ABSENT WITHOUT LEAVE POLICY

Version: 1.2
Ratified by: Quality Committee
Date ratified: September 2014
Name of originator/author: Edwin Ndlovu – Borough Lead Nurse
Name of responsible committee/individual: Quality Committee
Circulated to: Quality Committee
Date issued: September 2014
Reviewed by:D Njovana November 2019
Next Review Date; November 2022
Target audience: Clinical staff

Services Applicable

Trustwide X

Mental Health and LD

Community Health Services

1
 Version Control Summary

Version Date Status Comments/ Changes

1.0 September 2014 Draft New policy drafted in line with
the Pan-London Mental health
Partnership board.

1.1 September 2014 Final Name change from “Missing and

Absent Without Leave Policy to
Absent Without Leave Policy”

1.2 September 2022 Minor update to include

reference to the Use of Force Act

2
 CONTENTS

Section Title Page No.

1 Executive Summary 4
2 Introduction 5
3 Process to be followed when detained patient is missing 6
4 Process for absconding from hospital wards 7
5 Determination of Risk 8
6 Section 135(2) 8
7 Debriefing 9

Appendices

1 Missing Persons Information Pack 11

2 Low Risk Patients Flowchart 12
3 Medium/High Risk Patients Flowchart 13
4 Missing persons alert 14
5 Standardized Response to AWOL patients 18

3
 EXECUTIVE SUMMARY

Missing and Absent Without Leave (AWOL) Policy

• The safety of patients is at time a multi-agency task and this usually is between the
East London NHS Foundation Trust and the London Metropolitan Police.
• It is a requirement by the Mental Health Code of Practice 1983 and it applies to all
patient including those detained under the mental health act.
• To provide guidance to managers and staff regarding duties, responsibilities and actions
to be taken when a patient is absent without leave or missing.
• Describes the procedures to be followed by managers and staff upon a patient’s
admission and by managers and staff and the Metropolitan Police should a patient
go absent or is not where they are supposed to be.
• Outlines the procedure to be followed when a patient absent without leave is
located.

4
1.0 Introduction and Purpose of this policy
This policy describes procedures to be adopted and the role and responsibilities of both East
London NHS Foundation Trust and the London Metropolitan Police in the event of a patient
going missing from Hospital or other Trust Healthcare setting. The policy applies to both
informal patients and those detained under the Mental Health Act 1983. The policy was
developed in line with the London-wide Mental Health Partnership Board guidance on
Responding to AWOL Action Plan (2013). The aim of the Action Plan is to direct efforts on the
following activities to manager absconders in a productive way against a back of reducing
resources:
• The reduction of absconding from wards.
• Reduction of time spent by ward staff and the Police in gathering information that is
needed to locate a patient.
• The eradication of old practices that do not work.
• The development of existing protocols and procedures to reflect national standards for
Mental
Health Trust and the
Police.
• The development of a uniform approach across all London based Trusts to ensure
good practice is shared amongst Trusts.
• The development of a pro-active approach to tackling absconding behavior between
local wards and the local Police.
The Local Security Management Specialist (LSMS) is the designated “Single Point of Contact”
with the Police. Each Service/Directorate will have a named Modern Matron who will work with
the LSMS and the Police at a more local level together to discuss the problem profile and
solutions. This will be done through the local borough Police and Ambulance Liaison Meetings.

1.2 The policy is intended to help provide safe practice in the management of patients who are
missing or absent without leave based on their risk assessment.
This policy should be read in conjunction with the following Trust
policies:
 Admission and Discharge Policy
 Observation Policy
 Clinical Risk Assessment Policy
 Trust Incident Reporting Policy
 Record Keeping Policy
 Care Programme Approach Policy
 Leave’ for Informal Patients Policy
 Supervised Community Treatment Policy
 Safe Guarding Policies for Adults and Children
 Secure services policy and procedures on managing the absconding or escape of an
in-patient.
 Use of Force Act Policy

1.3 Negotiated time off the ward or to go on leave is an integral part of a patient’s care plan
designed to prepare and assess their suitability for discharge. The conditions of their leave are
discussed with the patient and a time agreed for their return to the ward. However occasionally
a patient will not return from leave or will stay away from the ward without permission. Within
reason, nursing staff should be aware of the whereabouts of each patient at all times. The
procedures set out in this document are designed to clarify the process for reporting patients who
are either missing from the ward/clinical area who have not returned from an agreed period of
leave.

