Missing and Absconded Patient Policy
Classification: Policy
Lead Author: Richard Bulman, ADNS Emergency
Medicine
Authors Division: Salford Health and Social Care
Unique ID: MisPat2002
Issue number: 5
Date approved: July 2016
Contents
Section
Who should read this document
1. Key practice points
2. Background/ Scope/ Definitions
3. What is new in this version
4. Policy/Procedure/Guideline
4.1 Prevention
4.1.1 Prevention wards
4.1.2 Prevention Emergency Department
4.2 What to do if a patient is missing
4.2.1 Internal local actions
4.2.2 Internal - Trust Site Search
4.2.3 External - Community
4.3 Assessing risk
4.3.1 Actions after assessing risk
4.4 Patients with capacity
4.5 What to do if patient is found
5. Explanation of terms
6. Roles and Responsibilities
1
2
3
4
5
6
7
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7
Appendix
Risk indicators for missing/absconded patients (SRFT)
Algorithm for missing/absconded patients (SRFT)
SRFT/ED missing/absconded patient report from
ED Mental Health Risk of Absconding Triage Assessment
Self-discharge action sheet
Police Powers relating to Patients Missing from Hospital
Implementation action plan
Document control information
Document Control
Policy Implementation Plan
Monitoring and Review
Endorsement
Equality analysis
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Who should read this document?
All Registered Nurses
All Ward Managers and deputies
Security staff
Site coordinators
Senior managers on-call
GMW staff
GMP staff
1. Key Practice Points
Salford Royal NHS Foundation Trust has a responsibility for all persons under
the Health and Safety at Work Act, including the well-being of patients whilst
on Trust Premises taking into consideration their clinical condition.
This policy will outline the correct processes to be used and how this may
differ depending on the individual patient’s circumstances, if they abscond
1.1 Patient presenting with Mental Health related problems need to have a
risk assessment carried out ASAP on arrival to ED.
1.2 For patients without capacity, preventative actions should be taken. If
they then abscond, full search processes, including Police, should be
commenced
1.3 For patients with capacity, local search processes should occur but
Police should not routinely be called, unless the patient is vulnerable or in
an especially high risk group
The aim is to simplify and clarify risk, to state the actions to be taken if a
patient is missing, and to have consistency between services, so that SRFT,
Mental Health Services (GM West) and Police services (GMP) are used
appropriately and efficiently
2. Background/ Scope/ Definitions
In the past if any patient left a clinical area before treatment had been
completed, the same process would occur irrespective of individual
circumstances. This would often involve a request to the Police to find the
patient and either check that they were well (the welfare check) and/or bring
the patient back to the hospital. As such there has often been a difference
between hospital practice and the GMP “Missing from Home Policy”, which
requires Police involvement for high risk patients, with high risk defined as:
"The risk posed to the individual is immediate and is likely to place the subject
in danger through their own vulnerability, or where are substantial grounds for
believing that they are a threat to others."
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The information given to the Police was often limited and sketchy with
attending Police not having enough information to act appropriately and within
the law (see appendix). Often they were faced with patients with capacity who
refused to return. This process left hospital nurses unclear of the risks
involved and Police resources stretched and unable to prioritise calls
appropriately.
