Patients who are Missing or Absent without Leave (AWOL) Policy

Patients who are Missing or Absent without Leave (AWOL) Policy DOCUMENT CONTROL: Version: 13 Ratified by: Quality and Safety Sub Committee Date ratified: 30 January 2017 Name of originator/author: Nurse Consultant, Adult Mental Health Services Name of responsible Clinical Quality Group committee/individual: Date issued: 10 May 2017 Review date: January 2020 Target Audience Clinical Staff in all areas

Section CONTENTS Page No 1. INTRODUCTION 4 1.1. Definitions 4 2. PURPOSE OF THE POLICY 5 2.1 The Trust Policy 5 3. SCOPE 5 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 5 4.1 The Board of Directors 5 4.2 Care Group Directors 5 4.3 Modern Matrons/Service Managers 6 4.4 Community staff 6 4.5 Responsible Clinician 6 4.6 Nurse/Clinician in Charge 6 4.7 The Police 6 4.8 The Mental Health Act Office 7 4.9 Inpatient Staff 7 4.10 Trust Patient Safety Lead 7 5. PROCEDURE/IMPLEMENTATION 8 5.1 Information to patients. 8 5.2 Risk Assessment 8 5.3 When is a patient classed as absent without leave or being missing 5.4 Required response by police 10 5.5 Information required by the police 12 5.6 Action to take if an informal inpatient goes missing 12 5.7 Action to take if a patient goes absent whilst being escorted or transported within the community 5.8 Action if a patient absconds from an address to which they have authorised leave. 5.9 Additional notification required for patients detained on Court orders or Ministry of Justice restriction. 5.10 Return of a patient who has been absent without leave or missing 5.11 Action to be taken if a patient is located at home but is refusing entry 5.12 Time limits for returning detained patients who are absent 17 9 15 15 16 16 16 Page 2 of 35

Section without leave CONTENTS Page No 5.13 Specific guidance for patients subject to Guardianship 17 5.14 Action to be taken when the patient returns 17 5.15 Specific action following the return of a detained patient 18 5.16 Record Keeping 19 5.17 Reducing the incidents of missing /absent without leave 19 5.18 Dealing with media enquiries 19 6. TRAINING IMPLICATIONS 19 7. MONITORING ARRANGEMENTS 20 8. EQUALITY IMPACT ASSESSMENT SCREENING 21 8.1 Privacy, Dignity and Respect 21 8.2 Mental Capacity Act 21 9. LINKS TO ANY ASSOCIATED DOCUMENTS 22 10. REFERENCES 22 11. APPENDICES 22 Appendix 1: Patient information sheet and action log for when a patient goes missing or absent without leave from an inpatient unit Appendix 2: Specific risk assessment for when an inpatient goes missing/absent without leave. Appendix 3: Notification report to the Care Quality Commission Appendix 4: Time limits for returning patients who are absent without leave or otherwise liable to be retaken 23 27 30 33 Page 3 of 35

1. INTRODUCTION 1.1. Definitions Trust Definitions The term missing applies to any situation where patients have absconded, are absent without agreement or planned leave or have not returned from leave, and are considered likely to act in a way that may present a risk to themselves or others. Confused or disoriented patients may also go missing if they wander away from their care setting. Absent without leave (AWOL) This term is used in connection with patients who are liable to be detained under the MHA and who absent themselves from hospital without authorised leave granted under section 17 or are subject to a Community Treatment Order (CTO) and have failed to attend hospital when recalled. A patient would also be considered AWOL if they failed to return within the time limits allowed for authorised section 17 leave or for a patient subject to Deprivation of Liberty safeguards to leave an In-Patient Service without the knowledge or agreement of the clinical team. In addition On the inpatient wards this definition also applies to any patient who has identified risks, regardless of their level of capacity to make a decision, who leaves the ward without having discussed their wish to leave with the multi disciplinary team. South Yorkshire Police Definitions A patient will be considered missing when their whereabouts cannot be established and where the circumstances are out of character or the context suggests the person may be a subject of crime or at risk of harm to themselves or another. A patient will be considered as absent if they are not at a place where they are expected or required to be. Every effort should be made within In-Patient Services to ensure that staff know the whereabouts of all patients in their care, however due to the majority of in-patient areas not being locked and therefore allowing a degree of free movement, there may be times when a patient cannot be found on the ward and staff are not able to account for their whereabouts. The risk of an in-patient being AWOL or missing is that they may either actively or passively harm themselves or others, or be exploited by others, or suffer harm due to an inability to care for them whilst they are away from the in-patient environment. Page 4 of 35