2.0 Definitions
For patients detained under the Mental Health Act AWOL is divided into two
categories:
missing patient must discuss this with the Caldecott Guardian as to whether the disclosure of

7
 • Failure of a patient to return from a period of authorised Section 17 leave, this will
include a patient absenting themselves during a period of escorted authorised Section
17 leave (absconding).
• A detained patient absenting themselves from hospital (absconding).

3.0 Process to be followed when a detained patient is not where they are
supposed to be.
Patients detained under the Mental health Act are expected to comply with the conditions of
Section 17 leave at all times. In patient wards must stress to all detained patients the importance
of adhering to the agreed section 17 leave conditions by returning back punctually from their
leave and support the patients to comply with this expectation. Each case where a patient returns
late from unescorted section 17 leave the reasons must be established and the appropriate
documentation competed. Discussion with the patient must take place to ensure that non-
compliance with the section 17 leave does not occur again and the results of this discussion must
be documented in the patient progress notes to ensure that they are considered in subsequent
risk assessment and management.
There will be cases where patients repeatedly return late from their section 17 leave or
breach other conditions of their section 17 leave e.g. alcohol or drug use whilst out on
unescorted leave. In such instances the section 17 leave would need to be reviewed with the
option to suspend the leave considered.

4.0 When a detained patient absents him or herself from hospital (Abscond).
If a patient is found to be missing, staff must initiate the agreed protocol set out in appendix
1a and 1b. The overriding principles are:
• Staff must confirm that the patient is in fact missing. Judgment must be used by the
MDT to decide when a patient is actually considered to be AWOL e.g. a patient who
is an hour late returning from leave may not be classed as AWOL: the same patient
who two or three hours later contacted by staff but is no home may be considered
AWOL.
• Once it is established that a patient is not where they are supposed to be or they are
AWOL an immediate and thorough search of the ward area and common areas in
the building and immediate area around the hospital/unit.
• Consider what, if any, risk his or her absence poses to either him/herself or others.
• Consider whether to call the Police or others to assist in locating the patient and
complete The Missing Person Information Pack (Appendix 1)
• Consider what action should be taken when the patient is located.
• If the patient is detained under the Mental Health Act, consider how the patient
should be returned to the hospital or clinical area.

4.1 Determination of Risk (Hospital Staff make Decision on Level

Risk)
Once it has been confirmed that patient has gone AWOL the nurse in charge of the ward at
the time in conjunction with others must decide whether the risks presented by the patient
are high, medium or Low. In order to make this decision the nurse in charge must refer to
the criteria in the table below if Police assistance in locating and returning the patient back to
hospital will be required. This criteria was developed by the Association of Chief Police Officers
Risk Assessment. It is important to note that just because a patient is detained under the Mental
Health Act does in itself indicate medium or high risk.

Low Risk: There is no apparent threat or danger to either subject or the public
Medium Risk: The risk posed is likely to place the subject in danger or they are a
threat to themselves or others
missing patient must discuss this with the Caldecott Guardian as to whether the disclosure of

7
 High Risk : The risk posed is immediate is immediate and there are substantial
grounds for believing that the subject is in danger because of their own
vulnerability or mental state, or the risk posed is immediate and there
are substantial grounds for believing that the public is in danger through the
subjects mental state.
Before hospital staff contact the Police to report an absconding patient, they will need to
ensure the standardised response to AWOL patients has been followed. Appendix 5….

