in what circumstances, following the report of a patient absent without leave.”
This report
“the police would not necessarily attend, even if called direct by a hospital staff member in the street following a patient about whom they are worried.”
Closely relatedConfidence 0.85 · high
This report
“I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity.”
Later report
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment.”
Responses
2023-0193-Response-from-East-London-NHS-Foundation-Trust.pdf ↗· East London NHS Foundation Trust
Stated action · next 3-6 months
“The Trust intends to incorporate scenarios involving patients going AWOL on escorted leave into its induction training for new staff in the relevant services. In addition there will be a 2-yearly refresher for Section 17 and Escort training. The scenario training will incorporate such situations and include reference to the information that needs to be considered by the escorting staff and fed back to staff on the wards to help in making a decision around risk and level of escalation needed. The”
2023-0193-Response-from-Home-Office.pdf ↗· Home Office
Stated action
“The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.”
2023-0193-Response-from-Metropolitan-Police.pdf ↗· Metropolitan Police Service
Stated action · September 2021
“Response The MPS currently has the Affinity Protocol in place and has done since September 2021.This is a collaborative partnership between local policing, NHS Trusts and mental health service providers, the aim of which is to achieve mutual understanding of each partner's responsibilities in respect of those patients detained under the Mental Health Act and who may abscond.”
2023-0193-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“I have asked that NHS England is sighted on the Trust's response to your Report, as well as the responses to the other cases and we will consider these carefully, to include whether any further action needs to be taken.”