3. What is new in this version?
3.1 Identification of risk level in patients presenting to the Emergency Dept.
with mental health related problems
3.2. Guidance on assigning risk level to patients who leave prior to
care/treatment being completed in the Emergency Department
3.3 Actions to be completed after risk level is determined
3.4 Guidance on what actions are required for patients with capacity
3.4 High risk patient identification form
4. Policy/ Guideline/ Protocol
4.1 Prevention
4.1.1 Wards
Identification and care of a patient with history of wandering, without
capacity
Nursing and Medical Staff should identify and document in the Nursing and
Medical notes if the patient has a history of wandering
If there is a risk of absconding the following should be noted:
 Document physical details of the patient including weight, height, eye, skin
and hair colour, any distinguishing marks/ any disabilities
 Document the patient’s normal routine
 List any areas to which the patient habitually wanders
 As with all patients, nursing staff should implement hourly rounding for
these patients to ensure a regular check and should record whether the
patient is on ward or whereabouts
 Consider 1-1 nursing (specialling) if the patient is making attempts to leave
the ward or deemed to be at high risk of leaving
 Ensure all available ward locking is in operation
4.1.2 Emergency Department
On arrival to the Emergency Department (ED) all patients will receive a clinical
triage. Patients presenting and categorised using Manchester Triage as “selfharm”, “overdose and poisoning”, “mental Illness” and “behaving strangely”
are at higher risk of leaving before being deemed safe to do so. As with all
other patients, they should have a clinical triage and clinical observations
taken.
Following clinical triage, all patients presenting within the four stated
categories should have a Mental Health Triage Assessment (appendix 4)
completed, if possible within 30mins of triage. The purpose of the mental
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health triage is to assist in identifying people who are at higher risk of harm if
they abscond and therefore may require prioritising to be seen sooner
Completion of the Mental Health Triage Assessment is the responsibility of the
coordinator in the area the patient is allocated to. They may subsequently
delegate to another member of the nursing team, but they remain responsible
for assessment completion. If the triage nurse is especially concerned about
a patient’s wellbeing they should not wait for subsequent assessment and
liaise with the Nurse-in Charge regarding a safe place for the patient to be
nursed
Patients assessed at high risk of harm if they abscond should be nursed in an
observable clinical area as soon as possible and Mental Health Liaison Team
(Greater Manchester West) informed immediately to allow prioritisation of their
caseload. Consideration should be made as to whether one-to-one nursing or
Security presence is required
4.2. What to do when a patient is missing
4.2.1 Internal – Local (nurse-in-charge dept/ward)
•
Identify the time and place that the patient was last seen.
•
Ensure the patient has not been delayed in another department.
•
Call patient on mobile and/or home phone number
•
Commence a search of all areas of the ward/ department
•
Allocate a member of staff to contact wards departments in close
proximity and the Security Control Centre to monitor the CCTV.
•
Request and complete a Missing Patient Report for security (Appendix
3)
•
One member of staff from the above wards/departments to search their
own area and report back within 15 minutes
•
Commence a site search if the patient is not found.
•
Complete an adverse incident report (AIR)
4.2.2 Internal - Trust Site Search
Nurse-in-charge to inform the following staff/prior to search:
•
Matrons/Lead Nurse/ADNS/site coordinator - to organise immediate
search of local areas
•
Security – thorough search of grounds, toilets, smoking shelters and
areas closed out of hours.
•
Contact patient’s relatives/carer (and give contact name and number)
•
Staff members assisting with search to bleep Matron/ Site Coordinator
with update
•
If the patient is not found on site, divisional senior nurse/site
coordinator to complete an AIR and escalate to external search if appropriate
after completing risk assessment (see below and appendix 1)
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DO NOT CALL THE POLICE UNTIL A RISK ASSESSMENT HAS BEEN
CARRIED OUT (appendix 1)
4.2.3 SRFT External sites- Community- Heartly Green/Maples.
Identify the time and place that the patient was last seen.
Actions:
•
Commence a search of all areas of the unit
•
Call patient on mobile and/or home phone number. Contact patient’s
relatives/carer (and give contact name and number)
•
Request and complete a Missing Patient Report (Appendix 3)
•
Complete an adverse incident report (AIR)
Escalation
•
Unit Nurse to contact their Lead Nurse and ADNS in hours/Site
coordinator (who will inform Senior Manager on-call) out of hours. Site
Coordinator to remain on hospital site at all times).
