ReducingMissingPatients.

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Strategies to Reduce
Missing Patients
A Practical Workbook
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Contents
Foreword 3

Executive Summary 4

Introduction 4

Strategy One: Understanding the problem 7

Strategy Two: Developing Entry and Exit policies 10

Strategy Three: Providing meaningful engagement 17

Strategy Four: Structuring the day 20

Strategy Five: Engaging Stakeholders 25

Appendix 1: The Five Strategy Self-Assessment Tool 27

References 32

Glossary 33

Acknowledgements
The authors wish to express their appreciation to the many people who have provided invaluable help
in the creation of this practical workbook. Special thanks are due to Malcolm Rae, Yvonne Stoddart
and Marion Janner for their practical advice and support, to Prof Len Bowers who remains the
pioneering expert in this field, and to Greater Manchester West Mental Health NHS Foundation
Trust for giving the authors the time to research and develop this document.

Authors
David Bartholomew, Senior Manager Adult Servicest
Dr David Duffy, Nurse Consultant
Nigel Figgins, Deputy Ward Manager
All authors are employed by Greater Manchester West Mental Health NHS Foundation Trust
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Foreword
The national suicide prevention strategy for England highlighted
people with mental health problems as a particular high risk group
for suicide. We know that a significant number of suicides occur
during a period of inpatient care. Managing risk effectively is
therefore essential.
In December 2006, the National Confidential Inquiry into Suicide and Homicide
by People with Mental Illness published its third report Avoidable Deaths.
Whilst the report outlines a number of positive findings, major problems of safety
still remain. This includes the number of inpatients dying by suicide whilst off
the ward without permission.

In mental health services it is important to balance patient autonomy with patient

safety and at times this can be challenging. This workbook has been developed to
help reduce the number of patients who go missing from mental health wards and
who place themselves or others at risk. In addition to providing straightforward
advice to staff who work in clinical settings, it also provides a range of positive
practice examples from around the country.

I am pleased to commend this workbook to all mental health services.