4.2 Low Risk

Hospital staff will attempt to locate patient and return within specified time limit.
If it is determined that the service user is of low risk, the minimum response which will be
provided will be as follows:
• Immediate search of the ward, unit and hospital grounds.
• If the patient is detained under the Mental Health Act, inform the Mental Health Act
Admin that the patient is AWOL and complete a Datix incident report.
• Inform the patient’s family, relative and/or friends and also enquire from them if they
have seen the patient, if the patient has returned to the home or is with them. The
family and friends must be kept informed of all actions taken by the Ward during the
period the patient is missing. It is important to consider the risk to children at this stage.
This may relate to the patient’s own children or others that the patient may come into
contact with. In the event that of increased risk to children the Trust Safe Guarding
childre4n policy and procedure must use to determine the appropriate level of action.
• Inform the Community Mental Health Team and other involved agencies. Seek their
help in locating the patient and returning them to the ward. This collaborative working
may also include discussion around who may be best placed to do this including the
decision to use Section 135 (2) and who should obtain the warrant.
• The risk status of the patient is to be periodically reviewed by the hospital as this may
change due to factors such as length of time without taking medication or their
vulnerability. If the risk level changes to medium or high risk then contact Police control
room.

There will be circumstances where it may be possible for the missing patient to come into
contact with medical or psychiatric services in other organisations. Consideration should be
given to disclose information to other Trusts. In order to work within the law the MDT
responsible for the care of the missing patient must discuss this with the Caldecott Guardian
as to whether the disclosure of information should take place.

4.3 Medium or high

Risk
Some patients will automatically become high risk if they are missing. These include vulnerable
adults, older people especially those who may be confused, children, suicidal patients, and those
with long term physical health problems that may require medication or may rapidly deteriorate
due to adverse weather conditions.

There are additional responsibilities for patient who are detained under the particular forensic
sections which will require the Ministry of Justice involvement.
If a missing patient is assessed as being either medium or high risk, the nurse in charge of the
ward will notify the Police control room immediately and will arrange for an officer to attend the
hospital to take details (Grab Pack - Appendix 1) for a Merlin Report and Police Risk
Assessment.

The Nurse in charge must ensure that missing person’s information pack (Grab Pack) is
completed and given to the Police to assist with the search for the missing patient. A copy of
the form must be kept on the ward with the patient’s records.
The Grab Pack will contain the following
missing patient must discuss this with the Caldecott Guardian as to whether the disclosure of

7
information:
• A description of the person in line with the Police Merlin documentation. Where
applicable a recent photograph of the patient, in the Forensic services this may be a
mandatory expectation.
• The most recent multi-disciplinary risk assessment name and dosage of any
medication the
patient may require preserving life as opposed to improving the quality
of life.
• The name and dosage of any medication along with the predicted or anticipated effect
of failing to receive it.
• Any physical inability to interact with others or diagnosed medical condition
linked to
vulnerability, e.g. visual impairment,
Alzheimer’s
• Any other factor(s) or circumstances which may affect the risk assessment of the
missing person.

There will be circumstances whereby particular people (family member or others) are known to
be at risk because of the patient being AWOL. In such circumstances urgent consideration
must be given to managing potential and actual risk using the patient’s risk plan to inform the
appropriate response. In such situations the Police will need to have a role in responding to such
risks.

The multi-disciplinary team responsible for the patients care must advise the Police about the
extent to which the patient’s absence may present a risk to the patient and / or others in order to
inform the Police decision about whether and at what stage to issue a missing patient alert to
the public via the media. At this stage, the Trust Communication and Public Relations
Department need to be advised and involved in cases where a patient’s unauthorized absence
may likely generate public concern (e.g. a Medium Secure Services patient failing to return from
leave).

There will be circumstances where it may be possible for the missing patient to come into
contact with medical or psychiatric services in other organisations. Consideration should be
given to disclose information to other Trusts. In order to work within the law the MDT
responsible for the care of the

missing patient must discuss this with the Caldecott Guardian as to whether the disclosure of

7
information should take place (Appendix
4.)
A Datix Incident From must be completed within four hours. A Datix report should be
completed even of the patient returns with four hours.