2. PURPOSE The purpose of this policy is to set out the arrangements for managing the risks associated with patients who are missing or absent without leave (AWOL): - From In-patient Services whilst they are receiving care and treatment within the Trust, or - Whilst on planned leave from the In-Patient Service This policy also applies to patients subject to a Community Treatment Order (CTO) recall who fail to return voluntarily to the hospital named in the recall notice. See Community Treatment Order Policy. The policy does not apply to community patients who have, or are at risk of, disengaging with services. See Policy on the Management of Service Users who have, or are at risk of, disengaging with Adult Community Mental Health Services. 2.1 The Trust Policy is: 3. SCOPE a. To reduce wherever possible the risk of patients going AWOL or being missing through effective risk assessment, care planning and communication b. To respond in a timely and consistent manner when patients do go AWOL or are missing, liaising effectively with other relevant agencies. This policy applies to: - All Clinical staff. - All AWOL or missing patients, whether they are informal or detained under the Mental Health Act 1983 (Amended 2007), or - Subject to Deprivation of Liberty safeguards. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 The Board of Directors The Board of Directors has responsibility for the implementation of this policy and the monitoring of compliance. This responsibility is delegated to the Trust Chief Executive who will delegate lead responsibility to the Chief Operating Officer. 4.2 Care Group Directors Are responsible for: The implementation of all policies and procedures which are in place to Page 5 of 35

meet the needs of patients. Monitoring adherences to this and other related policies. Adequate resources and training being available to the clinical team. 4.3 Modern Matrons/Service Managers It is the responsibility of the Modern Matrons/Service Managers to : Make their staff aware of this policy and contents. Bring any issues which may affect implementation of this policy to the attention of the Clinical Quality Group. Within the Forensic services to audit compliance with the Care Quality Commission (CQC) reporting requirements in respect of patients detained under the Mental Health Act 1983 who go absent without leave. Investigate any breaches in compliance with the contents of this policy. The provision and monitoring of operational and clinical supervision to clinical staff. 4.4 Community staff Community staff will: Cooperate with and assist In-Patient staff and the Police to identify the potential whereabouts of patients known to them who are AWOL or missing. 4.5 Responsible Clinician. The Responsible Clinician will: Be involved in the assessment of clinical risk for any patients on the wards who are admitted under their care. Review the granting of leave under section 17 for any patients detained under the Mental Health Act 1983 who have been absent without leave and then subsequently returned to the ward. 4.6 The Nurse/Clinician in Charge. The Nurse/clinician in Charge of the ward at the time of any patient going missing or absent without leave has a number of responsibilities under this policy and should refer to section 5 for full details. 4.7 The Police The Police responsibilities are: All reports of missing or absent people will be managed in line with the South Yorkshire Police standard operating procedure The police communications room will receive all reports of missing or absent patients on behalf of the police. Page 6 of 35

The police will manage and co-ordinate all reports from whatever source. The police will provide a service to receive reports 24 hours each day. The initial police attendance will be graded in line with Force Missing Persons Policy. The police will provide a Unique Reference Number URN for each report confirming receipt. The police will provide a reference number for those missing persons placed on the missing person data base. The police will initiate a safe return check for all patients where there are concerns regarding their vulnerability In all cases a record will be made on the Police National Computer (PNC). South Yorkshire Police are not providers of transport for patients, detained or otherwise. While it is accepted that there is a legal basis for police to assist with the transportation of persons to hospital when detained under the Mental Health Act; the threshold for such assistance is necessarily high. On every occasion, police will only provide or assist with the transport once alternative arrangements for a more suitable conveyance have failed. Any use of police resources must be risk assessed, justified and documented. Even then police constables must secure the authority of a supervisory officer unless in an emergency. 4.8 The Mental Health Act Office If a patient is detained under the MHA 1983 and goes AWOL the MHA Office will advise the RC and staff of the time limits associated with the relevant section for returning the patient as detailed in the MHA Reference Guide (Appendix 5). 4.9 Inpatient Staff Adhere to the relevant clinical risk assessment requirements for their clinical area as stated in section 5.2 of this policy. Adhere to guidance in section 5.7 of this policy. Staff working in the Locked Units (Amber Lodge/Jubilee Close/Coral Lodge) only will: In the case of detained patients who go absent without leave comply with the reporting arrangements to the Care Quality Commission as detailed in sections 5.7 and 5.16 of this policy. Refer to Amber Lodge Low Secure Absent Without Leave (AWOL) SOP http://www.rdash.nhs.uk/29843/amber-lodge-low-secure-absent-withoutleave-awol/ 4.8 Trust Patient Safety Lead The Trust Patient Safety Lead is responsible for the analysis of patient safety incidents and actions taken and the dissemination of learning from incident Page 7 of 35