Louis Appleby
National Clinical Director for Mental Health

3
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Executive Summary
Patients who go missing from
mental health wards present a
continuing challenge to mental
health services. They may place
themselves and others at risk, while
significant amounts of health service
time and resources are spent in
seeking to ensure their safety.
This workbook explains the background to the
challenge of missing patients and offers the
following five practical strategies which can
help to reduce the numbers who go missing:
Introduction
The problem of patients going missing
without permission from acute wards is
an important challenge for mental health
care. In a study by Bowers et al (1999)
4% of people harmed themselves or
others in some way following their
absence from the ward, while a more
recent report (Man Univ, 2006) found
that no less than 27% of inpatient
suicides take place off the ward, often
after the person has gone missing
Absence also prevents therapeutic input
from staff, and is anxiety provoking for
those involved. Such incidents also
create time-consuming work for nurses
and other professionals (eg police)
(Bowers et al, 1999.c)
Research has also shown that missing patient
incidents can affect carer and relative views,
and faith, in mental health services.
4
• Understanding the problem
• Developing entry/exit policies
• Providing meaningful engagement
• Structuring the day
• Engaging key stakeholders
Good practice examples are provided for each
strategy, together with contact details and a list
of useful references.
A self-assessment tool is included as an appendix
so that acute services can measure their own
progress and develop local action plans.
Patients present a high risk of going missing within
the first 2-3 weeks of admission (Bowers et al,
1999. b). This is when they may be experiencing
an acute phase of their illness and will often need
a period of time to settle into the ward and
familiarise themselves with the staff and the ward’s
boundaries and expectations. Some patients may
not believe that hospital admission is beneficial to
them or in their best interests. It is therefore a key
priority to ensure that staff begin to form a
meaningful, therapeutic and collaborative
relationship straight away (DH, 2006). One of the
main reasons why patients leave the ward without
permission is because they have social
responsibilities to address, like paying bills or to
ensure their property is secure. Staff will need to
assess and recognise these issues early on in
order to prevent further anxiety and worry that
would then lead to the patient choosing to leave.
Other reasons for going missing include
symptoms of mental illness, or discontent with
ward environment and care (Bowers et al,
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1999.a). Interventions to prevent missing patients
should target people who are newly admitted or
are experiencing an acute phase of their illness.
This involves assessing all new patients and
identifying the most likely patients to leave, then
implementing prevention strategies before this
can happen. Patients who have gone missing
previously are at greater risk from the same
behaviours again in the future (Meehan et al,
1999). Some inpatient units are not adequately
equipped with staff who are trained to manage
and address these needs and therefore
experience high rates of missing patients.
Avoidable Deaths (Univ Man, 2006), a 5 year
report of the national confidential inquiry into
suicide and homicide by people with mental
illness highlighted a number of key risk factors in
those patients who had gone missing without
staff permission, and subsequently committed
suicide. They were more likely to be young,
male, unemployed and homeless with high rates
of schizophrenia, previous violence and alcohol
and drug misuse. They were also more likely to
have had over 5 previous admissions and been
non-compliant regarding their medication in the
last month. However, 81% of this group had
been estimated as low or no immediate risk
and 48% had been estimated as being low or
no long term risk – with consequent lower
observation levels being applied prior to them
going missing. The report therefore raised
concerns about the robustness of risk
assessment processes and recommended a
joint management review of high risk patients
with other clinical teams as well as aligning CPA
and risk management. It also highlighted issues
re staff training, staffing levels and
communications and advocated the need for
closer contact with patients’ families and carers.
In the past, one intervention to help reduce
missing patient incidents was to simply lock the
doors. However, it has been suggested that
“physical security measures alone are not a
sufficient answer to the problem of absconding,
and nurses need to work harder to develop
supportive alliances with patients” (Bowers et al,
5
1999.b). Around half of patients who go
missing whilst already off the ward, possibly
whilst on section 17 leave, are attending
activities off the ward, at handover or at meal
times. The remainder use alternative means
such as removing glass from bedroom
windows, and climbing out or leaving via fire
exits (Bowers et al, 1998.e).
Ensuring the safety of service users, staff and
visitors, was highlighted as a key priority area
for service improvement in Pathway to
Recovery (HC, 2008) the Healthcare
Commission’s recent review of inpatient care. It
found that, although the frequency with which
detained patients were absent without leave
was relatively high, this was generally for brief
periods and that the rate varied considerably
between trusts. It recommended that
commissioners and providers of mental health
services need to focus on: promoting a more
positive therapeutic environment and better
engagement with service users to meet their
diverse needs; ensuring that risk management
systems are implemented in practice; and
looking at ways to minimise the likelihood of
patients going missing, using national guidance
and best practice approaches.
City University London published a self-training
package for staff (City Univ, 2003) on how to
reduce the numbers of patients going missing
from acute wards, based upon three research
studies which they had carried out. Their “anti-
absconding intervention” suggested the
following key actions:
• Rule clarity regarding entrance and exit policies
• Identify those at high risk of going missing
• Target nursing time for those at high risk
• Careful breaking of bad news
• Post incident debriefing
• MDT review following 2 episodes of
going missing
This material can be downloaded from
www.citypsych.com
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Seven steps to patient safety in mental health
(NPSA, 2008) provides a step-by-step process
to help mental health organisations, staff and
teams build a culture of safety and improve the
safety of service users. It acknowledges that
many patient safety problems, such as patients
going missing, have complex systemic causes
which require actions on an individual, team,
directorate and organisational level.
Aims of the workbook
When patients go missing from acute mental
health wards, they potentially place themselves
and others at risk. The purpose of this
workbook is to provide acute mental health staff
with a number of practical ways in which they
can effectively reduce the number of patients
who go missing from acute mental health
wards. It aims to:
• enable staff to view the ward as a whole system
• reduce the potential for patients to go missing
• improve the inpatient experience during
their stay, and
• make the ward a place which patients value
and find therapeutic.
Who should use
this document?
This guide is primarily targeted to all clinical staff
responsible for the care of people in acute
mental health wards.
Why this document is needed
Although a significant amount of research has
been carried out as to why patients go missing
and a number of important initiatives have been
developed, there has been no brief,
straightforward practical guidance readily
available for staff who work in clinical settings.
6
This workbook is intended to address this gap
and assist staff in their day-to-day work.
Scope and structure
of the document
The document explains the background to the
challenge of missing patients and then offers five
key strategies to help reduce the numbers of
people who go missing. Each strategy is explained
and accompanied by a practical task checklist
and a range of good practice examples. Finally, a
self-assessment tool is included in Appendix 1 so
that wards can measure progress against each
strategy and develop their own action plans.
How to use this document
Read through the document and then measure
the effectiveness of your own clinical areas
using the assessment tool in Appendix 1. This
can also be downloaded as a user friendly
Word template from www.virtualward.org.uk.
By following up the references and examples
of good practice, you should be able to develop
and implement a practical action plan to reduce
the number of missing patients on every ward.
Five strategies to reduce
missing patients
The available evidence indicates that strategies
regarding missing patients are needed which take
into account the fact that a mental health inpatient
service is a whole system. This workbook outlines
the following five key strategies to assist staff in
reducing the chance of patients going missing:
1) Understanding the problem
2) Developing entry/exit policies
3) Providing meaningful engagement
4) Structuring the day
5) Engaging key stakeholders
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Strategy One
Understanding the problem
When a patient goes missing, this
should be recorded as a clinical
incident. By seeking out this information
and analysing it, we can learn lessons
about who might leave, how they leave,
where they go to, the reasons they
leave and when this occurs. From the
analysis, we can then look to develop
preventative measures to help reduce
missing patients incidents.
Below are suggested questions that, when
answered, will help identify the areas of your
service which need addressing in order to
reduce the number of missing patient incidents.
Task Checklist
1) Contact your information services department
and collate the information relating to
missing patient incidents over the last twelve
months. Ensure that any information is
disaggregated by race, disability, gender, age,
sexual orientation, religion or belief so that
you can see whether there are any underlying
equality issues which need to be addressed.
2) You can supplement this information by
contacting your local police missing persons
lead. You can request data on how many
patients have been reported missing from your
ward or unit in the last 12 months. Information
