Procedure for the Management of
a Patient being Absent without
Leave (Absconding) from a
Hospital Environment
Procedure Checklist
Name of Procedure:
Management of a Patient being Absent Without Leave (Absconding) from a
Hospital Environment
Purpose of Procedure:
To outline the action to be taken by staff in the event of a patient going
missing from a general hospital environment without prior agreement, or
failing to return at the agreed time.
Directorate responsible
for Procedure
Name & Title of Author:
Acute
Trade Union
consultation?
Equality Screened by:
Yes/No/Not Applicable
Anita Carroll, Assistant Director of Acute Services - FSS
Anita Carroll, Assistant Director of Acute Services - FSS
th
Date
Procedure 10 December 2012
submitted to Policy
Scrutiny Committee:
Members of Policy Scrutiny Committee in Attendance: Vivienne Toal, Head of Employee Engagement
& Relations (Chair), Anne Brennan, Senior Manager, Medical Directorate, Anita Carroll, Assistant
Director of Acute Services – Functional Support Services, Claire Graham, Head of Corporate Records
(for Siobhan Hanna), John Graham, Trade Union Side representative, Carmel Harney, Assistant
Director of Allied Health Professionals, Governance & Workforce Planning, Marita Magennis, Head of
Social Work and Social Care Governance, Stephen McNally, Director of Finance & Procurement,
Fiona Wright, Assistant Director of Nursing Services, Governance & Workforce Planning
Procedure Approved/Rejected/
Amended
Procedure Implementation Plan
included?
Any other comments:
Date presented to SMT
Director Responsible
Approved.
Yes
Advised to change policy to a procedure.
Director of Acute Services
SMT
Approved/Rejected/Amended
SMT Comments
Date for review
2 year default
PROCEDURE DOCUMENT – VERSION CONTROL SHEET
Title
Supersedes
Originator
Scrutiny Committee &
SMT approval
Circulation
Review
Management of a Patient being Absent Without Leave
(Absconding) from General Hospital Environment
Version: 1.0
Reference number/document name:
Supersedes:
Description of Amendments(s)/Previous Policy, Procedure or
Version:
Name of Author: Anita Carroll
Title: Assistant Director of Acute Services - FSS
Referred for approval by:
th
Date of Referral: 10 December 2012
th
Scrutiny Policy Committee Approval (Date) 10 December 2012
SMT approval (Date)
Issue Date:
Circulated By:
Issued To: As per circulation List (details below)
Review Date: December 2014
Responsibility of (Name): Anita Carroll
Title: Assistant Director of Acute Services - FSS
Contents
Page No.
1.0
Introduction
5
2.0
Purpose
5
3.0
Rationale for the Procedure
5
4.0
Scope of Procedure
6
5.0
Responsibilities
6
6.0
Legislative Compliance, Relevant Policies, Procedures &
Guidance
7
7.0
Equality and Human Rights Considerations
7
8.0
Alternative Formats
7
9.0
Copyright
7
10.0
Sources of Advice and Further Information
8
Procedures
9
Appendices
Appendix 1 – Absent Without Leave Procedure Checklist
12
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 4 of 14
1.
INTRODUCTION
Absconding or ‘absent without leave’ refers to departure of a patient from a ward/
department without prior arrangement. The circumstances by which a patient
may be missing from hospital without first discussing his or her absence with
staff may be varied. A voluntary patient may lawfully leave hospital anytime he
or she wishes, however it would be desirable he/she discusses this with staff in
the first instance. Action must be taken however if the patient lacks mental
capacity or there are concerns that the patient represented a significant risk of
harm to him/herself or others.
2.
PURPOSE
The purpose of this procedure is to outline the action to be taken by staff in the
event of a patient going missing from a general hospital environment without
prior agreement, or failing to return at the agreed time.
3.
RATIONALE FOR THE PROCEDURE
3.1
As part of the orientation process when a patient is admitted,
Nursing/Midwifery staff must make patients aware that whilst they are at
liberty to leave and return to the ward/ department at any time, it must be
planned and agreed with the Nurse/Midwife in Charge of the ward/
department.
3.2
Staff caring for the patient must assess whether the patient is well enough
to leave the ward/ department, and whether they should be accompanied
if they do leave.
Staff should ascertain why the patient wants to leave, and where they are
going plus the estimated length of time they will be away from the ward/
department. Staff must be sure it is safe for the patient to leave.
3.3
Certain patients may represent an increased likelihood of absconding from
hospital care for a variety of reasons such as:
 patients with previous history of absconding
 those with confusion/disorientation
 patients under the influence of drugs and/or alcohol
 those with cognitive impairment who are not capable of maintaining
their own safety
 those with psychological disturbance
 those with a mental illness
(This list is not exhaustive of the circumstances/conditions where there
would be an increased likelihood of a patient being absent without leave.)
3.4
Where there is an increased likelihood of a patient being absent without
leave, the multi-disciplinary team must consider forward planning to
address this likelihood and have measures in place including a recorded
risk assessment in the patient’s record that will enable staff to respond
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 5 of 14
quickly and appropriately to such eventualities. This should be reflected in
the patient’s record and communicated to all staff involved in the care of
the patient.
4.0
SCOPE OF THIS PROCEDURE
This procedure applies to Acute and Non-Acute hospital settings within the Trust
namely:




Craigavon Area Hospital
Daisy Hill Hospital
Lurgan Hospital
South Tyrone Hospital
Mullinure Hospital
This procedure excludes Bluestone Unit and St Luke’s Hospital as these are
covered by other procedures.
5.0
RESPONSIBILITIES
5.1
Chief Executive
5.1.1 The Chief Executive has overall responsibility if a patient goes
absent without leave.
5.2
Directors
5.2.1 The Chief Executive requires Directors to establish and monitor the
implementation of these arrangements and compliance within their
area of responsibility.
5.3
Managers
All Assistant Directors, Heads of Service, Lead Nurses/Midwives and
Ward/Department Managers/ Site Managers have responsibility for
ensuring that:5.2.1 All staff are aware of this procedure and that they are implemented
within their area of responsibility.
5.2.2 Assessments of patients on admission are undertaken to identify
any risk of absconding.
5.2.3 Measures are put in place where there are patients with a known
risk of absconding.
5.2.4 General measures are taken to reduce incidences of patients
absconding for example:


Effective admission arrangements.
Patients involved in care planning and delivery.
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 6 of 14


Pro-active engagement with patient and their family/carers.
Ward/Department environment must promote patient safety.
5.2.5 All absconding incidents are reported in accordance with the Trust
procedure for reporting accidents/incidents.
5.4
Trust Staff
5.3.1 To familiarise themselves with this procedure and adhere to the
contents.
5.3.2 Advise line managers of any concerns or risks.
5.3.3 Ensure that their actions are prompt, thorough and sensitive.
6.0
LEGISLATIVE COMPLIANCE, RELEVANT POLICIES, PROCEDURES AND
GUIDANCE



7.0
SHSCT Management of Violence and Aggression Policy and Procedure
SHSCT Management of Adverse Incidents Policy
SHSCT Security Management Policy
EQUALITY AND HUMAN RIGHTS CONSIDERATIONS
This procedure has been screened for equality implications as required by
Section 75 and Schedule 9 of the Northern Ireland Act 1998. Equality
Commission guidance states that the purpose of screening is to identify those
procedures which are likely to have a significant impact on equality of opportunity
so that greatest resources can be devoted to these.
Using the Equality Commission's screening criteria, no significant equality
implications have been identified. The procedure will therefore not be subject to
an equality impact assessment.
Similarly, this procedure has been considered under the terms of the Human
Rights Act 1998, and was deemed compatible with the European Convention
Rights contained in the Act.
8.0
ALTERNATIVE FORMATS
This document can be made available on request in alternative formats, e.g.
plain English, Braille, disc, audiocassette and in other languages to meet the
needs of those who are not fluent in English.
9.0
COPYRIGHT
The supply of information under the Freedom of Information does not give the
recipient or organisation that receives it the automatic right to re-use it in any way
that would infringe copyright. This includes, for example, making multiple copies,
publishing and issuing copies to the public. Permission to re-use the information
must be obtained in advance from the Trust.
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 7 of 14
10.0 SOURCES OF ADVICE AND FURTHER INFORMATION
Line Managers should be contacted in the first instance, in relation to any
specific queries on the content of the Procedure. Line Managers should then
escalate queries which they are unable to address, to the Procedure Author.
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 8 of 14
ABSCONDING PATIENTS PROCEDURES
1.0
DEFINITIONS
1.1
2.0
A patient must be considered as absent without leave when he/she:

Fails to return from leave at an agreed time without giving details of
his/her whereabouts to the ward/ department;

Leaves a ward/ department without the knowledge of staff;

Evades his/her escort (whilst being accompanied by staff) and cannot
be found.
1.2
Nurse/Midwife in Charge refers to the person in charge of the ward/
department at the time.
1.3
In Integrated Maternity and Women’s Health Division the procedure
should be referred to if mother / mother and baby are absent.
STEPS TO BE TAKEN WHEN A PATIENT IS NOTICED TO BE ABSENT
WITHOUT PRIOR AGREEMENT
2.1
If a patient, has been noticed absent without agreement, or failed to return
to the ward/ department at the agreed time, then the Nurse/Midwife in
Charge of the ward/ department should try to locate the patient by initially
searching the immediate area, then via a mobile telephone, home
telephone, and regular point of contact.
At this stage the Lead
Nurse/Midwife/Head of Service or Site Manager (if out of hours) must be
informed.
2.2
The Nurse/Midwife in Charge of the ward/ department must organise a
search of the wards/ departments/ hospital grounds with the assistance
from Security/Porters (where available). Portering staff should also be
alerted to be vigilant in the vicinity of the hospital and grounds. Searches
beyond the immediate vicinity must be carried out by the police (PSNI).
Staff are not permitted off site.
2.3
If the patient is not located and the Nurse/Midwife in Charge has concern
he/she will check the patient’s record and contact relevant personnel
which may include the following. NB This list is not prescriptive.
1.
2.
3.
4.
Ward Sister/Sister in Charge and the Lead Nurse/Midwife
Site Manager
Consultant in Charge of patient or most senior doctor available
The patient’s next of kin/carer, PSNI, Child Protection Nurse,
General Practitioner, Community Psychiatric Nurse, Social Services
or any other person they feel may be able to assist in trying to
identify the whereabouts of the patient.
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 9 of 14
The Nurse/Midwife in Charge will have responsibility for ensuring the
completion of the Absent Without Leave Procedure Checklist (Appendix 1)
which could be used to assist locating the patient.
3.0
2.4
The Nurse/Midwife in Charge, upon notification has a responsibility in turn
to inform the Consultant in Charge of the patient, or in his/her absence,
the on call Consultant and complete an assessment of risk.
2.5
The Nurse/Midwife in Charge will provide the next of kin/carer(s) with
advice about what to do if they locate the patient and a specific point of
contact for communicating with staff throughout the period of absence.
2.6
In situations where there is a significant risk associated with the patient
(irrespective of their legal status) remaining outside the hospital
environment or another person is at risk in the community, for example the
patient’s child or wife/husband, this must be communicated to the PSNI by
the Nurse in Charge following detailed discussion with the Consultant and
the Ward Sister/Sister in Charge or Site Manager (Out of Hours). Whilst
the patient’s right to confidentiality must be considered, the safety of
others is considered to supersede the patient’s right to confidentiality
where significant risk exists. This discussion should be documented fully
in the patient’s record. Information provided to the PSNI should include a
full description of the patient, possible whereabouts and the risks posed to
the patient or others.
2.7
If the patient ‘absent without leave’ is detained under the Mental Health
(NI) Order 1986 then the Head of Service will inform the relevant Assistant
Director, who will advise on informing the Director, the Regulation and
Quality Improvement Authority and the Head of Communications. The
PSNI must be informed of a detained patient who is absent without leave
as the PSNI under Article 29 of the Order have a responsibility to assist in
returning the patient to a place of safety.
2.8
Patients who are concerned in Criminal Proceedings or Under Sentence,
Part 3 restricted Patient MH (NI) Order and are absent without leave the
Department of Justice must be informed.
2.9
Full, contemporaneous records of all action taken must be made in the
patient’s record and other relevant documentation.
ONGOING REVIEW AND ACTION PLAN WHEN A PATIENT IS LOCATED
3.1
If the patient is located, is safe and returns to the ward/department then
the Nurse in Charge must assess the patient and make a note in the