5.0 Police Decision on Risk Assessment.

Once it has been reported to the Police that a patient is missing, the Police will carry out their
own risk assessment based on the information provided by the Trust. The criteria they use is
described in above in paragraph 4.1. The Police will also conduct any enquiries necessary and
inform their supervisor and the Trust of their actions.

6.0 Reporting of AWOL to Mental Health Act Offices and the CQC
For any detained patient it is important that the correct procedures are followed for involving
both the
MHA offices and the CQC in reporting patient who are AWOL and if and when they
return.

7.0 Reporting to Mental Health Offices and Incident reporting

In all occurrences where a detained patient is AWOL the following procedures need to be
followed:
• The nurse in charge of the ward from where the patient is missing must ensure a Datix
Incident report has been completed.
• The nurse in charge of the ward at the time of the detection that the patient is
missing must
notify the MHA office that the patient is
AWOL.

8.0 Reporting of AWOL patient to the CQC.

There are statutory requirements to report cases of AWOL to the
CQC.
Incidents of AWOL from PICUs and Forensic Units at any time must always be reported to
the CQC.
For patient admitted to other units, any cases where a patient is AWOL and has not
returned by midnight of the day of the report must be reported to the CQC.

9.0 Trust and Police Collaboration (Patient Return)

A preliminary risk assessment should be conducted to help determine whether Police
assistance is needed. A number of factors need to be considered namely:
• The potential or actual mental state of the patient.
• Reasons or motives for why the patient absconded.
• Recent nursing observations
• Risk history
• Any other relevant information.

A joint action plan between the Police and Trust staff must be drawn up outlining how the patient
will be safely returned back to hospital. The Trust as the detaining authority, are responsible for
the return of patients absent without leave and should seek assistance from other professionals
and services in accordance with the presenting risk and circumstances. Police are not expected
to deal with the return of the patient on their own. There is an expectation that a minimum level
of hospital resources will be available for the joint work of locating and returning the missing
patient to hospital. The issue of arranging transport for the patient’s safe return and the
associated costs is the responsibility of the Trust.
The plan of returning a missing patient back to hospital if appropriate should consider the
following:
9
 • Should the patient be returned to the clinical area they absconded from or should a more
or less secure environment be considered due to potential changes in the patient’s mental
state.
• If there are concerns that the missing patient poses a danger to the public the Police
and the patient in-patient MDT or CMHT should consider referring the patient to the Multi-
Agency Public Protection Panel (MAPPP).

10.0 Section 135(2)

An application for a warrant under Section 135(2) should be applied for
where Someone who is detained under the MHA is AWOL, has been
located but refuses to allow staff access to them
• someone who is subject to Supervised Community Treatment has been recalled to
hospital but refuses to allow staff access to them or return to the hospital
Section 135(2) enables a Police constable to enter (if necessary by force) the place where the
patient is staying and return them to the place where they ought to be. It is good practice for a
suitably qualified and experienced mental health professional who knows the patient to
accompany the Police when they exercise the warrant.

Where community patients subject to Supervised Community Treatment (SCT) have been
recalled to hospital and failed to return to the hospital to which they have been recalled, it will
be the role of the Responsible Clinician and the Care -coordinator to organise their return. They
may be supported by the Police, where a risk assessment indicates that this is required or
wherever a warrant under Section135 (2) MHA needs to be executed to gain entry to a premises.

11.0 Assessment on Return to Hospital.

Once returned to hospital the patient should be reviewed by the nurse in charge as soon as
possible. In majority of cases especially those detained under a section of the mental act an
assessment by the ward doctor or duty doctor should be carried out. The assessment should
reflect the following aspects:
• Current mental state
• Time without medication
• Current level of risk.
• Level of observation required.
• Specific care needs, e.g. PICU, suspending further leave etc.
• In circumstances involving high risk patients, has a Datix been completed to prompt
a SUI
review.