can be collected from the police that
demonstrate how many times they have been
contacted and whether they were required to
return the patient back to the ward. More
detailed information can then be sought from
the incident forms themselves.
7
3) There may be times of the day at which
patients choose to leave sometimes because
there are less nursing staff about. Find out at
what times the incidents occur more
frequently and whether they are associated
with specific situations on the ward. An
example of this is could be at handovers, in
the evening or at the weekend.
4) Find out if the incidents are associated with
the same patient. If they are, seek the
patient’s view of why they are going missing –
this may be related to dissatisfaction or
social/equality issues. Clear management
plans for such patients should be discussed
and developed at a multidisciplinary team
(MDT) meeting.. Check what management
plans have been implemented to address
the problem and whether they are evaluated
for effectiveness.
5) Management of the environment will need
to be considered. Patients will often use fire
exits as a point of exit from the ward.
Consider how the patients are leaving and by
what route? Are they leaving covertly or
through the main entrance? How many fire
exits do you have? Are they alarmed? Do
areas accessible to patients off the ward, e.g.
exercise area or garden, allow unrestricted
access/exit out of the hospital/unit?
6) Are patients leaving the ward without the
knowledge of staff or are they not returning
from agreed periods of leave? Have patients
‘run away’ following escorted leave?
7) Following the patient’s return to the ward, do
the nursing staff update the risk assessment?
Are triggers for the incident recorded? All
relevant information including any equality
issues needs to be obtained from the patient,
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so that if it does occur again then staff
would have reliable information on the
habits of the individual, i.e. where they go,
who they see etc.
8) Are all incidents discussed within the MDT?
Are clear management plans formulated? Is
the patient involved in or informed of future
management plans? What are the obstacles
to implementing the plan?
9) Look at whether the reported incidents
resulted in a review by the clinical team and
whether an action plan was developed to
reduce a repetition.
10) Are unsuccessful attempts at leaving the
ward reported as ‘near miss’ incidents?
11) From the results obtained consider how
many incidents could have been potentially
prevented if one or more of the 5 strategies in
this workbook were in place. Identify how
many of these incidents could have been
prevented by initiating section 17 leave and/or
escorted leave with staff, relatives or friends.
EXAMPLE1
The Salford Absconding
Project (SAP)
Greater Manchester West Mental
Health NHS Foundation Trust
Issue(s) addressed re missing patients:
There was a disproportionately high incidence
of service users going missing from the
Inpatient Unit.
Approach adopted to reduce the number
of missing patients:
The SAP approach was to address the problem
within three stages:
8
1) Understand the problem Through analysis of
the missing persons data it was possible to
identify particular patterns:
• Defining those service users that had gone
missing and those that had not returned
from leave.
• Understanding those service users repeatedly
going missing (20% of service users
accounting for 60% of incidents).
• Establishing the time of day at which service
users were most frequently going missing.
2) Inter-agency Collaboration It was important
to focus on stakeholders who have influence
and are influenced by the problem of service
users going missing. The Police played a
major role and were involved and informed of
the specific actions being taken to address the
problem. Sharing the information from Stage 1
with the Police promoted a collaborative
approach with good understanding of the
context of the problem.
3) Action and Intervention This stage was
implemented simultaneously with Stage 2 and
worked around four general themes:
• Targeting the needs of those service users
who were repeatedly going missing (60%
identified in Stage 1). A common characteristic
of this group was that they were delayed
discharges awaiting secure accommodation. It
was therefore necessary to engage the PCT
and Secure Commissioners to support
transfers to appropriate services.
• Effective and timely use of the Psychiatric
Intensive Care Unit (PICU) to support open wards
in the assessment and management of service
users identified as at risk of going missing.
• Targeting the peak times that service users
were going missing through increased activity
and engagement at these times.
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• Introduction of “Plan Your Day” meetings with
service users in order that individuals were
involved in setting out at the start of each day
the specific activities and groups that they
would be involved with.
What worked well?
• Addressing the needs of the 60% group that
were repeatedly going missing led to an
immediate reduction in incidents through
proactive management.
• Service users were positive about the Plan
Your Day meetings and the collaboration with
the Ward Teams that this enabled.
What did not work so well?
The challenge for this initiative was the
sustainability. The delayed discharge of
service users awaiting specialist
accommodation has re-occurred.
Key benefits or outcomes:
Within the initial period analysed (9 months)
there were 201 incidents of service users going
9
missing which projected over a 12 month period
would have been 268, (16% higher than the
national average). In a 5 month evaluation period
following this there was >80% reduction
projecting under 50 such incidents over a 12
month period.
Lessons learnt:
• In order to plan effective interventions to
reduce incidents of service users going
missing, it was essential to analyse the
information of previous incidents.
• Inter-agency relationships are key.
• Reducing incidents of service users
going missing is more than about locking
doors. Collaboration and engagement has
a major influence.
For more details contact:
David Bartholomew, Senior Manager Adult
Services David.Bartholomew@gmw.nhs.uk
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Strategy Two
Developing entry and exit policies
Patients are admitted to adult acute
inpatient units for a variety of different
reasons. The function of an inpatient
unit is to provide care in the least
restrictive environment. The needs of the
individual may range from 1:1 on a PICU
to minimal observations on acute wards.
It is for this reason that entrance/exit
policies need to be flexible to the needs
of all patients whilst acknowledging
varying degrees of individual risk.
An entrance and exit policy allows staff to
monitor the flow of patients in and out of the
ward or mental health unit. Just as importantly,
it also allows staff the opportunity to engage,
assess and, if necessary, intervene with
patients. (Rae, 2007)
Task Checklist
1) Collate and analyse the current missing
person figures (see Strategy One above)
2) Identify from data collected if your service
would benefit from an entrance/exit policy in
your clinical area.
3) The ward manager will need to ensure
that the absence of entrance/exit policy
is recorded on the risk register or acute care
forum agenda in order for senior managers
to review.
4) Consider using the Missing Patients Toolkit:
A resource for acute hospitals, community
hospitals and mental health units for ideas
in creating policy or the City University’s
Anti-Absconding self-training package for
ward staff (See Reference section for details).
10
5) Identify a workable system that allows the
monitoring of patient’s movements to and from
the ward. A discussion group with ward staff
and or patients could achieve this. Ensure that
the system chosen is benefiting the patients
and not just for the convenience of staff.
Challenge any custodial roles and attitudes
(Rae, 2007). Examples of potential policy
include ‘signing in and out policy’, ‘locked
door policy’. Explore new technologies for
doors, e.g. swipe cards, keypads and fobs.
6) Arrange a consultation meeting. Inform
patients, advocates and Patient Advice and
Liaison Services (PALS) at community
meetings (or similar) about the proposed
system and why it is being considered.
Encourage discussion and feedback. A simple
questionnaire could be handed out to staff,
patients and relatives asking for their views on
how to improve the safety on inpatient wards.
7) Decide when to implement a trial period.
Enough time needs to be be allowed, for its
implementation, review of function and an
audit of missing patient incidents to occur.
8) Train all staff on how to implement and use
the new system.
9) Staff will need to explain to patients the value
and necessity of policies, making it clear that
it is for their own safety. This could include:
“Keeping inappropriate people out” (Rae,
2007). For new patients, provide policy
information in both written and verbal format
as part of the admission process.
10) At the end of the trial period, collect
missing patients data again. Audit and
evaluate the data by comparing it against
the previous figures. Collect subjective
feedback from all involved.
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EXAMPLE2
Use of Electronic Key Fobs
on an Acute Mental Health Ward
Cheshire and Wirral Partnership
NHS Foundation Trust
Issue(s) addressed re missing patients:
• The numbers of patients leaving the ward
without prior agreement.
• The time spent on managing level two
observations on the ward
• Daily risk assessment
• Allowed the ward to be locked without
preventing patients who were able to leave the
ward doing so.
Approach adopted to reduce the number
of missing patients:
• Entry and exit to Beech Ward is by the use of
an electronic key fob (Salto).
• Every patient on Beech Ward has their own
individual room which is also operated by
electronic key fob.
• This initiative enabled patients, following risk
assessment and discussion, to receive a
personal key fob programmed to allow entry
and exit to the ward.
What worked well?
• Communication throughout the project with
patients and staff at daily community meetings.
• Patients who did not receive an exit fob on
admission understood why and how it linked to
their intervention plan whilst on the ward.
What did not work so well?
On three occasions patients without a fob
did leave the ward without prior agreement.
This occurred when the door was open for
others to leave.
11
Key benefits or outcomes:
• 75% reduction in the numbers of patients
missing from the ward.
• Reduction in nursing observations solely for the
purpose of patients going missing.
