“Need for clear information to be given by hospital staff wnen making the 999 call to…”

The coroner’s concerns

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- 1) Need for clear information to be given by hospital staff wnen making the 999 call to report a patient has gone AWOL in order to proactively answer the known risk questions and maximise the opportunity for police to take timely action to trace the patient within the golden hour. | heard from GE service Director, that when a 999 call is made relevant information would need to be drawn from several sources including the patient’s form (personal/physical details & photo), any signing in/out form (last known clothing) and latest risk assessments/plan with details of recent incidents that inform the risk assessment. Inevitably, when a patient goes missing the AWOL policy needs to be followed including internal and external searches; notification of relevant senior staff etc. At times of pressure such as these it would be advisable to have all the relevant information in one location for ease of access by the designated person who makes the call. 2) Langley Green to ensure that hospital CCTV is accessible at all times for police viewing. 3) Langley Green to consid amendment of current AWOL policy. This may be necessary given indication that he does not believe staff need to wait to have a discussion with clinical staff. 4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces. 5) Police to consider joint policy with Adult Safeguarding Board. 6) Police to consider equal response to informal as well as sectioned patients if guided by clinical staff of high risk. | heard from senior staff at Langley Green that there is a discernibly different response from police when the missing person is an informal patient rather than under a MHA order. In the latter case, often a blue light police car is immediately dispatched to the hospital and a room/locality search takes place. This is not the case with an informal patient yet the same high risk of self-harm or suicide or risk of causing injuries to others may exist. In other words, there seems to- be a general perception that informal patients are less unwell.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2018-0021

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0