reports. This includes incidents of patients going absent without leave. 5. PROCEDURE/IMPLEMENTATION Staff working within the Trust inpatient Forensic services should also refer to appendix 4 for details of their area specific procedures. 5.1 Information to patients At the point of admission to the ward patients are to be advised of the fact that should they need to leave the ward for any reason they are to seek permission from a member of the clinical team. This will also apply in the event of the patient having planned leave from the ward as it is important that staff are able to account for patients whereabouts at all times. 5.2 Risk Assessment Staff should also refer to the Trust Clinical Risk Assessment and Management policy. Doncaster Community Integrated Services In-Patient Units A Mental Health clinical risk assessments will only be completed on patients who have identified cognitive impairment or Mental Health issues. Where it has been identified that a clinical risk assessment is required staff are to follow the guidance below. Adult and Older Peoples Mental Health, Leaning Disability and Forensic Services a. All patients will have a formal risk assessment completed on admission which will include identification of their risk of going AWOL or missing, including previous history and/or patterns. b. The risk assessment will be reviewed and updated whenever any changes in the patient s condition or risk profile are identified. d. Known triggers for increasing the likely hood of a patient going AWOL or missing must be recorded e.g. phone calls from particular friends and relatives. If the assessment indicates that the patient has an increased likelihood of absconding or going missing, details of their description should be recorded e.g. height and weight, other physical characteristics etc. The recording of this information must be kept in the patient s clinical record. e. The assessment should identify whether the risk is active or passive: Active Patient is likely to knowingly and overtly attempt to leave the clinical area Passive the patient may be confused and/or disorientated and Page 8 of 35

may wander out of, or away from the clinical area if unsupervised. f. All patients who are assessed as presenting a risk of going AWOL or being missing should have clearly recorded in their care plan appropriate levels of observation, supervision and security of the clinical environment for the level of risk assessed. When assessing the environment consideration must be given to the level of access the patient has to open windows, fire doors, or low roof lines. The care plan must be subject to regular review and must be communicated to all staff that need to be aware. g. For patients who have been identified at high risk of going AWOL or being missing the following should be included in their clinical record: - Personal description information - Places they are likely to visit - Details of any additional actions required in the event of them going AWOL or being missing - A photograph h. For patients who are confused and there is a risk that they may become separated from their escort, consideration should be given to the need for them to carry contact information on them when away from the wards. 5.3 When is a patient classed as AWOL or being missing Under section 18 of the Act, patients are considered to be AWOL in various circumstances, in particular when they: have left the hospital in which they are detained without leave being agreed (under section 17 of the Act) by their responsible clinician have failed to return to the hospital at the time required to do so under the conditions of leave under section 17 are absent without permission from a place where they are required to reside as a condition of leave under section 17 have failed to return to the hospital if their leave under section 17 has been revoked are patients on a community treatment order (CTO) (community patients) who have failed to attend hospital when recalled are CTO patients who have absconded from hospital after being recalled there are conditionally discharged restricted patients whom the Secretary of State Page 9 of 35

for Justice has recalled to hospital are guardianship patients who are absent without permission from the place where they are required to live by their guardian. Patients will be considered missing in the following circumstances: If an informal patient considered being vulnerable by the clinical team leaves the ward area without the staff being aware or has not returned from leave. If an informal patient who has been identified as posing a significant risk to themselves or others absents themselves whilst being escorted or transported in the community. If an informal patient who is assessed to have capacity, and whose whereabouts are known, is refusing to return to the ward and there is no immediate risk to themselves or others then they are not missing. In these circumstances staff should arrange a Multi-Disciplinary Team (MDT) review to agree if discharge is appropriate. It is important that community staff, and/or friends and family (where appropriate) are included in the MDT. For an informal patient whose whereabouts are known but the patient lacks capacity an urgent best interest meeting is to be convened to agree if discharge is appropriate. 5.4 Required response by the Police At the time of contacting the police, staff must be clear as to what response they are requesting from them. Where the police are asked for help in returning a patient, they must be informed of the time limit for taking them into custody (see appendix 5). They should also be told immediately if a patient is found or returned. Patients subject to detention under the Mental Health Act 1983 Any patients subject to detention under the Mental Health Act 1983 who leave the hospital without a valid section 17 are to be reported as Absent Without Leave, and a request made that they are located and returned to the hospital. Section 18 of the 1983 Act provides powers to the police for retaking into custody patients who are absent without leave and returning them to hospital, However alternative more suitable options for transport may be sought. Patients who are subject to The Deprivation of Liberty Safeguards. (DOLS) If a patient subject to the Deprivation of Liberty Safeguards leaves the hospital without the agreement of the Consultant Psychiatrist and/or Nurse a request should be made to the Police that as they are a vulnerable adult they are Page 10 of 35