• Increased time for nurses to engage in
therapeutic activity on the ward.
• Initiative extended to Juniper Ward at
Bowmere Hospital.
Lessons learnt:
• A need to focus on a daily risk assessment
• To check that patients have not been asked to
change room for any reason without the fob
being changed as well.
For more details contact:
Gill Edwards, Ward Manager, Beech Ward
gill.edwards@cwp.nhs.uk
EXAMPLE 3
Introduction of swipe
card system
Leeds Partnerships NHS Foundation Trust
Issue(s) addressed re missing patients:
• Reduced the number of patients on close/
intensive observations.
• Reduced the number of patients leaving the
ward without staff knowledge.
• Use of the swipe care generated an electronic
record check of who is in and out of the ward
• Created short timed delay on exit from the
ward giving staff further opportunity of seeing
people as they leave.
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Approach adopted to reduce the number
of missing patients:
• All Adult Acute Inpatient Wards have been
electronically locked (in and out) using a
monitored swipe card mechanism.
• Staff from each ward are issued with electronic
swipe cards that are programmed to access all
areas of the unit (not just their own ward, in
case of unnecessary delay in emergency).
• Patients are individually assessed with a view
to deciding who should not have a swipe card.
• Patients subject to detention would not
normally have a card.
• Informal patients would normally have a
swipe card to come and go. This would be
their default position as legally, informal
patients should be able to leave when they
want to without hindrance or delay.
• However all informal patients are assessed for
their level of risk and should the risk action
plan determine it appropriate, they would be
formally asked to consent (in writing) not to
have a swipe card. Should an ‘at risk’ patient
refuse to accept this option (as would be their
right) then the clinical team would have to
reconsider their treatment plan. This would
broadly have 3 options.
• Accept the patient’s perception of their own
risk and plan care accordingly sharing risk
with the patient.
• Consider the patient for discharge on the
grounds that they are not willing to comply
with reasonable treatment request and could
be safely supported elsewhere.
• Consider use of the Mental Health Act on the
grounds that the patient is refusing
treatment for their own safety.
• This approach introduced a level of
transparency that was not possible under
pre-existing open door arrangements.
12
• The swipe card in isolation is not an attempt to
reduce the number of missing persons. It is used
in conjunction with having the following in place:
• Having a care plan to address what action
should be taken where a history of going
missing is known at start of admission.
• Building better partnership relations with other
agencies. We have regular meetings with the
local police who feedback on the number of
missing persons per month and outcomes. A
joint missing person’s protocol has also been
generated between the two services (This is
currently under further review).
• Clinical team managers work with individual
ward clinicians to identify from police
feedback how missing person’s cases could
have been managed differently.
• Having clearer local guidance on what
actions clinicians should take for missing
persons which considers the assessment.
E.g. Often patients are not actually missing,
but are absent from the ward without
permission e.g. section 17 authorised leave.
• The above local actions would include going
into the community to pick up our patients
as we know where they are, rather than
draining police resource unnecessarily.
What worked well?
• Staff have an immediate system of being able
to identify who has authorisation to leave the
ward. E.g. if a patient asks to be let out of the
ward, then staff can immediately question why
they do not have a key. This prompts them to
stop and find out why before opening the door.
• It reduced the necessity to have staff ‘door
watching’ and promotes the use of direct
engagement.
• We no longer unnecessarily and unlawfully deny
people the right to come and go freely without
proper consideration and active thought.
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• There is no evidence to support the initial view
that the swipe card would be used as
‘currency’ and those patients would bribe,
persuade or intimidate those who were entitled
to have a card.
• Patients report feeling safe as this system is
also useful to make it easier to exclude
unwelcome visitors, especially those with
criminal intent.
• Systems are in place to ensure that missing
patients are reviewed clinically and
managerially following an episode where a
patient has left the ward without permission
or agreement from staff. We have developed
a missing patient action plan, for those at
highest risk, and post missing episode
interview process to help staff, and the
service user, understand the reasons for
going missing.
What did not work so well?
• Swipe card were initially placed on the inner
ward door. However we found that the time
delay was not sufficient. Swipe card system
are now also in place on the outer ward door
to enable an ‘airlock’ time delay.
• Staff initially needed further education
regarding the system to ensure that there was
documented evidence that patients without
keys had gone through an assessment process
of showing consent not to have a key.
• The entrance to the unit (building) is now also
awaiting the swipe card system as there have
been issues regarding people being able to
leave the building.
• Those without cards needing to enter
the ward (this could include visitors or
community clinicians) needed to ring a
buzzer to be let in. The switch to open the
door was behind the nurses’ station.
13
This was found to remove the ‘meet and greet’ of
welcoming visitors. The switch has now been
removed and staff now need to go to
the door to swipe it open. This gives staff an
opportunity to make face to face contact with
those entering the ward and clarify their
reason for visiting.
Key benefits or outcomes:
• A reduction in the number of occasions service
users leave the ward without permission.
• A reduction in missing persons
reporting average.
• Continuous development of staff
assessment and risk management skills.
• Clear information for service users and
their families regarding how to enter and
leave the ward.
• Improved relationships, joint working and
shared protocols with our partner agencies
including West Yorkshire Police, families
and carers.
• Staff are better able to manage visitors by meeting
and greeting them at the door (and redirect
people who do not need to enter the ward).
• Service users value the use of the swipe card
system and are able to contribute to the
decision making process regarding their own
safety and wellbeing.
• It is a system that our service users have been
consulted on and have reported having a
positive experience of.
Lessons learnt:
The main entrance to our unit should have been
a key consideration in implementing the swipe
card system. It was considered further along the
process, when it became apparent that this was
the key area that
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patients were able to use to leave (as opposed to
the initial thoughts that the ward exit doors were
the main security issue).
For more details contact:
Linda Rose, Acute Care Pathway Clinical
Governance Lead linda.rose@leedspft.nhs.uk
EXAMPLE 4
Managing entry and exit to the
acute wards in Doncaster acute
inpatient wards
Rotherham Doncaster and South Humber
Mental Health NHS Foundation Trust.
Issue(s) addressed re missing patients:
• In December 2007 the adult acute unit for
Doncaster services moved from a no longer ‘fit
for purpose’ district general hospital site to a
newly built and refurbished unit.
• Within the new wards the layout resulted in
service users being able to enter and leave the
wards without the knowledge of staff.
Approach adopted to reduce the number
of missing patients:
• Principles around service delivery were
reviewed against the backdrop of maintaining
and respecting a person’s autonomy and also
keeping them safe during an acute mental
health episode.
• As a result of this brief review the unit now
operates the following principles:
• The entrance to the unit is via a single entrance
• Each ward is also then only accessed by a
single route
14
• At the point of each entry, service users and
visitors use an intercom system to either the
reception desk or ward
• The entrances are all managed on a magnetic
lock to both enter and leave the wards
• These principles are supported by ongoing
individual risk assessments, individual
discussions with service users and their carers
about how to enter and leave the ward areas,
clear information and signage.
• All service users have 1:1 meaningful
engagement with a member of staff every day,
and any changes in their mental health is
documented and is reflected in the assessment
taken prior to them leaving the ward.
What worked well?
• Service users and their carers supported
this change.
• The mechanics of putting magnetic locks on
the doors did not make it appear like a
secure/locked ward.
What did not work so well?
• Other services, community teams and visiting
professionals sometimes have a lower
understanding about the issues and can see
the managed doors as an inconvenience.
• Publicity was limited to the immediate areas
and services whereas a wider programme of
communication would have improved the
implementation process.
Key benefits or outcomes:
• The wards have a ‘safer’ feel to them – service
users/carers feel safer when on the unit and
are not likely to go missing from the wards.
• Staff have greater confidence in the ward
layout and are more able to spend time
engaging with service users, rather than
watching and managing the doors.
ReducingMissingPatients.qxd 27/3/09 09:33 Page 15
• People who do not have a legitimate reason to
be on the unit/wards do not gain access.
• There is greater staff focus and consequent
skill and knowledge regarding risk assessment.
• All staff are aware of the whereabouts of each
service user and whether they are able to
leave the ward.
• There has been a reduction in the number of
those who go missing from the wards.
Lessons learnt:
• Be brave, having managed doors does not
make the wards into a ‘secure’ unit.
• Publicise the change the a wide audience for
greater community sign up to the changes.
For more details contact:
Deborah Wildgoose, Nurse Consultant
Deborah.wildgoose@rdash.nhs.uk
EXAMPLE 5
Empowering Service Users to
manage their leave by using a
signing in and out board
Birmingham and Solihull Mental Health
Trust – Solihull Directorate.
Issue(s) addressed re missing patients:
• The Solihull wards had remained unlocked and