All information acquired during this assessment must then be used to inform/formulate the
assessment of future risk and any changes to the care plan that may be required.

12.0 Time Limits

The Mental Health Act has stipulated times for returning patient to
hospital:
• A patient who has absconded may be taken into custody for up to six months after
going absent or until the expiry date of the current period of detention.
• Patients subject to short term Section of the mental Health act 1983 i.e. section 2,
section 4,
section 5(2) and section 5(4) cannot be retaken once the period of detention has
expired.

13.0 Patients who leave the United Kingdom while absent or AWOL.
• Patients who are liable for detention and who are AWOL and are found in Scotland,
Wales, Northern Ireland, the Channel Islands, and the Isle of Man can be retaken and

10
 held in custody whilst awaiting to be returned to the Trust. This is accordance with
section 88 and section 138 of the Mental Health Act 1983.
Patients who go outside the UK are not detained under the Mental Health Act while abroad and
there is no power to return them.

14 Debriefing, Learning and Prevention

Upon return the patient’s return to hospital a debriefing with the patient and a discussion relating
to the patient absconding or not returning from leave within the agreed time will need to take
place. The purpose of the meeting will assist the MDT to understand:
• The patient’s rationale for absconding or not returning within the agreed time frame.
• To review practices within the clinical area in analysing how this event could have been
avoided.
• Review the interagency working procedures between services involved e.g. Police,
Trust stuff etc.
• To identify lessons in order to reduce or prevent similar events from reoccurring and to
adjust
practices and procedures.

11
Appendix 1 – “Grab Pack”
Missing Persons Information Pack

“ Grab Pack”

Information to be given to the Police in the event of a service user, who is assess as being of either
Medium or High risk and is missing from the

ward. Please retain a copy of this form in the

case notes.

Name of person completing this form:

Telephone No: Time & Date of completion:

Surname: Gender:

First Name: Date of Birth:

Preferred Name/Alias: Religion:

Title: Ethnicity:

Preferred Language:
LEGAL
STATUS
Address:
Section:

Subject to supervised Community

Treatment:
Post Code: YES / NO

Telephone Number: Ministry of Justice Restriction:

Mobile Number: YES / NO

Main Carer/Next of Kin: Statutory Supervision by the Probation

Service
Relationship: YES / NO

Address:

Post Code: Ward:

Telephone No: Consultant:

Telephone No:
Other Key People
Name of CMHT & Care
service user will be
Coordinator:
in contact with:

12
Contact Details: Contact Details:

1. Description of Service User

i. In case of Forensic/Medium or High Risk patients, attach
photograph if available.
ii. Please include height, build, complexion, hair colour, distinguishing
marks to make decision as specific as possible.

13
2. Summary of Risk Assessment
i. Please attach latest risk assessment with specific details about
risk to self/others.
ii. Where relevant, include certain information (e.g. forensic
history/convictions/incidents within the last 24/48
hours/vulnerability).

3. Essential Medication and Treatment required in order to preserve

mental state i. Name and dosage
ii. Predicted or anticipated effects if not taken (include timescales for
predicted or
anticipated effects).

4. Description of any physical disabilities or diagnosed medical conditions e.g.

Diabetes, Alzheimer’s.

14
5. Any other factors or circumstance about the missing person which may
affect the risk of
Police risk assessment.
i. Please specify specific issues e.g. forensic history, carrying
weapons, past use of illicit substances.
ii. Any other information which might assist Police in directing their
search e.g. fascination with railways, liking takeaway food from a
particular shop, always wears a red jacket and black woolly hat,
said she wants to see Mamma Mia on stage.

15
 Appendix 2 – Flowchart A
Flowchart Missing / AWOL Service Users

Low Risk Patients

(Applicable for both missing informal patients and AWOL detained

patients)

1. Patient not where he/she ought to be.

2. Hospital staff conduct immediate search of the wards and grounds.

3. Hospital staff carry out and document risk assessment.

4. Low Risk. Hospital staff attempt to locate patient and 4a. Team debrief and learn
return within specified time limit. lessons.