located and returned to the hospital. Powers Under Mental Capacity Act To Return Patient Section 4 and 5 of the Mental Capacity Act provides powers to the police as well as staff to make a Best Interests Decision to return the patient to the ward. Section 6 authorises restraint provided that; The officer or member of staff reasonably believes that it is necessary to do the act in order to prevent harm to P. And that restraint is a proportionate response to (a) the likelihood of P's suffering harm, and (b) the seriousness of that harm. However the Police powers under section 4 and 5 of the Mental Capacity Act can not to be used to obtain a Mental Health Act assessment as there is provision within the Mental Health Act 1983( Amended 2007) for when these situations arise. Patients who are on the ward voluntarily and are assessed as being a significant risk to themselves or others These patients are missing and the Police will be asked to try and locate/return the patient to the ward. Once a missing person is found safe and well the Police will take appropriate action which will include; o notifying the ward as to the patients location o requesting that the patient returns voluntarily If the patient refuses to return to the ward voluntarily an assessment for detention under the Mental Health Act 1983 may need to be arranged, or where the person is located and lacks capacity and there is evidence via the best interest process that a return to the ward is in the person s best interest as there is a specific and immediate threat of harm to themselves or another person, or that failure to take immediate action could result in significant harm to that person they can be returned by the Police. However any restraint used must be proportionate to the likelihood of the person suffering from or inflicting harm and the seriousness of that harm (Mental Capacity Act 2005). Staff must note that Police officers are NOT equipped to carry out assessments of capacity. If capacity is in question, then an appropriate professional should carry out such an assessment. In addition to this if the patient is in a private place (such as a their home address), officers have NO powers without a warrant under S135(1) or S135(2) unless there is evidence of an offence being, or about to be, committed. The Sessey case (2011) clearly states that officers do NOT have powers to invoke the provisions of the Mental Capacity Act in order to seek a Mental Health assessment, as would be the case for a patient who had been admitted informally and was refusing to return to the ward voluntarily. Page 11 of 35

Patients who are on the ward voluntarily and are assessed as being a low or no discernible risk to themselves or others. If the patient has capacity, has been assessed as not posing a significant risk to themselves or others and their whereabouts are known as staff have managed to make phone contact with them and they are felt to be safe until they agree/want to return and can be returned by relatives/friends or be picked up by clinical staff no police response will be required. If clinical staff have been unable to make contact with the patient by phone a request will be made for either the patients care coordinator (if allocated) or the access team (if not allocated to a care coordinator) to undertake a safe and well check. 5.5 Information required by the police When contacting the police to report an inpatient as missing or absent without leave the nurse in charge of the ward must provide the following information:- o Patients full name and any nick names/aliases they are known to use. o Age. o Full physical description, including any distinguishing marks such as scars or tattoos. o A photograph (if available) o Details of clothing worn by the patient when last seen. o Patients legal status. o Patients mental state. o Details of any cognitive or sensory disability. o Detail of any known risks to self or others. o Detail of any physical disability /illness/ complication which may put the patient at increased risk. o Any known communication problems e.g. if the patients first language isn t English. o When the patient was last seen including where, time and by whom. o What action has been taken to try and locate the patient prior to reporting the matter to the police? o The specific and level of risk posed to the patient due to them being missing or AWOL (please refer to appendix 4) o Details of any places /addresses the patient is known to frequent. 5.6 Action to take if an informal inpatient goes missing or a patient detained under the MHA 1983 goes AWOL (including anyone subject to Deprivation of Liberty safeguards. Action to take if an inpatient goes missing Action to take if an inpatient detained under the MHA 1983 goes AWOL (including anyone subject to Deprivation of Liberty safeguards. Page 12 of 35

Staff must immediately notify the Nurse in Charge who will: a. Organise a search of the surrounding wards and other facilities in line with area specific procedures. b. Attempt to contact the patient using all relevant contact details available (Mobile telephone number, Landline, Email) to ascertain where they are and request that they return to the ward. c. Notify the patient s next of kin who may be able to offer information/insight regarding the patient or inform the team if they make contact. Staff should also consider any support that may need to be offered to family or carers at this stage. d. If the patient is not located, inform the Consultant psychiatrist/ RC during normal working hours. e. Inform Modern Matron /Service Manager, or if outside normal working hours the on call Manager. f. For informal patients: Inform the Police if there are significant concerns for the patient s wellbeing and safety to either themselves or others. The legal status of the patient must be fully explained along with the reasons for concern. g. For detained patients: Inform the policy in line with section 5.5 of this policy h. For Mental Health Services and detained patients, notify the Crisis Team who may be asked to assess the patient should they present in the A & E Department or make contact with the Crisis Team. i. Inform the patient s care co-ordinator and other community workers involved j. Notify Switchboard as they may receive calls with regard to the missing person. Action to take if an inpatient goes missing Action to take if an inpatient detained under the MHA 1983 goes AWOL (including anyone subject to Deprivation of Liberty safeguards. k. Inform the patient s GP in case the patient presents at the surgery for medication. Page 13 of 35