staff had historically avoided “door watching”,
and focused, instead, on high levels of
therapeutic engagement to actively manage risk.
• Whilst the frequency of service users going
missing from the wards was minimal, it was
apparent from discussions with the police that
15
even a small number of clients being reported
as missing had a large impact on resources.
• Staff were concerned by the fact that a
tiny number of clients would repeatedly
leave the ward.
• Solihull had historically used its High Dependency
Unit (HDU) at times to manage clients who
frequently left the ward for unauthorised periods.
This unit had been under review due to its level of
occupancy reducing over the last couple of years.
Approach adopted to reduce the number
of missing patients:
A new approach was adopted using a service
user signing in and out whiteboard on one of
the wards in order to:
• Encourage engagement/assessment and
interaction on leaving and returning to the ward.
• Enable clearly identified times for leaving the
ward to be recorded.
• Give responsibility for management of leave to
service users by recording when leaving the
ward and also identifying their time for return.
• Improve understanding of the implications of
adhering to leave arrangements by
encouraging greater collaboration between
staff and service users.
• Attempt to address the issues of boredom by
reviewing the model of care and significantly
increase the number of occupational therapists
and activity workers on the wards. This has
enabled an extended engagement and activity
program to be developed.
• Currently the wards doors have remained
unlocked, although there has been consultation as
to whether service users would prefer the ward
entrance to be locked. The general feeling was
that the current situation should remain with
regards to leaving the ward, although access to
enter the ward may be restricted due to the wards
being located within a main general hospital.
ReducingMissingPatients.qxd 27/3/09 09:33 Page 16
• Activities offered have tried to focus on a
mixture of ward based and community activities,
for example striders and strollers and also
Retired Greyhound Walking which have proved
very popular in reducing feelings of confinement
and promoting the healthy living agenda.
What worked well?
• The majority of admissions to Solihull have
been informal admissions. This has been in
part due to the fact that service users report
not feeling “locked in”.
• When staff have encouraged service users
to take responsibility for leave this has been
quite successful.
• There have been good examples of discussions
prior to and when returning from leave.
• The number of missing service user incidents
has remained low.
What did not work so well?
• The signing in/out board has been used on one
of the wards for a number of years. At certain
times it tends to revert back to Staff recording
on the board which could adversely impact
service users managing their leave.
Key benefits or outcomes:
• The wards currently remain unlocked.
• The numbers of patients taking unauthorized
leave have remained minimal.
16
• Incidents of frustration associated with leave
are minimal as service users report not feeling
locked in.
• Feedback from service users identified that
they do prefer the wards to remain unlocked
as they find this comforting.
• Service users do utilise the board and take
responsibility for their leave.
• The use of the HDU function has reduced to
such an extent that the 7 beds are no longer
required and this unit has been replaced with a
single bedded extra care room on each ward.
Lessons learnt:
• Developing a robust activity programme which
focuses on exercise and community activities
reduces feelings of containment.
• Using a signing in and out board can prove
effective when the whole team adopts an
approach of encouraging service users to take
responsibility for leave.
• There must be adequate staffing to ensure
there is engagement and discussion prior
to and returning from leave. Staffing levels
were reviewed using the NIMHE Acute
Workload Calculator.
For more details contact:
Martin Luke, Acting Deputy Director of
Nursing martin.luke@bsmht.nhs.uk
ReducingMissingPatients.qxd 27/3/09 09:33 Page 17
Strategy Three
Providing meaningful engagement
‘Meaningful engagement’ covers the
broad spectrum of assessment,
planning, implementation and
evaluation of care, through the use of
1:1 contact with the patient. This should
be achieved collaboratively and needs
to be meaningful to both the member of
staff and the service user. The 1:1’s
should continue throughout the
patient’s admission.
Meaningful engagement is clearly evidenced
through the ‘Re-focusing’ work by Nick Bowles
(2002), and ensures that all patients have the
opportunity once a day to discuss, explore and
ventilate their thoughts. Patient engagement
involves the use of basic interpersonal skills,
which should be possessed by all mental health
staff, and serves a therapeutic purpose as well
as encouraging effective communication
between staff and service user. Engagement is
more likely to be successful and meaningful for
both the nurse and patient, once trust and
rapport has been established.
Assessment is a vital way of identifying
behaviour that could lead to the patient not
remaining on the ward, early on in a patient’s
admission. Some risk factors to look out for
include: early stages of admission, social
responsibilities that need completing, patients
who present a high risk to themselves or others,
symptoms associated with illness and patients
with a history of going missing from mental
health units (Bowers, 1999). Good assessment
skills are paramount in order to gather relevant
information and interpret it accordingly.
17
Many issues that might lead to the patient going
missing can be resolved quickly and easily by
recognising the context of their lives and
understanding that individuals may have
different needs depending on their age, gender,
disability, race, sexual orientation, belief or
religion. This needs to be understood in order to
respond to them as individuals appropriately.
Attention also needs to be given to the patient’s
feelings about their care and their environment,
since discontent with this can also lead to the
patient choosing to leave over remaining in
hospital (Bowers et al, 1999). Good complaints
procedures need to be in place, as well as a
working culture of accepting and welcoming
criticism and suggestions for improvement.
Task Checklist
1) Review risk management strategies including
effectiveness of observation and engaging
policies. Consider the quality of any
interactions during such times, as this is likely
to have an impact on the patient’s experience
and choices they make.
2) Check that training and instruction on issues
of risk assessment and positive meaningful
engagement should “promote a sense of
personal responsibility on the part of the
service user” (Rae, 2007). This should be
included on any trust induction package.
3) Consider replacing the term special
'observation' with special 'engagement', as it
would be preferable for the patient to have
short periods of time with a member of staff,
who is ideally skilled to address any
expressed diverse needs, (including those
relating to strands of equality) rather than just
someone who observes from a distance.
ReducingMissingPatients.qxd 27/3/09 09:33 Page 18
4) Clearly identify, through risk assessment,
potential issues that might result in the
patient going missing (e.g. worried about
their cat, property needs securing).
Negotiate with patient a solution to their
concern, which benefits the patient and puts
their mind at ease. If any actions are agreed
staff must follow it through to the end, or risk
losing the trust that was established.
5) Recognise the importance of ensuring that
the patient understands the rationale for
being admitted to the mental health unit. All
aspects of their care and treatment needs to
be explained and efforts made to ensure
continuity of their care whilst an inpatient.
6) Check that patients are regularly seen
by their primary, named or allocated nurse.
Ensure the engagement is needs related.
Try to match the skills of your staff to the
needs of the patient, whilst maintaining
continuity of care.
7) In order to improve the interactions and
alliances between staff and patients,
encourage nursing staff to develop their
clinical practice in Solution Focused
Therapy, Family Therapy, Cognitive
Behavioural Therapy, and Psycho-
Social Interventions. All of these therapies
would help to increase the quality of 1:1
engagement and help to promote
recovery rates.
8) Staff need to be able to demonstrate
evidence of any interactions with their
patients, ensuring accurate record keeping (if
it hasn’t been written down, it didn’t happen!)
9) The shift co-coordinator needs to
allocate individual patients to staff members
at the commencement of the shift. Those
patients that have leave from the ward need
to be assessed that morning prior to any
leave, in order to assess for changes in
presenting risk.
18
10) Check that all patients are made aware of
who their nurse is for the shift/day. This
could be done verbally by staff, possibly at a
patient’s ‘plan your day’ meeting, or through
the use of a ward orientation board. All
nursing staff need to ensure they know who
their allocated patients are, and this can be
done via the handover at the
commencement of the shift.
11) Regularly check that nursing staff approach
their allocated patients and offer 1:1 time, or
arrange a time later in the shift. If a patient
does not want to engage, then nursing staff
will need to enquire as to the reason why
and document this accordingly.
12) Develop use of ‘protected time’ to ensure
that patients get undivided attention by ward
staff. This period of time best occurs when
there are no ward rounds and before
relatives visiting hours.
EXAMPLE 6
The use of protected time
Greater Manchester West Mental
Health Foundation Trust
Issue(s) addressed re missing patients:
• Proactively engaging service users during
inpatient admission.
• Improved risk assessment.
• Increased ward based activity.
Approach adopted to reduce the number
of missing patients during protected time:
• The nursing team gives all their time to the
patients on the ward.
• Visitors are not allowed on the ward
ReducingMissingPatients.qxd 27/3/09 09:33 Page 19
• No interdisciplinary work is conducted except
in cases of emergency.
• Telephone calls are diverted to the ward
administrator.
• All nursing staff are required to spend time
with patients in communal areas, engaging in
meaningful 1:1 or group sessions.
What worked well?
• This has proved to be a simple but effective
method of promoting meaningful engagement.
Protected time is targeted to take place
at times when an increased number of
service users are likely to go missing and
