AWOL - Missing or Absent without Official Leave

45 Pages·2016·0.99 MB·English

AWOL - Missing or Absent
without Official Leave

Target Audience

Who Should Read This Policy

   
All Clinical staff

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AWOL - Missing or Absent without Official Leave Policy

Page
Ref. Contents

1.0 Introduction 5
2.0 Purpose 5
3.0 Objectives 5
4.0 Process 5
4.1 When is a Patient Deemed to be Absent without Leave (AWOL)? 6
4.2 Procedure for When a Patient Absents Themselves 6
4.3 Community Treatment Order Patients Absent Without Official Leave 11
4.4 Procedure for when a Patient does not Return from Leave 11
4.5 Refusal to Return by a Patient 12
4.6 Actions in the Event of Prolonged Absence 13
4.7 Who has the Power for Returning the Patient to Hospital? 14
4.8 Section 135(2) Warrant 14
4.9 Time Limits for Returning a Patient who has Gone AWOL 15
4.10 Media 16
4.11 Debriefing and Learning Lessons from Incidents of Absence 17
5.0 Procedures connected to this Policy 17
6.0 Links to Relevant Legislation 17
6.1 Links to Relevant National Standards 19
6.2 Links to other Key Policies 20
6.3 References 21
7.0 Roles and Responsibilities for this Policy 22
8.0 Training 24
9.0 Equality Impact Assessment 24
10.0 Data Protection and Freedom of Information 24
11.0 Monitoring this Policy is Working in Practice 25

Appendices
1.0 Strategies to Reduce Incidents of Missing Patients 27
2.0 Gerry Simon Procedures for Restricted Patients 29
3.0 Patient AWOL Flowchart 31
4.0 Informal Patients- Missing Person Flowchart 32
5.0 Missing Patient Reporting Form 33
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6.0 Local Search Guidelines 35
7.0 Degree of Harm - When to Inform Agencies/ Individuals 38
8.0 Attending Court for a Warrant Section 135(2) 39
9.0 Execution of the Warrant 40
10.0 Form CTO3 Regulation 6(3) (a) - Mental Health Act 1983 42

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Explanation of terms used in this policy

Absent Without Official Leave (AWOL) - A detained inpatient subject to the provisions of the
Mental Health Act 1983 who has deliberately or unthinkingly absented themselves from the ward/unit
or who fails to return on time from authorised leave

Detained Patient - Inpatients that are subject to lawful detention under the Mental Health Act 1983

Informal patient - Any inpatient who is not detained under the Mental Health Act 1983, or any
other relevant legislation

Leave - The term leave includes escorted excursions outside of the hospital accompanied by staff,
relatives or other authorised persons. A detained inpatient absconding from such an excursion will be
recorded as absent without leave

Ministry of Justice - One of the largest government departments, its duties include protecting the
public and to reduce re-offending by mentally disordered offenders They achieve this by carefully
monitoring restricted patients detained in hospital or the community

Missing Patient - A generic term for informal patients who absent themselves from the ward/unit or
who fail to return on time and whose unknown whereabouts and continued absence arouses concern.

Judgement must be used by the ward/unit team to decide when a patient is classed as ‘missing’ e.g. a
patient who is an hour late returning from leave may not yet be classed as missing; the same patient
three hours later who has not responded to phone calls and who is not at home may be. Alternatively
high-risk patients must be classified as missing the moment their whereabouts are not known

Restricted Patient - Restricted patients are mentally disordered offenders who are detained in
hospital for treatment and who are subject to special controls by the Justice Secretary due to the level
of risk they pose. They are usually treated in secure hospitals, and will be given gradual access to the
community as part of their rehabilitation only when it is safe to do so

Risk Assessment - All inpatients are subject to continual risk assessment in accordance with the
Clinical Risk Management Policy and as such, the decision regarding risk in relation to leave and the
patients subsequent failure to return should be assessed and documented prior to leave being
granted. The assessment should include:
- Risk to self (neglect, self-harm, suicide)
- Child protection
- Risk of harm to others
- Risk to property

Supervised Community Treatment - When a Responsible Clinician considers with the rest of the
care team that a detained patient is well enough to leave hospital but is concerned they may not
continue with their treatment, or may need to be admitted to hospital again at short notice for more
treatment or for some other reasons

Adult at Risk - A person over 18 years of age who is or may be unable to take care of him or
herself, or is unable to protect him or herself from significant harm or exploitation

Absconding - A detained inpatient who absents him or herself from hospital

Absent - An inpatient that is not subject to the provisions of the Mental Health Act 1983, otherwise
defined as “informal” can be absent but not absent without official leave

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1.0 Introduction
Mental Health Act 1983 Code of Practice requires that hospitals have a clear written
policy detailing the action to be taken when a detained patient, or a patient subject to
supervised community treatment, goes missing.

