Missing Patients Procedure
Missing Patients Procedure
10/06/2006
14/01/2014
29/01/2014
14/11/2015
V 1.0
Yes
14/01/ 2014
Charlie Scholes / Dr Nabila Muzaffar / Dr David Cumming /
Julia Ferrari / Caroline Gill, Barry Sneddon, Catriona
Cameron
Group Committee Specialist Mental Health Care Group
Mental Health Unit Management Team
Final Approval
This document can, on request, be made available in alternative formats
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Contents
1.0 Introduction..................................................................................................................4
2.0 Policy Statement ..........................................................................................................4
3.0 Scope ............................................................................................................................4
4.0 Flowchart......................................................................................................................5
5.0 Process.........................................................................................................................6
5.1 On Admission .............................................................................................................6
5.2 Missing Persons Action Plan (MPAP) created on admission .....................................6
5.3 Missing Person Coordinator .......................................................................................6
5.4 Person Identified as Missing Missing Persons Report Form ...................................6
5.5 Searching for Missing Person ....................................................................................6
5.5.1 Initial Search of Clinical Area ...............................................................................6
5.5.1.1 Forth Valley Royal Hospital Only ......................................................................7
5.5.2 Search of Acute and Community Hospital ...........................................................7
5.6 Initiate MPAP .............................................................................................................7
5.7 Contacting Police .......................................................................................................7
5.8 Contacting Managers .................................................................................................8
5.9 Contacting Informing Relatives / Named Person........................................................8
5.10 Contacting Other Agencies ......................................................................................8
5.11 Instruction for a Detained Patient with Restrictions (Mental Health, Criminal
Procedures)......................................................................................................................8
5.11.1 Notice of Incident Circular..................................................................................9
5.12 Offender Management Team ...................................................................................9
5.13 Patients detained under a specified section of Criminal Procedures (Scotland) Act
1995 .................................................................................................................................9
5.14 Returning to Hospital..............................................................................................10
6.0 Appendices ................................................................................................................12
6.1 Appendix A Missing Persons Action Plan (MPAP) ................................................12
6.2 Appendix B Missing Persons Report Form (MPRF) ..............................................13
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1.0 Introduction
In the event of a patient being missing, or absent without leave, the most important factor
is ensuring their safety and their safe return.
It is imperative that all communication is clear and concise and well documented. This will
ensure that all parties involved will have accurate information so that appropriate action
can be taken to facilitate the safe return of the missing patient.
2.0 Policy Statement
This policy is part of a suite of documents which aim to ensure NHS Forth Valley provides
safe, effective and person centred care and services.
This policy outlines how clinical services will respond to Missing Persons and links to the
other relevant policies are below:
3.0 Scope
This policy applies to:
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4.0 Flowchart
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5.0 Process
5.1 On Admission
All persons admitted will be risk assessed, this will include an assessment of the risk of
absconding, and this assessment will be documented in the paper / electronic case record
5.2 Missing Persons Action Plan (MPAP) created on admission
All patients being treated in clinical areas covered by this policy will have a Missing
Persons Action Plan (MPAP) (Appendix A) completed on their admission to document
what actions would be taken in the event of that patient being missing. This will be part of
their care record.
The MPAP will be based on the recorded level of risk assessed by the care team. When a
patient is found to be missing from a ward or department, the individuals MPAP must be
referred to, and will help determine the action to be taken.
It is the responsibility of the patients clinical team to ensure that the MPAP is documented
clearly as part of the patients treatment plan and recorded within their case notes.
Showing what action the care team has decided is necessary in such an event.
5.3 Missing Person Coordinator
The Nurse-in-Charge / Shift Co-ordinator will identify a member of the clinical team to coordinate the activities described in this procedure (missing patient coordinator). This duty
would normally be carried out by the Nurse-in-Charge / Shift Co-ordinator.
5.4 Person Identified as Missing Missing Persons Report Form
In deciding that a patient should be reported as missing or absent without leave, the
missing patient co-ordinator of the ward should take into account first-hand recorded
knowledge of the patient's agreed destination/known reason for time out of the ward along
with the time factor agreed with the patient for them to return to the ward.
The Missing Persons Report Form (Appendix B) should be completed.
This will be used, is a communication aid that will ensure consistency of information, and
will be held in the patients current records.
5.5 Searching for Missing Person
5.5.1 Initial Search of Clinical Area
The Missing Person Co-ordinator should attempt to contact the patient by use of their
mobile phone number if available or contact details as noted in the patient record.
A search of the clinical area and hospital grounds should be carried out by nursing staff
from the ward / department the patient is missing from. The number of staff searching will
be determined by known risk factors on an individual basis. At this time the missing
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person co-ordinator should consider phoning the patient's next of kin / named person as
part of the initial search process.