it complements a number of approaches
to address this problem.
• Each protected period of time varies and is
dictated by the patient’s needs and desires:
Sometimes staff and patients have a general
chat and everyone joins in, and on other
occasions people engage in quizzes with mixed
staff/patient teams. Protected time allows
nursing staff the opportunity to engage with
their allocated patient in a 1:1 if they have not
already done so.
• Documentation and other office based activity
is important in the delivery of care on acute
inpatient wards. Protected time has helped
improve the balance between this and the
opportunity for nurses to provide therapeutic
engagement.
19
What did not work so well?
• Nursing staff felt under pressure to ensure
office-based tasks were completed.
• It is important to continually evaluate the
progress and benefits through team meetings
and individual supervision.
Key benefits or outcomes:
• There is no empirical evidence to demonstrate
that this approach has had a direct impact
upon the reduction of service users going
missing from hospital. It has however been
recognised that during the periods of protected
time there is a reduction in incidents on the
ward that have previously been associated with
stress leading to service users going missing.
Lessons learnt:
• Protected time provides an ideal opportunity
for nurses to spend time with patients where
by they are not distracted by other task
orientated duties.
• This adds to the service user experience
and also supports the development of clinical
skills of nurses.
For more details contact:
Sheila Hulme, Deputy Ward Manager
Sheila.hulme@gmw.nhs.uk
ReducingMissingPatients.qxd 27/3/09 09:33 Page 20
Strategy Four
Structuring the day
Bowers et al (1999) reported that
patients often leave mental health units
because they feel trapped and
claustrophobic, or disinterested and
bored whilst on our wards.
A structured day provides patients with the
opportunity to engage in meaningful and
therapeutic activity. Examples of these include
recovery groups, self esteem groups, and
community meetings. We can also reduce ward
disturbances, and the tendency for violence by
adequately structuring and resourcing our
wards to enable diversional, recreational, and
social activities to take place.
A structured day not only occupies the patient,
but helps with their symptoms by engaging
them in therapeutic activity. It also encourages
social interaction. Patients are more likely to feel
valued, because nursing staff are putting time
and effort into their recovery.
“We must ensure opportunities for exercise and
fresh air, or the need for observation, continuous
risk assessment, communication and giving of
information, responsibility, and the development
of therapeutic alliances and effective personal
support and care” (Rae, 2007 p15).
Task Checklist
1) Positively promote activities to patients and
staff. Encourage all patients and staff
members to take part in therapeutic groups
and activities.
2) Through meaningful engagement and
assessment, identify the patient’s interests and
needs. This can be achieved according to
interest (e.g. music, sport, embroidery) or
20
presenting symptoms (e.g. poor self esteem,
anxiety, trauma). This will enable you to identify
a suitable activity or therapeutic programme.
3) Liaise with other professionals such as
Occupational Therapy, Psychology or
Support, Time and Recovery (STR) worker
to develop a range of therapeutic activity
programmes for positive engagement, which
can be tailored to meet the diverse and
cultural needs of the individual. You can also
develop links within the local community,
looking at drop-ins or volunteers to run
groups, service users to identify and facilitate
special interest groups. An employment
worker could volunteer to attend a morning
session and look at social inclusion work.
4) A patients meeting can be arranged to occur
every weekday morning. This meeting can
inform patients of the groups and activities
for that day or the week ahead. Try to ensure
attendance of as many patients as possible.
5) Staff need to maintain involvement in groups/
activities. It not only offers staff a valuable
opportunity to build a therapeutic alliance
with patients, but also demonstrates that
nursing staff value the initiative.
6) Display information about activities and groups
around the communal areas of the ward,
promoting available activities for the week
ahead, whilst ensuring that issues of translation
and forms of communication that address the
partially sighted etc are addressed. Ensure that
these activities include activities both on and off
the ward. Include this information in the
patient’s handbook, which is given to each
patient upon admission.
7) Any identified group/activity needs to be
care planned, and regularly reviewed
according to changing needs.
ReducingMissingPatients.qxd 27/3/09 09:33 Page 21
8) During 1:1 time with allocated staff members,
assess the suitability for the day’s activity/
group.
9) Ensure that activities also include those
outside normal working hours (including
evenings and weekends). Patients are more
likely to go missing when there is limited
activity on the ward.
10) Document attendance at such activities.
This information needs to be fed into
the MDT meeting.
11) Groups and activities need to be
continuously reviewed, by seeking the
opinions of those involved. Seek service
user suggestions for alternative groups.
EXAMPLE 7
Out of hours activities
in Doncaster’s acute
inpatient wards
Rotherham Doncaster and South Humber
Mental Health NHS Foundation Trust.
Issue(s) addressed re missing patients:
It is well documented that the underlying social
and therapy needs of service users on acute
wards have not been well met. Acute Problems
(SCMH, 1998) suggested that 40% of service
users received no social or recreational activity at
all during their stay. This results in long episodes
of boredom and a disconnection for service users
with their own social communities. When bored
and discontented service users leave the ward in
search of other connection and recreation.
Approach adopted to reduce the number
of missing patients:
• A pilot was run for 3 months within the two
Doncaster adult acute admission wards and PICU.
21
• The project was to provide social and
recreational activities between the hours of
4.00pm and 8.0pm each weekday evening and
all day on Saturday and Sunday.
• Workers were employed on a sessional basis.
They had a variety of skills and experience in
providing social and recreational activities.
• They were given a largely free hand to arrange
flexible and responsive programmes with
service users on the wards.
What worked well?
• The pilot was evaluated as successful in that it
met all its objectives for providing out of hours
activities to service users.
• Following the pilot, funding was obtained for two
permanent full time activity workers. These are
now in post and continue to provide activities to
service users in the identified ‘out of hours’ times.
• The activity workers focus on the provision of
activities that are socially inclusive and support
service users maintaining contacts with their
communities. Working alongside the OT and
nursing staff, they facilitate out of hours
activities on the wards that may then be
continued within the community once a
persons’ hospital stay has ended.
• The Out Of Hours service is now a highly
regarded embedded component of acute care
within the Doncaster adult inpatient service.
What did not work so well?
As a result of the hours worked by the out of
hours activity workers, there was a feeling of
being disconnected with the ward staff. This is an
ongoing issue that requires particular attention to
ensure their integration within the ward teams.
Key benefits or outcomes:
• The numbers of those who go missing from the
Doncaster wards was initially low. However as
ReducingMissingPatients.qxd 27/3/09 09:33 Page 22
part of the project evaluation the most
commonly reported outcome for service users
was reduced levels of stress, both on a personal
level as well as that of the environment.
• The project was described as having provided
comfort, enjoyment and a sense of fun in an
acute inpatient setting.
Lessons learnt:
• Running the project as a pilot gave the
opportunity to see it work in practice and
measure the outcomes prior to rolling it out.
• ‘Therapy’ should be defined by patient need
and as such can range from formal 1:1 work
to an informal shopping trip.
• A small investment can make massive changes.
For more details contact:
Deborah Wildgoose, Nurse Consultant
Deborah.wildgoose@rdash.nhs.uk
EXAMPLE 8
Multi-agency policy development
for missing patients
North Staffordshire Combined
Healthcare NHS Trust
Issue(s) addressed re missing patients:
• In 2002-4 the Harplands Hospital, a provision
of nine mental health wards located close to
the acute care hospitals of the city of Stoke-
on-Trent, had a disproportionate amount of
missing person incidents logged with the police
(around 400 incidents a year).
• This problem acted as the trigger for joint
working between the hospital and a local police
22
inspector tasked with tackling the problem.
The result of the process was a revised multi-
agency response to patients going missing
from hospital.
• Patients feeling bored in hospital.
• Lack of therapeutic engagement.
• Lack of support for female service users.
Approach adopted to reduce the number
of missing patients:
• Proactive risk management plans considered
the proportional response to individuals should
they become missing, based on risk and past
patterns of behaviour.
• The policy also recognised the difference
between those absent without leave
(whereabouts known) and those who were
truly missing (whereabouts unknown) and
introduced an escalation of welfare checks
to identify whereabouts before triggering the
already overloaded police ability to respond
to cases. The principle of this idea was that
those logged with the police presented
particular risk and were therefore a priority.
• The introduction of the new policy and
associated increased awareness of the issue
led to a reduction of cases logged with the
police in the subsequent year (below 300).
• When the hospital was first opened in 2001 a
team of diversional activity workers was
developed across the acute inpatient service to
offer direct engagement with patients in group
or individual sessions offering a range of ‘low
key’ activities particularly designed to tackle
the need to occupy patients in meaningful
activities (in line with ‘Acute Concerns’). This
service together with a ‘central therapies’
provision has evolved into our current provision
of therapeutic programmes offering a layered
approach to meaningful engagement in
activities and therapies.
ReducingMissingPatients.qxd 27/3/09 09:33 Page 23