•
Patient’s GP (in normal working hours)
If patient not found
• If the patient is not found after a comprehensive search the Site
Coordinator/ Senior Manager on-call/ADNS should discuss with the
DDN/Executive-on-call (if out of hours)
• Unit Nurse-in-Charge (with assistance of the divisional senior nurse/site
coordinator) to complete an AIR and escalate to external community search if
appropriate (follow 4.2.3 above) after completing risk assessment (see below
and appendix 1). Site coordinator to Call Police if patient lacks capacity or
site coordinator in liaison with unit nurse feels patient fits into an especially
vulnerable group.
4.3 Assessing risk
Use the “Risk Indicators for Missing/Absconded Patients (SRFT)” (appendix 1)
to decide the risk level of the patient.
If unsure speak to your Lead Nurse/ADNS/site coordinator
Additional advice can be sought from the Lead Nurse Emergency Dept or
ADNS Emergency medicine or out-of-hours the Nurse-in-Charge Emergency
Dept
4.3.1 Actions after assessing risk
Having determined risk level using appendix 1, follow the “Algorithm for
Missing/Absconded Patients from SRFT” (appendix 2) to decide actions
4.4 Patients with capacity
One of the key issues to determine both risk and actions is whether a patient
has the capacity to make their own decisions about their health and treatment:
Patients presenting with mental health related problems:
Follow process as outlined in 4.2
These patients will usually be in the ED or EAU and already have a completed
Mental Health triage assessment. In normal circumstances the Mental Health
Liaison Team (MHLT) should be responsible for determining the risk of harm
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and therefore if Police are to be contacted. Where possible MHLT should
make the phone call to the police
Patients with physical conditions:
Under normal circumstances a patient with capacity is free to make a decision
about their care and treatment and this includes the right to leave against
medical advice. For this group of patients the Police have no ability to return
the patient against their will. Consideration though, should be made whether
the patient is vulnerable ie. due to age: under 18 or elderly, and the increased
risk that their age may put them in.
If a patient with capacity decides to take their own discharge please complete
the self-discharge action sheet (appendix 5)
4.5 What to do if patient is found
Once patient is found
•
Senior Nurse/site Coordinator to obtain maximum information regarding
the physical and psychological condition of the patient.
•
Lead Nurse/ADNS/Senior Manager on-call, as advised by Senior
Nurse/Site Coordinator, to establish if a patient with capacity is willing to
return and to determine the type of vehicle: numbers and discipline of staff to
collect the patient safely.
•
Patients found by Police, if appendix 1 and 2 are followed, will be
returned by the Police
•
If the patient is found unconscious or deceased 999 should be
contacted immediately .
•
Upon positive identification of patient, immediately inform the relatives
and call off the search.
•
Inform security control and the police (if they have been called and not
found by them) that the patient has been located
•
Nurse-in-charge of the ward/dept to ensure the patient is examined by
a clinician on arrival back to hospital.
•
Nurse-in-charge to ensure full documentation of event occurs and care
plan is updated.
•
Nurse-in-charge to ensure action plan is put in place and
communicated to all staff to prevent a repeat occurrence
•
Site Co-ordinator must ensure the manager on-call is fully updated with
adverse incident updated to reflect finding the patient
6. Explanation of terms
ED – SRFT Emergency Department
GMW – Greater Manchester West Mental Health Foundation Trust
GMP – Greater Manchester Police
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7. Roles and responsibilities
ADNS (Emergency Medicine) to disseminate to Divisional Directors of
Nursing, Assistant Directors of Nursing, Lead Nurses, Matrons, Senior
Manager On-Call and Site Coordinators
ADNSs to ensure a robust strategy to communicate the policy to all staff
Lead Nurses to disseminate to Ward Managers and obtain signed
confirmation
Ward Managers to disseminate to all staff and obtain signed confirmation.
Policy to be put on synapse (ADNS EM)
Divisional Directors of Nursing to ensure policy is raised at Risk/Governance
meetings.
The Patient Experience Sub Committee will be responsible for approval of the
policy.