l. Notify hospital security if available. m. If any child safeguarding issues have been identified, inform Children and Family Services or the Duty Social Worker if outside normal working hours. n. Inform anyone who is felt may be at risk from the patient, as identified in their risk assessment and risk management plan. o. Report the incident accurately using the Electronic Incident Form (IR1) via the Trusts Safeguard electronic incident reporting system. p. Where in use make a record on the ward s 24-hour report. q. If the patient is still absent after 12 hours, the following people should be notified during normal working hours or the next working day: o Patient s Psychiatrist/Responsible Clinician o Manager/Matron o Ward Manager o Patient s GP o Care Co-ordinator o Family/Carers Action to take if an inpatient goes missing Action to take if an inpatient detained under the MHA 1983 goes AWOL (including anyone subject to Deprivation of Liberty safeguards. r. If the patient fails or refuses to return to the ward, discuss with their Consultant the need to carry out an assessment under the Mental Health Act 1983 (Amended 2007), or for the patient to be discharged in their absence with appropriate community follow-up being arranged and communicated to them. Where possible the clinical team who provided care to the patient in the community prior to admission, or in the Crisis team in the case of patients not previously known Page 14 of 35

to services are to be involved in this discussion. s. For Locked Units (Amber Lodge/Jubilee Close/Coral Lodge) only: In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the AWOL Notification Form to the CQC. Then send the original to the Service Manager/Matron/MHA Office. t. If the patient remains absent after 24 hours the Service Manager/ Matron will notify their Manager of the patient s absence (if not already aware). NB: Dependent on the level of risk, there may be times when the Service Manager/Matron is notified immediately. If out of hours staff should use their area specific on call procedure. u. Comprehensively record all actions taken in the clinical record. 5.7 Action to take if a patient goes absent whilst being escorted or transported within the community a. A search of the immediate area should be undertaken by the escort. b. In the event that the patient is not found, the escort will contact the ward and inform the nurse. c. The Nurse/Clinician in Charge of the ward will implement the actions from Section 5.7 of this policy. 5.8 Action if a patient absconds from an address to which they have authorised leave a. The member of staff who receives the information will try to obtain the following details and make a record of them: o Date and time patient was last seen o Where o Who by o Whether or not the patient gave any indication as to where they intended to go o If they took any clothing, money, or passport with them. b. Inform the relevant Service Manager/Matron and the patients Responsible Page 15 of 35

Clinician. c. The Service Manager/Matron will take relevant action as detailed in Section 5.7 of this policy. 5.9 Additional notification required for patients detained on Court orders or subject to Ministry of Justice Restriction Orders a. For any patient detained under Section 37/41, Section 47/49, Section 48/49 who are AWOL the Service Manager/Matron must notify their Manager who will inform the Ministry of Justice of the patients absence. b. For patients detained on Sections 35, 36, 37 or 38 who have not been found following initial searches the Service Manager/Matron will notify the Courts Business Manager. 5.10 Return of any patient who has been AWOL or missing a. A adult with capacity (over 16 years of age) not subject to detention under the Mental Health Act 1983 (Amended 2007) can not be taken back to the ward without their consent. b. If the patient can not be persuaded to return, staff should contact their Service Manager/Matron and Consultant Psychiatrist for advice. Any subsequent action is dependent on a risk assessment of the current situation and the safety of the patient and others. c. In the very exceptional circumstance of a child under 16 years of age who is not subject to detention under the Mental Health Act 1983 (Amended 2007), Parental Authority is required prior to the return of the child Unless the child is deemed to be gillick competent. When deciding on the most appropriate method for conveying the patient to hospital The Code of Practice recommends that the following must be considered: - Transport options - Distance to be travelled - Patient s views, age and any disability they may have - Risks associated with the method of transport - Risks of patient behaving violently or re-absconding - Safety of the people conveying and accompanying the patient 5.11 Action to be taken if a patient is located at home but is refusing entry If the patient is detained, an approved mental health professional (AMHP), any member of the hospital staff, any police officer, or anyone authorised in writing by the hospital managers may apply for a warrant under S 135(2) the Mental Page 16 of 35

Health Act 1983 (Amended 2007) which provides for the retaking of a patient who is already detained under the act and is AWOL. For informal patients who are located in the community but refuse to return or allow entry, a request should be made for a visit to be undertaken by community staff who are involved in the patient s care. Where patients do not have an allocated community worker, the request will be made to the Crisis Team or District Nurse. Following the community services assessment, a decision will be made regarding further action required to support the patient. 5.12 Time limits for returning detained patients who are absent without leave Detained patient who go AWOL can be returned to the ward for up to six months after going absent or until the expiry date of the current authority for their detention or guardianship whichever is later. Staff should refer to appendix 5 for specific guidance/ If at the time the person goes AWOL the authority for detention or guardianship has been renewed in accordance with Section 20 but the new period has yet to begin, the renewal is ignored and the six month limit for returning the patient applies (Mental Health Act 1983 (Amended 2007, Memorandum page 27, 71)). NB: These time limits do not apply to patients subject to restrictions under Section 41 or Part 4 of the Act who continue to be liable to be returned at any time. 5.13 Specific guidance for patients subject to Guardianship Any patient subject to Guardianship who is absent without permission from an address where they are required to reside by the Guardianship Order, may be taken into custody and returned to that place of residence by the named guardian, any member of staff of the responsible local social services authority or by any person authorised in writing by the local social services authority or private guardian. 5.14 Action to be taken when the patient returns a. It is the responsibility of the Nurse/Clinician in Charge to inform everybody previously notified of the patient s absence of their return. b. The clinical team will review the patient s risk assessment and update the care plan accordingly, including consideration of the level of observations required to prevent further occurrences. c. A search may be initiated for weapons or drugs if it is felt necessary. See Policy relating to the searching of property or persons. d. Staff should only contact the on call Doctor outside of normal working Page 17 of 35