• In 2006 a new initiative was developed Key benefits or outcomes:

(Protected Therapeutic Engagement Time) to
allow inpatient teams uninterrupted time with
patients on a daily basis, for one hour a day all
visitors were banned from the ward area
(professionals, relatives, support staff and
managers alike).
• Through the trusts volunteer coordinator our
female ward has developed a pamper room
and a pamper trolley service staffed entirely by
volunteers, offering a range of treatments from
facials to manicures and hand massage.
What worked well?
• Ward teams used more appropriate methods of
locating patients whose risk was not immediate
or who have a predictable pattern of behaviour
rather than overloading the local police
response mechanism. This was redirected
towards the most urgent cases or those who
posed the highest level of risk or vulnerability.
• The therapeutic programme has continued to
develop over the last two years to include a
wider range of therapies and diversional
activities including: structured therapeutic
groups and individual therapies,
complimentary therapies, psychological
therapies, and community based therapies.
What did not work so well?
• Due to problems in volunteer recruitment the
pamper trolley has had patchy success, but
recent recruitment has improved things. The
service itself is well received.
• Welfare checks by the ambulance service for
absent patients whose whereabouts was
known have fallen by the wayside as the new
contracting arrangements have developed.
The number of patients missing reported to the
Police dropped from over 400 to less than 300 in
the year following the introduction of the multi-
agency policy.
Lessons learnt:
• It is important to allow (through policy) the
flexibility of responses to patients absenting
themselves from hospital.
• Responses will vary depending on the immediacy
of risk and predictability of behaviour.
• It is also important to offer a differentiation
between those missing from the ward whose
whereabouts are known and those missing,
whose whereabouts are unknown.
For more details contact:
Rob Grant, Matron, Acute Inpatient
Services, Harplands Hospital
rob.grant@northstaffs.nhs.uk
EXAMPLE 9
Star Wards
Star Wards is a project of the social justice
campaigning charity Bright and works with
mental health trusts to improve inpatients'
daily experiences and treatment outcomes.
Our vision is all patients are on wards where:
• talking therapies play as substantial a role
as medication
• patients are supported in our management of
our symptoms and treatment
• there is a strong culture of patient mutual support