There are a number of factors which contribute to the incidence of absconding:
boredom through lack of therapeutic activity; ward environment; patient mix; potential
for bullying or harassment; drug and alcohol misuse. Lack of regular access to fresh
air and to a peaceful environment may also contribute to disengagement from care
and absconding.

Episodes of unexplained or unauthorised absence from care and treatment may
serve to disrupt recovery and prevention of such episodes is considered an integral
component of risk management plans for all patients.

Section 18 of the Mental Health Act 1983 allows for the return of detained patients
who are absent without official leave. Every effort must be made to ensure that all
patients (and where appropriate carers) understand their rights under the MHA 1983
and the processes involved within Section 18. This can be achieved using the
following resources: approved translation services; advocacy; leaflets; large print
forms; visual aids; family/carer assistance (where appropriate) and support from the
equality and diversity team.

It is the responsibility of the healthcare professionals involved within the process of
Section 18 MHA 1983 to ensure that the patients’ right to equality, diversity, respect,
confidentiality and advocacy is maintained throughout.

2.0 Purpose
The purpose of this policy is to define the responsibilities and provide guidelines for
staff in relation to the appropriate identification, searching for, reporting of and
subsequent requirements for dealing with patients who go missing or absent without
official leave (AWOL).

3.0 Objectives
 Enable staff to act appropriately according to the legal status of the patient
 Enable staff to respond appropriately to the level of current risk
 Enable staff to provide appropriate services in the least restrictive manner
 Promote a collaborative approach with other organisations who may become
involved e.g. Police
 Highlight the need for staff to consider the cultural, spiritual and special needs
of the absent without leave patient or missing person
 Enable staff to adhere to the rights and principles outlined in the Mental Health
Act and the Police and Criminal Evidence Act

4.0 Process
Multidisciplinary Teams caring for inpatients with absconding histories or risk
assessed as at risk of absconding, are recommended to refer to Appendix 1 when
developing and implementing care plans in order to try and reduce incidents of
patients missing or absconding. Appendix 1 outlines good practice strategies that
can be adopted in clinical settings with patients presenting risk issues of absconding.
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4.1 When is a Patient Deemed to be Absent without Leave (AWOL)?
Patients are deemed to be AWOL if they:
 Are absent from hospital without official leave granted under Section 17 with the
RC’s authorisation
 Fail to return to hospital at the end of an authorised leave of absence
 If the patient is refusing to return from leave and has no intention to return after
the Responsible Consultant (RC) or out of hours on call RC has revoked the
leave and recalled [Community Treatment Order (CTO) patients] the patient to
hospital, the patient will be AWOL. CTO patient is not officially AWOL until they
have been given notice by the RC in writing of this (Appendix 2)
 Are absent without permission from the address where they have been given
leave
 Supervised Community Treatment (SCT) patients that have been recalled to
hospital and then abscond
 SCT patients that do not return to hospital when recalled
 When the patient is subject to detention under the requirements of The Mental
Health Act 1983 (Amended 2007) or Deprivation of Liberty safeguards and has
left without explicit and written permission of the Responsible Clinician

4.1.1 A patient who is not detained under the Mental Health Act who leaves hospital
without permission is classed as a missing patient

Patients will be considered missing in the following circumstances:
 If an informal patient considered to be 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, with capacity whereabouts are known, but they are refusing to
return to the ward and there is no immediate risk to themselves or other they are not
missing. In these circumstances staff should arrange a Multi-Disciplinary Team
(MDT) review to agree if discharge is appropriate. It’s important that community staff,
and/or friends and family are informed (where appropriate)

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.

4.2 Procedure for When a Patient Absents Themselves
Any member of staff, who becomes aware that a patient has gone absent without
official leave or is otherwise unaccounted for, should immediately inform the Nurse in
Charge of the patient’s ward. The Nurse in Charge implements the following
procedure (see Appendix 3 and Appendix 4).

4.2.1 Stage 1- Initial Search
The Nurse in Charge will instigate a log to provide a record of the searches to be
carried out. This will include details of the immediate area to be searched and by
whom as well as where the search is extended to other areas and to whom it has
been delegated. The log will provide a readymade record for the Nurse in Charge’s
subsequent report.

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The objective of an initial search is to confirm or otherwise that the patient is
physically missing from the confines of the building/ premises/ grounds.