5. Complete DATIX form. For detained patients,

contact CQC and Mental Health Act Office.

6. Inform family/relatives and Carer.

8. Report to Police if still missing after 4 hours.

9. Re-assess level of risk and follow procedures 10

– 21 if appropriate. Refer to Appendix 3

16
 Appendix 3 – Flowchart B
Flowchart Missing / AWOL Service Users

Medium/High Risk Patients

(Applicable for both missing informal patients and AWOL detained

patients)

Follow procedure 1 – 3. Inform Mental Complete DATIX form. For

Health Unit of detained patients, contact
Ministry of Justice CQC. For reporting
when a restricted requirements, see Policy.
10. Report the service user patient goes
missing to the Police. missing.

12. Police carry out

risk assessment.
11. Staff complete Missing
Persons Information Pack and
pass to the Police.

14. If patient is not found,

consider referral to MAPPA.
13. Police and Hospital staff
develops and document a
joint action plan.
16. Encourage patient to return
under own free will OR return
with ambulance and Police as a
15. Patient located before last resort.
section expires.

18. If patient is not found,

17. Patient refuses to return consider referral to MAPPA.
to
Hospital.

20. Assess risks and

appropriate care needs.
19. Consider use of section
Ensure joint planning
135(2) and apply to Magistrates
court for warrant. procedure in place to convey
patient safely back to Hospital.

21. Mental Health

Team debrief Unit of Ministry of Notify Mental Health
together and Justice to be Office.
learn lessons. informed of return
of restricted
patients.
18
Appendix 4 – Missing Person Alert

MISSING PERSON ALERT

SURNAME:

FORENAME:

ALIAS:

Date of Birth:

Physical Description:

Height:

Ethnicity:

Build:

Eye Colour:

Hair, Colour and Style:

Any Distinguishing Features:

Additional Information:

Known Risks:

Medication:

18
Mental Health Act Status:

Any recent episodes of absconding that might help establish links to whereabouts of missing
person:

Team contact Details if person located:

Address:

Telephone number

Email:

PLEASE DESTROY 7 DAYS FROM RECEIPT (PHYSICALLY OR

ELECTRONICALLY)

18
Appendix 5 – Standardised Response to AWOL Patients

Before the member of ward staff reports an absconding patient to the Police, they will first
ensure that the following 5 steps have been taken

1. That a search of the hospital and ground in accordance with a standard search plan
previously prepared by the Hospital security management has been carried out – recording on
the Police AWOL grab pack the date, time and full name of the staff member who carried out the
search.
2. That telephone calls to the absconding patient, carers and care coordinator, relatives and
friends have been make and that enquires have been made of other patients on the ward. The
name of the member of staff who undertook these enquires and the date and time to be
recorded on the Police AWOL grab pack.
3. That a member of ward staff has reviewed the circumstances of the absconding patient against
the 10 questions under the heading “Absconder Classification” below and recorded on the
Police AWOL grab pack the classification that they believe is most suitable (either “missing” or
“absent”).
4. That the minimum information recorded in (Standardised response - Police AWOL grab pack)
has been prepared and is immediately available for handing to or emailing to the Police at the
time of reporting.
5. That the outcome of a risk assessment covering the risks of self-harm, harm from others and
risks of
harm to others is either Medium or
High.

Absconder
Classification

1. What is the specific concern in this instance?

2. What has been done so far to trace this individual?
3. Is this significantly out of character?
4. Are there any specific medical needs?
5. Are they likely to be subjected to crime?
6. Are they likely to become a victim of abuse?
7. Are they currently at risk to sexual exploitation?
8. Are they likely to attempt suicide?
9. Do they pose a danger to other people?
10. Is there any other information relevant to their absence?

Following a review of the questions above, the ember of ward staff who calls the Police will record the
patient as missing or absent according to which of the following definitions best fits the circumstances.

Missing – “Anyone who’s 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 another.”

Absent – “A person not at a place where they are expected or required

to be.”

18