Appendices
Appendix 1: Risk Indicators for Missing/Absconded Patients (SRFT)
Appendix 2: Algorithm for Missing/Absconded Patients (SRFT)
Appendix 3: SRFT/ED Missing and absconded patient report
Appendix 4: ED Mental Health Risk of Absconding Triage Assessment
Appendix 5:Self-discharge action sheet
Appendix 6: Police powers relating to patients missing from hospital
Appendix 7: Implementation action plan
Appendix 1: Risk Indicators for Missing/Absconded Patients (SRFT)
The purpose of the following categorisation framework is to: Assist staff to appropriately categorise a missing/absconded patient. If there is
any doubt a senior doctor and senior nurse/site coordinator must be consulted.
 Allow for clear and appropriate communication to the Police with regard to
levels of concern.
 To Assist Police in prioritising their responses and the allocation of their
resources.
When the risk category has been determined follow the Algorithm for
Missing/Absconded Patients and complete the complete missing/absconded patient
form for high risk patients.
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HIGH RISK
 Is the patient acutely or chronically confused? i.e. dementia
 Is the patient vulnerable ie. due to age; under 18 or elderly
 Is the patient deemed not to have capacity?
You need to consider if they have:
 an impairment or disturbance in the functioning of the mind or brain and an inability to make decisions.
A person is unable to make a decision if they cannot:
 understand the information relevant to the decision,
 retain that information,
 use or weigh that information as part of the process of making the decision, or communicate the decision.
 Is the patient suffering from a mental health problem and is an immediate risk to themselves or others? (In ED
the duty CPN must be consulted when categorizing a patient presenting with a mental health problem).
 Has the patient taken a potentially lethal overdose that needs monitoring or treatment?
 Is the patient suffering from an injury or illness that requires urgent/lifesaving medical attention or treatment?
 Has the patient suffered a significant head injury or left without having a head injury assessed?
ACTION
 Ring Police (101) ‘Concern for Welfare’
 Complete Missing/Absconded Patient Form
LOW RISK
 If the patient deemed to have capacity i.e. considered to be able to refuse treatment.
 Has the patient been a victim of domestic assault, and is there a concern there will be a repeated assault?
Complete MARAC/Child Safeguarding referral if appropriate. (Note: there is a risk to the victim if the telephone
number is not safe to contact and the perpetrator answers the phone!
 Are you concerned that the patient has not made it home safely, but does not need to return for treatment?
 Was the patient appropriate for discharge i.e. normal blood results?
 Did the patient leave without discharge information or medication?
 Has the patient left with a cannula insitu? Consult district nurses if you are unable to contact the patient directly.
 In ED was the patient suitable for self-care or deflection?
Appendix 2:
ACTION
 No Police involvement
 Contactfor
patient/patient’s
GP if necessary
Algorithm
Missing/Absconded
Patients
This is not an exhaustive list …
(SRFT)
Discovery of a patient that has left without completing assessment or treatment
Identify if the patient is HIGH or LOW risk, refer to indicator (appendix 1)
(If you are unsure involve Nurse-in-Charge (ED)/site-coordinator and or the
clinician/doctor in this decision)
Is the patient HIGH risk?
No
2.
Yes
1. Inform NIC/site-coordinator that you suspect a patient has absconded.
2. Perform local check of the department to attempt to locate the patient.
Advise patient not to
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LOW RISK
1.
Missing and Absconded
Patientarea
Policy
leave the clinical
informing
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staff isfirst.
3.
In ED, if the patient has left before
being seen with a low risk illness or
injury document and discharge as ‘Did
not wait’.
If the patient left without routine
information or TTO attempt to contact
the patient via telephone and
document result and inform clinician
who can inform the GP if needed.
If the patient has left with a cannula
insitu attempt to contact the patient. If
you are unable to contact the patient
make an urgent district nurse referral.
DO NOT CONTACT THE POLICE.
N.B. For
Page
8 ofLOW
16 RISK
missing/absconded patients a
missing/absconded patient form
does NOT need to be completed.