The nature of the search required will be determined by the level of risk assessed and
identified to protect the safety of the missing person, patients, the public and staff.
The search process will include an open door search, i.e. that all doors should be opened
during any search, not just into rooms but any cupboards or areas where a person could
gain access and hide. A link to the safety and security in hospitals section of the Mental
Health (Care and Treatment) (Scotland) Act 2003 can be found below to give more
information on search powers:
http://www.legislation.gov.uk/asp/2003/13/section/286
NB: If someone goes missing during the night it is the responsibility of the team coordinator to assess the level of risk involved before carrying out a search of local grounds.
It may be appropriate to contact the police immediately for assistance.
5.5.1.1 Forth Valley Royal Hospital Only
As soon as there is any concern that a patient is missing clinical staff will contact SERCO
security department immediately asking for assistance from their CCTV network operators.
SERCO should be provided with a physical description of the missing person, what the
missing person was wearing and, if seen, in which direction they were travelling.
Serco Security Office Contact Number ext. 67892 (01324 567892)
5.5.2 Search of Acute and Community Hospital
Please restrict the search to common public areas of the hospitals. If a search of other
clinical areas out with the ward / department the patient is missing from is essential. Liaise
with duty Clinical Nurse Manager (CNM) for advice and assistance to ensure that
disturbance to other patients is kept to a minimal.
5.6 Initiate MPAP
If the patient cannot be found in the immediate area of the ward/department and hospital
grounds, the missing person co-ordinator will initiate the directions in the Missing Persons
Action Plan.
5.7 Contacting Police
The police will then be contacted as well as the other identified individual's listed on the
communication summary in the "Missing Persons Report Form" (Appendix B) taking into
account any additional information recorded on the MPAP.
The information recorded on the "Missing Persons Report Form" will be referred to in the
event of the Police being notified, a copy can be given to the attending Police Officers to
assist in the reporting of the incident. During the initial information gathering of reporting a
patient missing it is appropriate to supply a copy of the patients Risk Assessment. The
Missing Persons Report Form will also be used to pass on relevant information at the ward
report, during the nursing staff shift changeover.
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The Missing Person co-ordinator will be the point of contact for the Police Division and will
liaise directly with the Police. At this time the co-ordinator will fully explain the urgency of
the situation according to the level of assessed risk identified for the missing person.
Contact Central Scotland Police Service Centre. 01786 456000
5.8 Contacting Managers
During the hours of 0900 to 1700 Monday to Friday the CNM / SM should be informed of
the missing person and any associated risk/concerns. Out with these hours and public
holidays, the On-Call Manager will be informed.
The CN / CNM / SM will be informed of the missing person and may then contact the
Service Manager or General Manager if it has been identified that the missing person is a
severe risk to themselves or others.
5.9 Contacting Informing Relatives / Named Person
Relatives and/or the named person should be informed as soon as possible giving details
of the circumstances leading up to the patient being declared missing, subsequent action
taken and immediate plans.
Clinical staff will at this time ask the relatives / named person to contact the clinical area if
the missing patient makes contact with them.
5.10 Contacting Other Agencies
Where a patient is known to other essential services e.g. Social Work, Supported
Accommodation, contact should be made with these services to determine if any contact
with the missing person and any information on possible locations. These conversations
will be documented in the Missing Persons Reporting Form.
5.11 Instruction for a Detained Patient with Restrictions (Mental Health, Criminal
Procedures)
In the event that a patient absconds when detained with restrictions, this includes service
users detained under:
Section 52 D
Section 52 M
57a Compulsion Order
54 (assessment order)
52M Treatment Order
59 Restriction Order
S136 transfer for treatment direction (TTD)
of the Criminal Procedures (Scotland) Act 1995, it is the RMO's responsibility to report all
incidents to the Scottish Government and the Mental Welfare Commission, and best
practice would indicate also informing the designated Mental Health Officer.
Reportable incidents are outlined by the Mental Welfare commission here:
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http://www.mwcscot.org.uk/media/100310/notifying_the_commission.pdf
Hospital authorities must advise the police immediately of an escape, serious assault,
abscond or other serious incident involving a restricted patient. Immediately there after, the
Responsible Medical Officer (RMO), or duty RMO should make a telephone report to the
Scotland Government Health Directorate (SGHD).
5.11.1 Notice of Incident Circular
All contact numbers including Out of hours' telephone and pager numbers for SGHD
officials are given and are held on the ward where the patient is being cared for. These
should be used to contact officials between the hours of 5pm and 8.30am, on weekends
and public holidays.
