Missing Adult Patients - Procedure for the Management of Missing Adult Patients - a Joint Protocol between LTHT and West Yorkshire Police
|Next review: 11/03/2023|
Supported by: Trust Clinical Guidelines Group
Approved By: Executive Team
|Copyright© Leeds Teaching Hospitals NHS Trust 2021|
This Clinical Protocol is intended for use by healthcare professionals within Leeds unless otherwise stated.
Management of missing adults procedure
- Procedure to be Followed
- Key Principles
- Duties within the Organisation
- Roles and Responsibilities
- Link to other Documents
- Monitoring Arrangements
- Appendix 1: Management of Missing Adult Patients Protocol: A joint protocol between LTHT and West Yorkshire Police
- Appendix 2: Quick Guide Flow Chart
- Appendix 3: Risk Assessment Tool
Leeds Teaching Hospitals NHS Trust (LTHT) has a duty of care for the safety of its patients. This procedure is designed to protect patients who could come to harm if they went missing from LTHT patient areas. It highlights the responsibilities of LTHT and Police personnel along with the need to undertake formal risk assessments and escalate concerns about potentially vulnerable patients.
The Procedure is broken down into the following categories: purpose, scope and the procedure to be followed and the roles and responsibilities of all staff working at LTHT in managing patients missing or at risk of absconding from the LTHT patient areas.
This procedure is designed to protect patients who could come to harm if they were to go missing from the LTHT patient areas. This procedure is aimed at all LTHT healthcare workers.
The procedure applies to all areas within LTHT where there is a potential risk of patients being absent from clinical areas.
NHS: National Health Service
LTHT: Leeds Teaching Hospitals Trust
DoLS: Deprivation of Liberty Safeguards
CSU: Clinical Service Unit
CPN: Community Psychiatric Nurse
CLIC: Connecting Leaders in Care
PPSS: Professional Practice Standards & Safety Team
NSA: Nursing Specialist Assessment
ED: Emergency Department
MISPER: Missing Person
NAR: No Apparent Risk
NMC: Nursing & Midwifery Council
GMC: General Medical Council
MHA: Mental Health Act
HoN: Head of Nursing
ADOp: Associate Director of Operations
Missing person: Is defined broadly as a person whose whereabouts is unknown. The national Police definition of missing persons is anyone whose whereabouts cannot be established will be considered as missing until located, and their well-being or otherwise confirmed. (College of Policing, 2020)
Patient: An NHS patient is defined as a person receiving care or treatment under the NHS Act.
Missing patient: Will be defined as a person who has been receiving care or treatment under the NHS Act and who has left the NHS premises without going through normal leave or discharge processes and whose whereabouts is unknown.
Adults at Risk: Adults at risk are those aged 18 years or over who have needs for care and support. This can include such adults who have capacity to make their own decision. Statutory adult safeguarding duties apply equally to those adults with care and support needs regardless of whether those needs are being met, regardless of whether the adult lacks mental capacity or not and regardless of setting (Care Act 2014). This may include self-neglect where the refusal or avoidance of care provisions may result in significant harm.
Children and Young People aged 16 - 17 years: Children and young people aged 16-17 years may be patients on adult wards or accessing adult departments. This procedure does not apply to children or young people under the age of 18. Colleagues should refer instead to the Safeguarding - Child Abduction and Missing procedure:
Deprivation of Liberty safeguards (DoLS): A set of safeguards introduced in 2009 for the authorisation of care plans that restrict patients in such a way that amounts to a Deprivation of their Liberty.
If a patient is required to stay in hospital in their best interests and this is authorised by a DoLS, then this also gives authority for them to be returned to the hospital in their best interests.
Welfare Checks: West Yorkshire Police will deploy officers if requested by the staff as a concern for safety, particularly involving vulnerable adults and individuals with mental health conditions. However, Police do not have the power to enter a person’s home to conduct a welfare check and the referral must meet their criteria. (Welfare Checks Deployment Procedure, 2020). Please refer to Appendix 1, section 8.2 and West Yorkshire Police Welfare Checks Deployment Procedure (2020) prior to making any referrals to ensure the patient meets Police referral criteria.
MISPER: This is an acronym used by the West Yorkshire Police categorising a missing person. Police will use this acronym when referring to the patient reported to the Police as missing.
Within this procedure all patients noted to be absent from the ward or department, without prior arrangement, must be treated as missing. Steps to assess level of risk and appropriate action and management must be followed as detailed in the procedure.