hours about the return of an absent patient if there are concerns about the patients mental state or physical presentation and the medical attendance is needed. E Any further periods of leave from the ward are to be suspended until a full multi disciplinary review has been undertaken. 5.15 Specific action following the return of a detained patient Notification to the Care Quality Commission Locked Units (Amber Lodge/Jubilee Close/Coral Lodge): When a detained patient who absconds has been reported to the Care Quality Commission returns, part two of the AWOL notification form is to be completed and Emailed to the CQC and a copy to MHA Office to them (see Appendix 2). Patients returned within 28 days If a patient is returned within 28 days and the current authority for detention or Guardianship has not expired, that authority remains until its expiry date. No form is required to continue the detention or Guardianship. If a patient is returned within 28 days and the authority for detention or Guardianship has expired or has less than seven days to run, it can be extended by up to seven days beginning with the day the patient returns. During these seven days the patient must be assessed with a view to either renewing that authority for detention or Guardianship or discharging the patient. The Responsible Clinician may renew the section in the usual way and the renewal will take effect from the date the original period ended. Patients returned after 28 days If a patient is returned after 28 days have elapsed, the Responsible Clinician must assess the patient within seven days of return to determine whether detention or Guardianship is still appropriate. Where the authority for detention or Guardianship has expired it can be extended by up to seven days beginning with the day the patient returns. If continued detention or Guardianship is thought necessary, the Responsible Clinician must submit the relevant form, and the renewal will take effect from the expiry date of the original Section once the forms have been received by the Hospital Managers. Patients returned subject to DOLS If a person is under an urgent authorisation or standard authorisation there is no specific legal authority under the Mental Capacity Act to return the patient to the hospital they are detained to if the patient refuses/objects or resists. This would need to be discussed with the clinician in charge of the person s care and treatment as in these circumstances it may be necessary for clinical staff Page 18 of 35

to make urgent arrangements under section 135(1) to undertake a MHA assessment or for police to consider their powers under section 136 where applicable and appropriate. If the urgent authorisation has already expired and the Trust is waiting for assessments for a standard authorisation to be authorised the patient should be treated as a missing person and apply the relevant part of this policy/procedure, taking into account patients vulnerability and risk to self and others. 5.16 Record keeping Throughout any instance of a patient going Absent Without Leave or Missing from the ward clinical staff are to complete an IR1 and keep a full and chronological record of all action taken, and information received. This is to be recorded on the Patient Information sheet and Action Log for when a patient goes missing or absent without leave from an inpatient unit, a copy of which will be retained in the patients clinical records. (Appendix 1) 5.17 Reducing the incidents of Missing/Absent Without Leave Good clinical risk assessment and engagement of patients is the most effective way to reduce the instances of patients going missing or absent without leave. However it is vital that staff consider the clinical environment and take appropriate action to reduce /eliminate opportunities for inpatients to leave the ward without staff being aware. This will also include the need to secure any windows or doors which have been used as an unauthorised exit by patients to prevent other patients leaving by the same route. 5.18 Dealing with media enquiries a. Any media enquiries relating to a patient who is AWOL or missing are to be referred to the Trust Communications Department on (01302) 796816. b. Staff must not answer any enquiries themselves. c. If necessary a press statement will be issued by the Trust Communications Department. d. In the event that staff become aware that the patient s family or friends have, or may contact the media, they are to notify the Trust Communications Department. 6. TRAINING IMPLICATIONS Whilst there are no specific training needs in relation to this policy the clinical staff to whom it applies will be made aware of its contents in the following ways: Page 19 of 35