Where, exceptionally, no contact can be made with an official, a message may be left with
the Security Guards at the Scottish Government main phone number, Victoria Quay.
Security will relay the message to an official as soon as possible. Please note that on no
account should patient details be left as part of such a message.
Main Scottish Government phone number - 0131 556 8400
For further information on this section:
www.scotland.gov.uk/Publications/2010/06/04095331/17
5.12 Offender Management Team
It is essential that if any patient is on enhanced Care Programme Approach and is being
managed under Multi-Agency Public Protection Arrangements. The Offender Management
Team is informed by nursing staff immediately someone is suspected of being missing.
Offender Management Team Phone Number: 01324 574920
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guidance for return to clinical areas will be documented in the Missing Person Action Plan
with instruction on who requires to be contacted in the event of the patient going missing.
A patient detained under the Mental Health (Care and Treatment) (Scotland) 2003 Act may
be taken into police custody anywhere in the United Kingdom and returned to Scotland
(Section 290 1C Mental Health (Care & Treatment) (Scotland) 2003 Act.
5.14 Returning to Hospital
When the patient's whereabouts are eventually known, the co-ordinator will, if necessary,
make arrangements for the return of the patient, having due consideration to their current
legal status, defined under the Mental Health and Criminal Procedure Acts. This would
include arranging the appropriate level of escorting staff, requesting an ambulance or
liaising with the Police Service for return of the missing person. If there are difficulties
arranging transport to return a patient to hospital advice can be requested from the CNM.
There may be times when the relatives, named person or friend may offer to return the
missing patient to hospital. This will be assessed by the clinical team taking into
consideration the Missing Person's Action Plan.
Where available, if using hospital transport there has to be one driver and a two nurse
escort with one being a 1st level registered nurse. If requesting an ambulance to transport
the escorting nurses and the patient back to hospital it will be two members of the nursing
team as above. The number of staff involved will be determined by known risk factors on
an individual basis.
Depending on the physical wellbeing of the person, it may be necessary to request
ambulance assistance in returning the patient to hospital; it may be considered that an
assessment at Accident and Emergency is required before returning to the clinical area.
The escorting staff will have to assess the level of risk this way have on the safety of the
patient and staff and the risk of further absconding.
If an informal patient refuses to return to the ward the Responsible Medical Officer/Doctor
should be informed immediately. If there is no clear guidance in the Missing Patient Action
Plan, the decision on what action to be taken next will be the responsibility of the RMO.
When a missing patient is returned, the missing person co-ordinator will inform the
individuals and agencies that had been notified of the patients absence and recorded this
on the Missing Persons Reporting Form (Appendix B). In all cases, due regard should be
paid to the time of return, in respect of possible unnecessary disturbance of
relatives/others, during the night.
An initial assessment of the patients physical, mental and legal status will be undertaken
by the clinical team. Information from the assessment will be recorded in clinical notes and
an Incident Record completed (IR 1 Form). Any relevant information reported back from
the escorting staff pertaining to where the patient had been who they had visited and /or
any incidents during the escort will be recorded in the clinical notes and on Missing
Persons Reporting Form (Appendix B).
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6.0 Appendices
6.1 Appendix A Missing Persons Action Plan (MPAP)
MISSING PERSON ACTION PLAN
Consultant
Legal Status
Category / problem
Inpatient Service
Name
DOB / CHI
Address
Action plan
Review Date
Absconds / Wanders
from ward
Inpatient Service
Absconds whilst
being escorted /
accompanied / home
leave
Inpatient Service
Fails to return by
agreed time
Previously
Absconded?
Date Written
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Yes
No
Date
If Yes, where
found?
Signed
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UNCONTROLLED WHEN PRINTED
Signature
Signature
CHI Number
Consultant
Date
Time
Date of Birth
Height
Build
Colour of Eyes
Yes
No
Spectacles
Yes
Time
Place
No
Date
5. Conditions causing concerns (i.e. Nursing Alerts from Nursing Profile, Learning
Difficulties, Vulnerability)
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No
Yes
No
9. Copy of missing
persons form to police
Yes
No
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Initial
Report of
Name of
Date /
Return /
Person
Time
Discharged Contacted
Charge
Nurse
CNM / SM
RMO /
Doctor
Police 01786
456000
Serco
Security
Office 01324
567891
NOK /
Named
Person
GP
Social Work
MAPPA
Provision
Offender
Management
Team
(MAPPA /
CORO)
Restricted
patients
contacted
Scottish
Government
Date
Initial
13. Comments (to include information received by nurse in charge from patient, Police or
other person on return of patient)
Signature
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Date
Time
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