Patient Found
No
1.
2.
3.
4.
Yes
Inform NIC/site-coordinator that patient is confirmed as missing.
Inform Security and relay Important Patient Information (TABLE 1)
ED - If the patient attended for the mental health reasons bleep the
Mental Health Liaison Team (3411) to ensure calling the police is
necessary.
Attempt to contact patient via documented telephone number or next of
kin if appropriate.
HIGH RISK
1.
2.
3.
4.
5.
6.
7.
8.
Call police on 101
Explain circumstances and state that there is a ‘concern for the patient’s welfare’.
Relay Important Patient Information to the call handler, and document the log number.
HIGH RISK should be brought back to the ward/department if they lack capacity.
HIGH RISK with capacity should be brought back to the department if agreeable and appropriate.
ED - complete missing/absconded patient form and return to the missing/absconded patient file.
Document details in nursing documentation.
Complete AIR.
Patient Found
1.
2.
3.
Inform NIC/site-coordinator, clinician and police (if they have not returned them) that the patient has returned.
ED - If patient has returned they must be booked back into the ED.
ED - update the missing/absconded patient form, in the missing/absconded patient file located in majors.
TABLE 1. Important Patient Information
1.
2.
Time/Place last seen in department
Patient description:
 Age
 Gender
 Height
 Hair colour
 Skin colour
 Description of clothing
 Distinguishing features/behaviour
Any escorts/NOK with patient
Clinical condition/information
Does the patient have the capacity to refuse treatment
Does the patient need further clinical treatment or assessment
SRFT/ED Missing/Absconded Patient Report Form
3.
4.
5.
6.
Patient Name:
Hospital Number:
Last seen: Time
Location
Perceived Risk (circle) CF Missing/Absconded Algorithm and Indicators:
HIGH
LOW
NIC/Co-ordinator informed:

Mental Health liaison informed (circle): Yes
Department search completed:
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No
N/A

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Security informed (Ex 64436):

Time:
Attempted to contact Patient via telephone:

Result of patient contact:
Description for patient:Age:
Gender:
Height:
Hair colour:
Skin colour:
Clothing:
Build:
Distinguishing
features:
Accent/language:
Any other information:

Police Informed:
Time:
Log number:
Result/Follow up:
AIR Completed (circle):
Yes
No
AIR Number
Form completed by:
Sign:
Date:
Please photocopy this form.
One copy for medical notes and one in the Missing/Absconded Patient file.
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Appendix 5:Self-discharge action sheet
Please consider the following and ensure the relevant actions are taken
Yes
1
No
Does the patient
have the capacaity
to make a decision
to leave hospital
Have you
attempted to
telephone patient
and/or NOK or
other contact
Please complete
questions 2-4
3
Has the patient left
with an IV cannula
inserted
4
Has the patient
other devices in
place eg urinary
catheter,
5
Have you ongoing
concerns regarding
a patient’s health
Is the patient
especially
vulnerable
Contact Rapid
Response 8am22pm or Out-ofHours Community
Nursing team for
advice re visits or
attendance (and
see Q7)
Contact Rapid
Response 8am22pm or Out-ofHours Community
Nursing team for
advice re visits or
attendance (and
se Q7)
At earliest
opportunity inform
patient’s GP
Contact social
services
emergency
number for advice
Give details of the
nature of the risk
to relevant
community service
2
6
7
Could the patient
be a risk to staff
attending the
patient’s
residence?
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Go to Q3
Please refer to the
Missing and
Absconded Patient
Policy (this policy)
(a) Call patient
immediately to
explain risks
(b) Consider calling
NOK/contact,
however be aware
that this could be
seen as a breach of
confidentiality
Go to Q4
Go to Q5
Document patient’s
own decision to
discharge self
Document patient’s
own decision to
discharge self
n/a
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Appendix 6: Police powers
relating to patients missing from
hospital
GMP Definition of a Missing Person
Anyone whose whereabouts cannot be established and where the
circumstances are out of character or the context suggests the person may be
subject of crime or at risk of harm to themselves or others.