Prior to commencing the local search staff must ensure that the safety of other
patients is maintained. They must also ensure that they maintain their own safety. A
search area may be specifically denoted as being unsuitable to be searched by a
lone member of staff. However, for all search areas due care and consideration
should be given to the time, weather, knowledge of the patient, to determine the level
of staff required to conduct a safe search. All completed searches must be
documented in the patients nursing notes on the day of the search and on the
Missing Person form if required by the police (see Appendix 5).

If the patient is not located, the Nurse in Charge must then contact other wards,
departments or services on the same site and asking for any sightings, times of
sightings and request that a similar, thorough search is undertaken within their
buildings/ areas in negotiations with other agencies. As indicated above the Nurse in
Charge will document all this in her log.

Please see Appendix 6 for Local Search Guidelines for Trust sites. The guides
ensure that the Nurse in Charge organises and delegates a thorough search of the
ward and other areas within the building, including any adjacent rooms, corridors,
cupboards, stairwells, pathways or roadways.

4.2.1.1 Action to be taken if the Patient is confirmed as Missing
Once the patient is confirmed as missing or unaccounted for; the Nurse in Charge
notifies the patient’s Consultant Psychiatrist/ Responsible Clinician or Medical Team,
(duty RC out of hours) whichever is most relevant, as soon as possible within
working hours. Out of hours the Manager on Call would be informed and the medical
team the next working day.

4.2.2 Stage 2 - Determine the Level of Risk
The Nurse in Charge undertakes a risk assessment of the situation. Risk
assessments inform and support any further decision-making.

The risk status of patients will vary in line with a number of factors and may alter over
time. It is therefore imperative that regular entries relating to the patient’s current risk
status are clearly documented within the patient’s risk assessment and associated
care planning records.

Risk factors are taken into account at all stages of a patient’s assessment and are
considered when admission to hospital or detention under the Act is proposed. Other
issues, such as impairment of memory or an inability to appreciate danger may be
factors to be included in on-going risk assessment.

For the purpose of determining what/ when to notify internal and external agencies
within these procedures the person in charge must ensure a clinical risk assessment
is completed at all times and documented within the patient’s case records.

NB: A missing patient’s risk category (High, Medium or Low) can alter whilst the
patient is absent without leave and all agencies must be informed of any decision to
alter their Risk Category.

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4.2.2.1 Engage with Key Stakeholders
If a patient goes missing or absent without official leave, the impact can be lessened
with good engagement with the main stakeholders in securing return, this can be
achieved by:
 Police / Ambulance / relatives (conveyance) depending on the level need/ risk.
 Ensuring informative protocols for absent without leave/ missing persons are in
place
 Ensuring relatives and carers are fully involved in the care team and the
process of their relative’s care needs at this time
 Ensuring a good working relationship with carers and relatives and ensuring
contact people and phone numbers are communicated
 Ensuring regular discussion and shared understandings of this policy translated
into practice with key staff for all relevant areas
 Ensuring all patients are offered access to an Occupational Therapy (OT)
assessment within three days of admission and repeated weekly if they initially
refuse

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
located and returned to the hospital.

4.2.2.2 Notifications
If appropriate, Attempts should be made to make contact with the patient via any
known contact details including friends and relatives (where appropriate) to establish
1) their location, 2) current risk factors, and wherever possible 3) organise
arrangements for the patients safe return to hospital.

The nearest relatives or next of kin should be informed immediately, unless there are
clear reasons for not doing so. If the relatives are not informed the reasons for this
decision should be clearly documented in the patient’s clinical records. They must be
kept up to date with any developments as well as offering reassurances where
required. Meanwhile the following formal notifications, by the person in charge, to
both internal and external agencies must be followed if the patient cannot be located:

Police - Where the risk assessment shows the patient to be a high risk or a medium
risk, as agreed by the Ward Team (which includes the Responsible Clinician or
consultant psychiatrist and the patient’s representative where relevant) the AWOL/
missing person should be reported to West Midlands police on 101 or 999 if urgent
(see Appendix 7). They should be reported either as ‘missing’ or ‘absent without
authorisation’ depending on the level of risk posed. All information should be entered
into the patients nursing notes and when required, onto the Missing Persons form
(Appendix 5) which the police may request a copy of.

The police will implement the West Midlands Police Management, Recording and
Investigation of Missing Persons (April 2012) for all AWOL/missing patients reported
to them as soon as they are notified. The police will want to know the time limit to
take or re-take patients to a hospital or particular place.

On receipt of the notification of a missing patient, the police (at their discretion) direct
an officer to attend the ward or unit from where the patient has been reported as
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missing. It needs to be noted that a missing person for the NHS may not be a
missing person for the police. They will bring a Missing Person record sheet with
them to complete with Trust staffs assistance and an incident number will be
provided.

