“Chris was known to abscond from secure mental health detention during periods of…”

The coroner’s concerns

Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions. (1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the leave was only to the adjacent car park, to facilitate a smoking break, and 1 member of staff accompanied up to 6 patients. The Trust's own Root Cause Analysis report confirms that the practise was at this time for 1 staff member to accompany those patients who wished to smoke to the adjacent carpark. (2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate. (3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?

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, 2023-0053

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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