patient’s record to this effect.
3.2
The Nurse in Charge should contact all relevant personnel to notify them
that the patient has returned.
3.3
If concern exists that the patient may subsequently abscond again
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 10 of 14
following their return then options to prevent this, should be considered by
the multi-disciplinary team and appropriate action taken.
3.4
4.0
5.0
An Incident Form must be completed in accordance with the Trust
procedure for reporting of accidents/incidents.
WHEN A PATIENT REFUSES TO RETURN OR CANNOT BE LOCATED
4.1
If the patient is located and refuses to return, attempts should be made to
persuade the patient to return. The Nurse in Charge will discuss the case
with the responsible Consultant in Charge or most senior doctor available
and if there are concerns regarding the patient’s mental capacity for
making an informed decision then urgent referral should be made to the
appropriate Mental Health Team.
4.2
If the patient is located and refuses to return, and there are no concerns
regarding their mental capacity, following consultation and agreement
between Consultant and Ward/ Department Manager the patient should
be discharged from hospital in accordance with Hospital Discharge
Procedures.
4.3
If it has not been possible to locate the patient within 24 hours
consideration should be given to discharging the patient in their absence.
Ongoing enquiries with regard to the missing patient will continue by the
PSNI. The PSNI will maintain an active case file and will take the lead
role in co-ordinating and leading the ongoing enquiries.
4.4
An Incident Form must be completed in accordance with the Trust
procedure for reporting of accidents/incidents.
PRESS ENQUIRIES / PRESS RELEASES
5.1
All press enquiries received should be directed through the existing
channels in respect of press enquires. At this point, the Head of Service
should undertake to ensure that the Communications Manager has been
briefed on the developing circumstances.
5.2
If the Clinical team feel that a press release with regard to concerns
relating to a missing person may be beneficial, then this should be
discussed with the Communications Manager who will explore with the
Police.
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 11 of 14
Appendix 1
Absent Without Leave Procedure Checklist
CHECKLIST TO BE COMPLETED BY NURSE/MIDWIFE IN CHARGE
IN THE EVENT OF A PATIENT ABSENT WITHOUT LEAVE
Patient Name:
Hospital Number:
Address:
Date of Birth:
Telephone/contact details:
Ward/Dept:
Patient noticed missing.
Date of Admission:
Date:
Time:
Circumstances:
Risks/concerns:
Action Taken on discovery of a patient absent without leave (please tick as
appropriate):
Action
Yes
No
Name of Contact
Date & Time
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 12 of 14
Ward/Dept searched?
Security Porters/ Porters
contacted?
Grounds searched
immediately?
Hospital Buildings
searched?
Ward Sister/Sister in
Charge informed?
Lead Nurse informed?
Site Manager informed?
Consultant or most
senior doctor available
informed?
Child Protection Nurse
informed?
Next of kin/carer
informed?
Casualty Departments
informed?
PSNI informed?
IR1 completed?
Key worker contacted?
GP contacted?
Social Worker
contacted?
Communications
Department
informed?
Department of Justice
informed?
Action Taken as required on return (please tick as appropriate):
Action
Yes
No
Name of Contact
Date & Time
Ward Sister/Sister in
Charge informed?
Lead Nurse informed?
Site Manager informed?
Consultant or most
senior doctor available
informed?
Child Protection Nurse
informed?
Next of kin/carer
informed?
Casualty Departments
informed?
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 13 of 14
PSNI informed?
Key worker contacted?
GP contacted?
Social Worker
contacted?
Communications
Department
informed?
Department of Justice
informed?
Incident recorded in
patient’s record?
Incident Form
completed?
Signature of Nurse in Charge:
Date:
Comments re action taken on return, eg likelihood of subsequent absconding.
Plan of action from multidisciplinary team, eg discharge, interventions to reduce the
potential of further incidents of absconding (give date of discharge if applicable).
Signature of Ward/Dept Manager:
Date:
Signature of Team Leader:
Date:
Signature of Head of Service:
Date:
Southern Health and Social Care Trust
Management of a Patient being Absent Without Leave (Absconding) from a Hospital Environment
Version 1.0 June 2012
Page 14 of 14