By the service manager /matron at local induction and when there is a change to practice. Details of the policy review will be published in the Trust s Monthly Team Talk. This policy is also included in the Mental Health Act Training. Trust staff also receive training in respect of the following: o Deprivation of Liberty Safeguards o Safe Guarding Adults o Mental Capacity Act 2005 7. MONITORING ARRANGEMENTS AWOL incidents will be reviewed on an ongoing basis to ensure that the factors which lead to these incidents are fully taken account of in policy and practice reviews, in order to learn lessons and to facilitate ongoing organisational learning. Area for monitoring Analysis of incidents and actions taken/learning from incident reports Actions taken/organisati onal learning from incidents Policy implementation Monitoring process Quarterly Incident Report Directorate reports Action/practice change/ organisational learning report Clinical records audit Responsibility Health and Safety Lead/Modern Matrons Health and Safety Lead Actions taken/ organisational learning report produced by Senior Managers/ Matrons for Health and Safety Lead Modern Matrons/Service Managers in conjunction with the clinical audit department. Frequency Reported to Quarterly Quarterly Quarterly Annually Risk Management Sub Group Assistant Directors Relevant Business Division Governance Group/Multi- Agency Group Organisational Learning Forum/Risk Management Sub Group. Business Divisions Governance Groups Clinical Effectiveness Committee Business Divisions Governance Group Page 20 of 35

Area for monitoring Number of patients absent who meet the criteria for notification to the Care Quality Commission Monitoring process Audit of the Notification Reports Responsibility Service Manager/Matron Frequency Reported to Quarterly Mental Health Legislation Committee and Relevant Business Division Governance Group. 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on this Policy s webpage on the RDaSH website. 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). Indicate how this will be met There is no requirement for additional consideration to be given with regard to privacy, dignity or respect. In respect of the reporting requirements for patients who are Absent without Leave staff will abide by the Trusts information sharing protocols 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) Page 21 of 35

9. LINKS TO ANY ASSOCIATED DOCUMENTS Incident reporting Policy, Health and safety polices, RDaSH Internet Police Liaison policy, Security Policies, RDaSH Internet Mental Capacity Act 2005 Policy, Clinical Polices, RDaSH Internet. Mental Capacity Act 2005- Deprivation of Liberty Safeguards, Clinical Polices, RDaSH Internet. Clinical risk assessment and management policy, Clinical Policies, RDaSH Internet Policy for the care of inpatients who are identified as posing a significant risk to themselves or others, Clinical Policies, RDaSH Internet Policy relating to the searching of property or persons, Clinical Policies, RDaSH Internet. Policy on the Management of Service Users who have, or are at risk of, disengaging with Adult Community Mental Health Services, Clinical Policies, RDaSH Internet 10. REFERENCES Jones, Richard (2012) Mental Health Act Manual fifteenth Edition, Sweet and Maxwell Department of Health (2008) Code of Practice Mental Health Act 1983 11. APPENDICES Appendix 1: Patient information sheet and action log for when a patient goes missing or absent without leave from an inpatient unit Appendix 2: Specific risk assessment for when a patient goes missing or absent without leave. Appendix 3: Notification report to the Care Quality Commission Appendix 4: Amber Lodge Low Secure Services Standard Operating Procedure for when a patient from Amber Lodge goes absent without leave (AWOL) Appendix 5: Time limits for returning patients who are absent without leave or otherwise liable to be retaken Page 22 of 35

APPENDIX 1 Patient Information sheet and Action Log for when a patient goes missing or absent without leave from an inpatient unit. Date/Time last seen Police Incident Number [ ] Name of Patient:. (include known alias if used) Date of Birth:.. Age:. G.P.. Sex: Male/Female (delete as appropriate) Mental Health Act &/or Mental Capacity Act Status: Patients clinical Risk Assessment: Any known physical health care needs which put them at risk.. Ward: Tel No: Date:. Time:. Height: Build:. Complexion: Skin Colour:.. Eye Colour:... Hair (colour/style): Facial Hair:. Distinguishing Features: (include tattoos/plaster casts etc In possession of a vehicle?. Cash/Clothes taken?. In possession of a mobile phone (if yes number). Places frequented: Where may have gone? Page 23 of 35

If missing before, where found? Nearest relative:.. Name & Address:.. Tel No: Known friends: Name & Address:.. Tel No: Please provide details below of the reasons for reporting missing, and category chosen, include mental state, special concerns/risks, suspicious circumstances, medication needs and any known reason for patient leaving Page 24 of 35

Action Date By whom &Time Please use 24hr clock. When patient goes AWOL/ missing Undertake immediate search of ward and surrounding area. Attempt to contact patient on their mobile phone Attempt to contact patient on their landline number. Inform the patients Consultant. Complete the specific risk assessment for a missing /AWOL patient Inform the Police and provide all details as required. Notify the patients next of kin. Notify switchboard. Notify the Crisis team. Notify the patients care coordinator. Notify the patients care coordinator. If there are any safeguarding children concerns inform children and family services or the duty social worker outside of normal working hours. Complete an IR1 Notify Hospital security if available. Inform on call manager. Obtain update from Police. Amber Lodge only complete the notification to the CQC. If patient found and returned to the ward. Inform the patients Consultant. Inform the Police. if they have not returned the Page 25 of 35 Additional information Including details of why an action not taken.