The Trust has a duty of care for the safety of its patients. Patients with the capacity to decide have a legal right to leave the hospital unless they are detained under the Mental Health Act 1983 or under an urgent or authorised Standard Deprivation of Liberty order or by an alternative court order. In certain circumstances the Trust has a duty of care to share information with partner agencies (police/community NHS services) where a safeguarding issue has been raised, in order to protect that patient from further harm, this includes where leaving the ward is assessed to put the adult at significant risk.
To reduce the risk of harm to patients, NHS organisations should consider:
- Fitting alarms on fire exits and/or exit gates.
- Securing areas not used by patients, so patients cannot inadvertently wander into them.
- Reviewing the Missing Patient Procedures to ensure staff have clear guidance on how to reduce the risk of patients going missing, what to do when they find a patient has gone missing and on checks for adverse effects when a missing patient is returned.
- Developing plans to support systematic and effective searches of hospital buildings and grounds when patients cannot be located.
- Ensuring hospital staff, community staff, and other agencies such as the police and social services have a shared understanding of each other’s roles and responsibilities related to missing patients.
Any concerns staff may have should be recorded in the appropriate clinical record, including a current description of the individual. This should also be communicated to all staff responsible for looking after the individual.
Patients who are identified as a cause for concern and want to leave the ward / department need to be assessed by a registered professional and a common sense judgement made on the basis of information at hand. If the patient is allowed to leave, a verbal contract should be agreed as to the length of time the individual can be absent and the potential outcomes if they do not return. The verbal contract or agreement made between the patient and staff is to be documented on PPM+ as a clinical note or free text annotation. If the patient remains absent beyond the agreed date and time as per the contract, staff are to contact the patient and document the outcome on the clinical note/ free text annotation.
In order to protect those patients that are most vulnerable and may go missing, Leeds Teaching Hospitals NHS Trust has worked closely with the West Yorkshire Police Force to compile the joint procedure (appendix 1) which now constitutes the operational procedure of the LTHT Missing Adult Patient Procedure. This joint procedure outlines the processes that should be undertaken in the event of a person going missing from the Trust, whether they are an inpatient, outpatient or receiving care within the Emergency Departments. Patients assessed of being at risk may, at times, need increased supervision. Ward and or department managers need to discuss staffing implications with their appropriate Matron.
In the case of a missing adult patient, clinical staff have the responsibility to report and manage the incident as detailed within this procedure and complete a Datix. In addition to the Datix, staff are advised to add the missing incident on PPM+ as a clinical note/ free text annotation referring to the Datix reference number. Where the patient is known to safeguarding or a safeguarding concern has been raised this should be logged with the LTHT Safeguarding Team. Where patients have not returned within 24 hours and are deemed to be as high risk, the Senior Manager will need to arrange an urgent multi agency meeting as per procedure.
The key principles of the procedure are to maintain patient safety by:
- Adequate risk assessment, planned intervention, clear reporting mechanisms, and systematic review
- Identifying when a patient is considered a “missing patient”
- Taking the appropriate action in an effective and timely manner
- Reducing the possibility of any harmful outcomes to the patient
- Ensuring that relatives of any missing patient are informed as soon as possible and update any development
- Establishing the principles for the recognition and search for patients missing from the wards/hospital
- Ensuring the safety and correct treatment to patient on return to the hospital area
- Establishing and reviewing reasons for patient going missing and lessons learned
All CSU’s are responsible for implementing this procedure and ensuring staff are aware of their roles and responsibilities relating to missing patients. If a patient is known to have a previous history of absconding, appropriate interventions should be implemented to reduce this risk. Adults at risk could potentially be those with confusion (temporary or permanent) to time and place, that are mobile and those that have fluctuating capacity and understanding of their medical needs, who may wish to leave a clinical area for whatever reason. Staff will follow the process outlined within the joint procedure (appendix 1), use the flow chart (LTH3035) (appendix 2) and the missing patient risk assessment (LTH2817) (appendix 3) to risk assess, manage, report and escalate any concerns relating to any patient that goes missing.
The Chief Executive
The Chief Executive has overall accountability for ensuring that LTHT has the necessary infrastructure for the management of the procedure. The Trust’s Chief Executive, as Accountable Officer, is responsible for the effective identification and management of missing patients. However, the Chief Executive delegates the authority for the development and action of the policy to the Chief Nurse.
The Chief Nurse has the delegated responsibility from the Chief Executive to undertake the following:
- Development and review of this Procedure following consultation and advice from Heads of Nursing, Head of Safeguarding, Matrons, Professional Standards and Safety Team, Lead Professional Mental Capacity Act, CSM’s, communications team and LTHT Security Services and West Yorkshire Police.
- Revision and approval of the procedure following consultation process.
- Two yearly review of the Procedure. It may be revised in the interim depending on new or changes to regulations.
