Patient escape Amber Lodge or forensic service procedure

1 Aim

The aim of this document is to provide service specific guidance for colleagues who work in the forensic service when dealing with an escape situation to ensure effective management and reporting of the incident.

2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including bank and students.

3 Link to overarching policies

This procedure will run in conjunction with the trust policy for patients missing or absent without leave (AWOL) policy.

4 Procedure

4.1 Definition of escape

A detained patient escapes from a unit or hospital if he or she unlawfully gains liberty by breaching the secure perimeter that is the outside wall, fence, reception or declared boundary of that unit.

4.2 Action to be taken if a patient goes absent without leave whilst an inpatient in the forensic service

• Colleagues must immediately notify the nurse in charge.
• Colleagues are to inspect and review all safety and security checks ensuring these are completed fully.
• Colleagues are to notify switchboard as they may receive calls with regard to the missing person.
• If any damage is discovered ensure the environment is made safe immediately, for example, remove debris, lock off the area if this is required, following the blanket restrictions policy for this and report accordingly.
• Colleagues should remain in the area that is damaged at all times until fully fixed to ensure no further incidents of escape can occur.
• Ensure no other patients are able to access the site of escape.
• If possible take photographs of the area of egress including any damage caused.
• Report damage to estates for inspection and repair as a matter of urgency.
• As the patient has exited the external perimeter they are now officially absent without leave so the nurse in charge of the shift at the time of the escape is to take responsibility for implementing the trust patients missing or absent without leave (AWOL) policy.

4.3 Action to be initiated

• Notify the police immediately and complete a missing person police form, making clear the patient’s legal status, the multi-agency public protection agency (MAPPA), Ministry of Justice (MoJ) and the Mental Health Act (MHA) Office, ensure all identified risks and potential whereabouts if known are communicated.
• Notify the patient’s responsible clinician who in the case of restricted patients will notify the Ministry of Justice during normal working hours. Out of hours contact the on call consultant.
• Notify immediate management within working hours and the on-call manager for escalation out of hours.
• If applicable notify the patient’s next of kin as the patient may contact them.
• Record all actions completed in the patient’s electronic record, SystmOne. This must be contemporaneous and reflect the timeline of actions as documented on the report for the patient’s commissioning bodies.
• Report the incident on the electronic trust system, RADAR
• In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the absent without leave notification form to the Care Quality Commission. Then send the original to the service manager, matron, or Mental Health Act office.

4.4 Action to be taken if there is an identified risk to another person or persons in the event of a patient escaping

Colleagues are to refer to the patient profile, which can be found at the front of the patient’s file as per business continuity planning. Information will be included in this patient profile detailing person or persons who may be at risk in the event of a patient escaping and being absent without leave. Colleagues are to use this information to:

• notify identified people at risk from the individual as detailed in the risk assessment and management plan that the patient has left the unit unsupervised
• identify any victim issues that need to be taken into account and liaise with police and the victim liaison officer, informing them as appropriate
• if subject to multi-agency public protection agency (MAPPA) notify the agency of the situation
• notify the Public Protection Unit (PPU) and assigned officer if applicable
• if there are identified child or adult safeguarding issues notify the appropriate social service or outside or normal working hours the duty social worker.
• notify switchboard who may receive calls with regard to the missing person
• include this information when completing accurately the trust incident reporting system

4.5 Action for ward colleagues to take if the patient has not returned to the unit by midnight on the first day of absence

• In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the absent without leave notification form to the Care Quality Commission. Then send the original to the service manager, matron, or the Mental Health Act Office.
• All pertinent information can be found on the patient profile document stored at the front of the patient file which is required for business continuity purposes.
• Report to the responsible clinician if they have not yet been made aware.

4.6 Action to be taken when the patient returns

• Facilitate assessment of the patient and consider a rub down search, drug and alcohol testing if clinically indicated or required as part of the patient’s risk management plans.
• Suspend any further section 17 leave until a full multi-disciplinary team review has been undertaken with the responsible clinician.
• Modern matron to inform patient commissioning bodies and initiate an after action review and share learning as appropriate.
• When a detained patient who absconds has been reported to the Care Quality Commission and returns, part two of the absent without leave notification form is to be completed and emailed to the Care Quality Commission and a copy to the Mental Health Act office to them (see appendix O).

4.7 Action to be taken as soon as possible or during the next working day

• Undertake a full comprehensive inspection of the environment inclusive of the area used as means of escape with the trust’s local security management specialist, patient safety lead and estates lead.
• Escalate internally to all of the senior leadership team.
• Ensure any identified works that are needed are or have been reported to the estates department.
• Review and update as appropriate all risk management plans for patients ensuring high risk patients are prioritised. Liaise with commissioner for “red flag” patients as appropriate.
• The multi-disciplinary team are to continue to review the patient who has escaped considering care pathways, discussing with the case manager if medium secure is to be considered.
• Request a critical friend review from another secure care provider and action any recommendations from this.
• Complete a serious incident investigation as per trust policy if not already completed.
• Arrange urgent forensic service incident control meeting consisting of trust leads and senior management team.
• Twice weekly meetings are to be undertaken to ensure all urgent actions are completed and signed off by all stakeholders.
• Inform patient commissioning bodies and all documentation as required.

5 Appendices

Please see forensic services manual webpage for appendices attached to this procedure:

• appendix O unauthorised absence of a person detained under the Mental Health Act (1983)

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Document control

• Version: 3.
• Unique reference number: 531.
• Approved by: Clinical effectiveness group.
• Date approved: 13 May 2025.
• Name of originator or author: Forensic Outreach Liaison team manager.
• Name of responsible individual: Chief nurse.
• Date issued: 24 June 2025.
• Review date: 30 June 2028.
• Target audience: All colleagues working in the forensic service.
• Description of change: Minor amendments.

Page last reviewed: June 24, 2025
Next review due: June 24, 2026

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