Powers to Return Missing Patients and Enter Property
Public Place
Private Place
Patient’s Power
Power to
Power to
Capacity
to
Power to Enter
Return
Return
Enter
No power to
enter unless to
save “life & limb”
ie they have a
condition that
Patient
may be life
No power to
has
N/A
No power to
threatening if
return
capacity
return
they do not
receive
immediate
medical
treatment
Yes, police have
Yes, police have
power to return if
power to return if
patient lacks
patient lacks
Patient
capacity and is
No power to
capacity and is
does not
in need of
enter unless to
in need of
N/A
have
immediate
save “life & limb”
immediate
capacity
medical attention
(as above)
medical attention
(Cannot be used
(Cannot be used
to obtain MHA
to obtain MHA
assessment)
assessment)
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Patient
has
Mental
Health
Issues
N/A
No power to
return unless
they are
detained under
s.2 or s.3 of the
MHA or s.136
below applies.
No power to
enter unless to
save “life & limb”
(as above) or
s.135 warrant is
obtained by
mental health
professionals
No power to
return unless
they are
detained under
s.2 or s.3 of the
MHA
Section 136 Mental Health Act
If a constable finds in a place to which the public have access, a person who
appears to him to be suffering from mental disorder and to be in immediate
need of care or control, the constable may, if he thinks it necessary to do so in
the interests of that person or for the protection of others, remove that person
to a place of safety within the meaning of S.136 above
Remember;
 Police cannot insist or force a person with
capacity to return to hospital
 Police are not formally trained to assess a
person’s capacity
 Police cannot remove cannulas
 Police are not qualified to assess a person’s
mental health
 Police can only enter an address by force in
cases of emergency in order to save life and
limb
Consider;
 Why are you calling the police?
 What do you want to achieve from police
involvement?
 Is it appropriate to call the police?
 Do the police have the powers?
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Appendix 7: Implementation action plan
Action plan lead
Action plan
Action plan
review date
Richard Bulman
Results
Approach
Deployment
Assessment
and Review
Objective
Action required
(reference to
detail)
Action Lead
responsibility
Action
implementation
strategy
(reference to
detail)
Start (S)
Completion
(C)
Review (R)
date
Only
absconded
patients who
fit policy
criteria for
calling the
Police are
rung through
Implementaion of
policy
(a) All patients
fitting mental
health criteria in
ED have mental
health risk
assessment
completed within
30mins of triage
(b) GMWest staff
assess all patients
fitting the mental
health criteria who
have absconded
from Ed or EAU
and decide if
Police should be
called
(c) Medical
patients with
definite capacity
are not rung
through to Police
Julie Newton
(LN ED)
1.Policy agreed at
SRFT board
2/10/14 (RB)
2. Call meeting
with operational
ADN (inc
Safeguarding
AND) to launch
policy (RB)
3. ADNs to
implement across
divisions and into
ward teams
4.Continued
assessment of
Police calls weekly
5. Monthly joint
GMP/GMW/SRFT
meeting (inc
appropriate vs
inappropriate calls)
6. Absconded
patient policy
included in ED and
EAU new RN
induction
7. All ED RNs sign
as trainied by
31/12/14
(s) 2/10/14
(c) 2/10/14
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Jill Phillips
(MHL Lead,
GMW)
Richard Bulman
(ADN Emergency
Med)
Progress
(reference to
detail)
(s) 2/10/14
(c) 16/10/14
(s)16/10/14
(c) 2/11/14
(r) 4/11/14
(s)1/9/14
(c) 1/9/14
(r) 1/9/14
(s)1/9/14
(c) 1/9/14
(r) 31/12/14
(s)1/10/14
(c) 3/11/14
(r) 4/04/15
(s)1/10/14
(c) 31/12/14
(r) 4/04/15
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