The officer may wish to gain further details, including evidence that the patient is
formally detained under the Act.

The Nurse in Charge must ensure that they are able to provide full and detailed
information relating to the AWOL/ missing patient to the officer attending, and that the
Nurse has access to the patient’s case files to assist in the provision of this
information. The Nurse must ensure this information is ready prior to police arrival to
save time using Appendix 5 if required. Appendix 5.a details the risk based
questions the police may ask the caller.

The police will undertake their own risk assessment of the AWOL/ missing patient
and will act according to their internal procedures. The police risk assessment will be
based on the information provided by Trust staff and it is imperative that detailed
information is provided accurately and swiftly.

If the police locate the patient, they may either return the patient to hospital or inform
the appropriate Trust Manager of the patient’s whereabouts.

Where a patient who is liable to be detained is believed to be on premises to which
access has been refused, then an officer of the hospital can be authorised by the
Service Manager to apply to a justice of the peace for a warrant under 135(2).

The authorised member of staff will attend court (see Appendix 8). The warrant will
authorise any police constable to enter the premises, if need be by force, and remove
the patient. The constable may be accompanied by an officer of the hospital in the
execution of the warrant (see Appendix 9).

Relatives - The patient’s nearest relative (if detained or liable to be detained) must
be informed immediately that the patient is known to be absent without leave. A
telephone call may be the most appropriate method of contact for the nearest
relative, but alternative methods of contact, as preferred by the relative, must be
recorded in care plans/ CPA documentation and used by staff accordingly. There
may be times when it is impractical to notify the nearest relative immediately, but all
efforts must be made to inform the nearest relative within one hour after the patient’s
absence is known, in line with Appendix 7 guidance.

Contact details for the nearest relative and carer if appropriate should be established
on or shortly after the patient’s admission to hospital and a telephone number should
be recorded in the patient’s case records and be easily accessible.

For informal or voluntary patients, the next of kin and/ or a friend/ carer/ relative
previously identified by the patient should be notified immediately unless there are
sound reasons for not doing so. An example where it may not be appropriate to notify
the next of kin or others is where a voluntary patient has expressly stated that they
do not want their relatives to know their whereabouts and there are no assessed
risks.

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Contact details for the next of kin or others should be established as soon as
possible after the patient’s admission to hospital. Telephone number(s), or other
contact details, should be recorded in the patient’s case records and be easily
accessible. Contact preferences, outlined above should also be recorded and easily
accessible in the patient’s case records.

Responsible Clinician or Consultant Psychiatrist - The patients Responsible
Clinician or Consultant Psychiatrist should be informed immediately. This will also
ensure the home office is informed depending on the category of the detained
patient.

Governance Assurance - All AWOL’s /Missing persons have to be reported on
DATIX. Where the risk is classed as high or medium, this should be rated as an
amber/red incident and reported to the Governance Assurance Unit as soon as
possible.

Mental Health Act Office (detained patients) - Contact the Mental Health Act
Officer for all unauthorised absences (if you are using Datix, this will be done
automatically once you click submit).

Care Quality Commission - Care Quality Commission must be notified of all
AWOLs (detained patients) if they are resident in a PICU or secure ward within 24hrs
and if on a general psychiatric ward if they have been AWOL after midnight on the
day the AWOL commenced. The person in charge/ Ward Manager/ Team Leader will
be contacted to enable completion of the CQC form by the risk administrator who will
submit it to the Care Quality Commission on the Manager's behalf.

Ministry of Justice - The Ministry of Justice should be informed in relation to any
patients detained under restraining orders who go absent without official leave..

If the patient is deemed through assessment to be high-risk, consideration must be
given to alerting other Mental Health/Acute Trusts, this decision would be made by
the Multidisciplinary Team.

On-going contact with all of the above persons must be maintained whist the patient
is AWOL, if required continue to hold Care Programme Approach reviews to ensure
all involved are kept informed.

4.2.2.3 Out of Area
When a patient, who is liable to be detained, is located outside of the West Midlands,
the Service Manager or Manager on Call if out of hours, is delegated to act on behalf
of the Hospital Managers to authorise the detention of the patient at a local hospital
in writing. Such authority can be provided by fax. The Manager should also ensure
that the relevant clinical details are provided to the host hospital.

Where a detained patient is taken to another hospital, the Service Manager may
make arrangements for the return of the patient or delegate responsibility for
organising the patient’s return to the Nurse in Charge of the ward. The person
organising the return should ensure that the appropriate transport and escorts are
organised to collect the patient, usually within 3 days of receiving notification of their
whereabouts.

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