- The dissemination and implementation of this procedure will be managed through Corporate Nursing and CSU’s. The procedure will be circulated through Connecting Leaders in Care (CLIC) Forum and will be available on Leeds Health Pathways.
Executive Directors are responsible for assuring that appropriate resources are in place to ensure that the correct procedures can be followed in the event of a missing adult patient.
CSU Clinical Directors, Heads of Nursing, General Managers & Matrons
CSU are responsible for ensuring that the management of procedure is disseminated and implemented by their teams.
Some areas may need, or wish, to develop specific guidance for patients with specific needs as identified after local risk assessment.
Ward Managers are responsible for the dissemination and implementation of the procedure. Ward Managers must ensure that risk assessment forms and quick guide flow charts are available for use and ensure staff are aware of where to access the procedure and related documents.
Ward Managers must consistently monitor the staff adherence to the procedure and appropriate actions to be taken to address any issues identified.
All clinical staff have a duty to maintain patient safety and well-being. Staff should be aware of this procedure and the actions for which they are responsible. Staff are responsible for undertaking assessments to identify those adult patients who may be at risk of going missing.
Unregistered staff should report concerns about a patient who may be a potential risk of going missing to the clinical staff in charge. It is the responsibility of the clinical area/ staff reporting a missing patient to follow the process identified within the procedure, follow the flow chart and report the incident on Datix system. All staff must ensure that all missing patient incidents are reported and investigated in accordance with the Trust’s Incident Reporting and Investigation Policies.
All security staff should be aware of the Management of Missing Adult Patients’ Procedure. Security staff should ensure that all missing adult patients’ incidents escalated to Security are investigated. The Trust Security Advisor will provide advice on actions to control or reduce the risk level and work in conjunction with departmental managers when areas are identified as at risk.
West Yorkshire Police
West Yorkshire Police (WYP) has a responsibility to respond to the referrals made by LTHT staff reporting a missing patient. WYP will assess the risk level of the patient reported and measure this against their criteria of “real, immediate and substantial risk to life of the patient or the public”, appropriate measures will be taken to commence investigation.
NB: Where the term Senior Manager is used within the procedure, this is to be the Matron (or their deputy), or out of hours Clinical Site Manager, with responsibility for the area where the patient has gone missing.
College of Policing Authorised Professional Practice (2020) Major investigation and public protection: Missing person - https://www.app.college.police.uk/app-content/major-investigation-and-public-protection/missing-persons/ (March 2020)
Joint Procedure between LTHT Hospital Trust and West Yorkshire Police - Management of Missing Adult Patients Procedure (appendix 1) -
LTHT Missing Patient Quick Guide Flow Chart (LTH3035) (appendix 2) - http://lthweb.leedsth.nhs.uk/sites/nursing-midwifery-and-allied-health-professionals/connecting-leaders-in-care/perfect-ward/missing-persons-flowchart
LTHT Missing Patient Risk Assessment Tool (LTH2817) (appendix 3) - http://lthweb.leedsth.nhs.uk/sites/nursing-midwifery-and-allied-health-professionals/lth2817
Safeguarding - Child Abduction and Missing Procedure
Welfare Checks Deployment Procedure (West Yorkshire Police) - http://lthweb.leedsth.nhs.uk/sites/nursing-midwifery-and-allied-health-professionals/WYPWelfareChecksDeploymentProcedure2.pdf
Adherence to The Management of Missing Adult Patients Procedure will be monitored by the Adult Safeguarding Governance Committee and Professional Practice Standards and Safety Team (PPSS). Referrals made for all missing/absconding incidents will be reviewed through the Datix reporting system, police referral logs and security calls to assess the procedure’s effectiveness. The PPSS team will liaise with WY Police to analyse data on missing persons monthly to monitor LTHT performance and identify gaps.
|Target patient group:||Missing adult patients|
|Target professional group(s):||Secondary Care Nurses
Allied Health Professionals
- Care Act (2014)
- DoLs – Deprivation of Liberty Safeguards – Standard Operating Procedure (2020) Leeds Health Pathways.
- Mental Capacity Act (2005)
- Mental Health Act (1983)
- National Policing Improvement Agency (NPIA) (2010) Guidance on the Management, Recording and Investigation of Missing Persons (second edition).
- Safeguarding - Child Abduction and Missing Procedure (2020) Leeds Health Pathways.
- The Patient who Absconds (2018) The Royal College of Emergency Medicine
- Welfare Checks Deployment Procedure (2020) West Yorkshire Police
- West Yorkshire Police Missing Persons Policy (2017)
LHP version 1.0
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