Action Date &Time Please use 24hr clock. By whom patient. Notify the patients next of kin. Notify switchboard Notify the Crisis team. Notify the patients care coordinator. Notify the patients care coordinator. Notify Hospital security if available. Inform on call manager Review and update patients risk assessment Review observation levels for the patient Discuss with patient their reasons for leaving the ward, and record in clinical records. For detained patients only suspend any section 17 leave unit a review has been undertaken by the patients Responsible Clinician. If patient found but refuses to return to the ward. Convene Multi disciplinary meeting to agree required action. Additional information Including details of why an action not taken. Page 26 of 35

APPENDIX 2 Specific Risk Assessment for when an inpatient goes missing /absent without leave. To assist the police in prioritising their response to any reports of missing / AWOL patients they have asked that staff complete the following by circling all that apply. In the case of any patient with a combination of low, medium or high risk their overall rating will defer to the highest identified risk. Risk Factor High Risk Medium Risk Low Risk Subject to detention under the Mental Health Act 1983. These patients are considered to be in the high risk category. Not applicable Not applicable Patient is subject to a Deprivation of Liberty Order. Patient was admitted to the ward voluntarily Behaviour or Mental State. Age range Sensory impairment. These patients are considered to be in the high risk category. Patient has been assessed as presenting a significant risk to either themselves or others. Patient has been identified as being vulnerable due to: o Learning disability o Impaired capacity due to their mental state. o Cognitive impairment. o Confusion. o Dementia. o Head injury Patient is under the age of 18,or 18 years and older but assessed as vulnerable. Significant recent loss of : o Sight o Hearing,or o Speech, And has been Not applicable Not applicable Patient has been assessed as presenting no risk to themselves or others.. Patient has mental health or learning disability diagnosis but is able to function independently and has capacity Patient is over 18 but under 19 years of age. Previous loss of sight / low vision which may put the patient at risk in an unfamiliar environment. Over the age of 19 and not considered to be vulnerable. Long term hearing or speech loss with which the patient manages independently. Page 27 of 35

Risk Factor High Risk Medium Risk Low Risk identified as having limited coping ability. Medication Ongoing clinical care. Substance Misuse. Weather conditions. Is there a suspicion that the patient may have been abducted Is there a suspicion /evidence that the patient is a victim of domestic abuse. Safeguarding Children, Patient requires essential medication for a physical disorder. Patient requires essential clinical care for example: o Has venous access. o Has drains in place. o Has open wounds. o Requires O2 therapy. o Has retention of isotopes or a ruthenium implant. Patient has a current or previous history of drug misuse and has a venous access line in-situ. If severe weather conditions are being experienced and exposure to these increases the risk to the patients health. If yes it is high risk. If yes it is high risk If there are known safeguarding issues and the child is subject to Page 28 of 35 Patient requires clinical care but arrangements can be made for them to have it at home. If the patients admission was as a direct result of their illicit drug or alcohol use. If the child is under the care of the local authority No essential medication required to prevent a rapid deterioration in their physical health and wellbeing. Patient does not require any ongoing clinical care. No history of drug or alcohol misuse. If no it is low risk. If no it is low risk. No known safeguarding issues.

Risk Factor High Risk Medium Risk Low Risk safeguarding proceedings. Safeguarding Adults. If there are known safeguarding issues which are subject to safeguarding proceedings. No known safeguarding issues. Page 29 of 35

The end of the APPENDIX 3 Unauthorised absence of a person detained or liable to be detained under the Mental Health Act 1983 RESTRICTED information AWOL Notification reference: Statutory notification about the unauthorised absence of a person detained or liable to be detained under the Mental Health Act 1983 Care Quality Commission (Registration) Regulations 2009 Regulation 17, as amended by the Care Quality Commission (Registration) and (Additional Functions) and Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2012 Completing this form Please use this form to notify CQC of any absence without leave (AWOL) of a person who is detained, or liable to be detained 1, under the Mental Health Act 1983 in a hospital designated as low, medium or high security. You should complete this form as soon as possible after the incident is noted, but not to the detriment of taking necessary actions to deal with the incident on a practical level. How to fill in the form The notification form is a protected Word document. When filing in on a computer, you can move from section to section by pressing your return, tab or arrow keys, or by using your mouse. You can put crosses in check boxes by pressing your spacebar when they re selected or by clicking the box with your mouse. You must provide information in the mandatory sections (marked*). Please also provide all other requested information. It is acceptable to return part 2 of the form separately from part 1. Please type all entries where possible and enter dates in the format dd/mm/yyyy. You can email the form VIA NHS.NET ONLY by arrangement with the Mental Health Operations Team by calling 03000 616161 (press option 1 when prompted). Or you can send by secure fax on: 0148 477 2179 1 Including patients failing to return from s.17 leave of absence from hospital, or absenting from escorted leave or detention under short-term powers of s.5, 135 or 136. Page 30 of 35