23
ReducingMissingPatients.qxd 27/3/09 09:33 Page 24
• patients benefit from a full programme of
daily activities
• patients retain and build on our community ties.
Star Wards was created following the
experiences of Bright’s Director, Marion Janner,
as a detained inpatient. We are constantly
discovering NHS hospitals which are providing an
exceptionally high quality of service to inpatients,
including those with the most complex and
challenging needs. Over 500 wards are
members, including forensic, eating disorder,
learning disability, elderly and children and
adolescents wards. They are providing a fabulous
range of meaningful therapeutic, social and
recreational opportunities for enriching
inpatients’ experiences.
Key benefits or outcomes:
• “Better client feedback, increased staff
satisfaction, less aggression and violence,
more therapeutic contact”
• The pioneering research on missing patients by
Len Bowers and colleagues at City University
identified that providing meaningful activities for
patients is a key element in reducing this risk.
24
The heart of Star Wards’ work is inspiring a full
programme of daily activities for inpatients.
• While we don’t have specific data on our
impact on reducing the numbers of patients
going missing, our fist national members’
survey showed that 50% had experienced a
reduction of violence as a result of taking part
in Star Wards.
• As the factors related to violence and missing
patients are similar (eg quality of relationships
with staff), it is likely that involvement with Star
Wards has a positive effect on enabling
patients to remain on the ward.
• The problem-solving and creativity skills that
staff deploy through their involvement can be
applied with great effect to addressing the
individual factors motivating potential incidents
of patients leaving the ward when it’s not safe
for them to do so.
For more details contact:
www.starwards.org.uk or
marion@brightplace.org.uk
ReducingMissingPatients.qxd 27/3/09 09:33 Page 25
Strategy Five
Engaging stakeholders
If initial assessment and interventions
have failed, and the patient goes
missing from the mental health unit or
fails to return from leave, effective
locally agreed processes need to be in
place to ensure the safe return of the
patient. This will be based on a shared
understanding with key stakeholders
such as the police of each other’s roles
and responsibilities. Therefore, it is
good practice to have a policy for
missing patients which includes a
locally agreed integrated protocol of
what can and cannot be done, in
relation to locating and returning those
patients back to the ward.
In reporting a missing patient, the police will
require certain information about the patient.
Such information needs to be readily available in
the patient’s notes, prior to such an incident
occurring (e.g. a description of the patient
should be gathered upon admission). This
ensures good communication with the police,
and help to achieve a timely and safe return of
the patient.
Other people who are often involved when
patients go missing are carers and relatives.
We often rely on relatives to inform us if a
patient turns up at their home. This can put
them in compromising positions, as patients
can then believe that their relatives are
‘informing’ on them rather than helping to
ensure their safety. It is often upsetting and
worrying for relatives and carers to find out that
their loved ones are missing.
25
Missing patient incidents take up many hours of
valuable nursing and police time. Any
opportunity to save time and resource need to
be seized, while still maintaining patient and
public safety.
Task Checklist
1) Develop a missing person’s policy, with
integrated joint protocol with local police
force. Consider using Missing Patients
Toolkit: A Resource for acute hospitals,
community hospitals and mental health
units (see Reference section for details).
2) Have pertinent information about patients to
hand. Gather this information upon admission
to the ward. It should include a full
description of the patient, the name and
contact details of next of kin, the patient’s
present and past risks (if relevant), contact
details of family and friends, also any
information of where the patient may go.
3) Services will need to make sure that services
users, relatives and carers are aware of the
purpose of acute care, ie to provide safe and
sound interventions, to assess and respond to
acute manifestations, and for relatives/carers
to understand inherent risks (Rae 2007).
4) Arrange regular meetings with police to
address and update issues. Seek agreement
with local police force for the effective joint
management of missing patient incidents.
5) Invite the Police to visit the unit to understand
how mental health units operate. Develop a
shared understanding of each other’s roles and
responsibilities in relation to missing patients.
ReducingMissingPatients.qxd 27/3/09 09:33 Page 26
6) Attempt to develop a good working
relationship with family members or carers.
This could be done by inviting them to MDT
meetings, or by encouraging regular contact
with nursing team. Clearly, this would need to
be done within the boundaries of
confidentiality. Make carers/relatives aware of
the role of nursing staff, the ward
environment, including the limitations of
nursing strategies.
EXAMPLE 10
Police Liaison
Greater Manchester West Mental Health
Foundation Trust
Issue(s) addressed re missing patients:
• Inter-agency Collaboration
• Information Sharing.
Approach adopted to reduce the number
of missing patients:
Establishment of regular Police Liaison Meetings.
What worked well?
• It created a regular opportunity to discuss the
problems experienced by both services in order
to identify collaborative solutions.
• It provided the opportunity to resolve issues
at a strategic level.
26
What did not work so well?
Initially these meetings took place on a quarterly
basis. This was not frequent enough and was
therefore increased to monthly.
Key benefits or outcomes:
• Prior to the regular police liaison meetings, the
service operated in a reactive manner to issues
requiring police involvement. The majority of
this related to incidents of service users going
missing, an issue that was using a large
amount of Police resources and subsequently
placing a strain on the relationship of
operational staff within both services.
• Through the regular meetings, with missing
patients as a regular agenda item, a shared
understanding of the problem was developed.
Whilst this cannot be evidenced as reducing
incidents, it formed an essential component of
the “Salford Absconding Project” highlighted in
Good Practice Example 1.
Lessons learnt:
• Where there is a problem that causes a drain
on another organisation’s resources,
relationships can become strained when
reactive approaches are employed.
• Through the regular liaison meetings it has been
possible to develop a more proactive approach
to problem solving with longer term benefits.
For more details contact:
David Bartholomew, Senior Manager Adult
Services David.Bartholomew@gmw.nhs.uk
ReducingMissingPatients.qxd 27/3/09 09:33 Page 27
Appendix One
The five strategy self-assessment tool
The self-assessment tool template can
be downloaded as a user friendly word
document from www.virtualward.org.uk
Introduction
Each of the five good practice strategies has a
self-assessment tool linked to it. The purpose of
this tool is for you to assess where you are in
relation to the strategy.
Complete red, amber or green as appropriate
for the statement, which most nearly matches
the situation on your ward.
Choosing red indicates that you are not
achieving this strategy. Therefore you would
move to the development planning stage. How
you go about planning and implementing is
entirely up to you. We would recommend group
discussion with colleagues, patients and carers.
Enter in the Development Plan what is required
to achieve the strategy.
Choosing amber highlights that the strategy is only
partially being achieved, and that more planning
and developmental work needs to be done in this
area to achieve the full strategy. Again you should
enter in the Development Plan what is required to
meet the strategy. Evidence demonstrating partial
achievement would also need to be present.
If green is chosen this means that you are
achieving this strategy. Evidence to support this
need be documented.
Each tool will not take too long to complete, but it
will be important to allow enough time for
discussion. Your team should ideally complete the
tool collectively, having met and discussed it fully.
27
You may find it useful to share the tool in
advance and encourage members of staff to
think about the statements before the meeting.
Scoring and
Incident evaluation
To understand the effectiveness of the strategies
within the guidance it is necessary to look at
changes in the nature of incidents within the
service. One way of doing this is to complete a
quarterly evaluation of the score. It is anticipated
that there will be a positive correlation between
understanding the degree to which the strategies
are being implemented and the number of
reported incidents: i.e. if a service is achieving
100% green on all strategies, they could expect to
have a reduction in incidents, both serious and
none serious. Conversely, a service that has 100%
red could expect to have a high level of incidents.
It is not necessary to measure against all
incidents but is suggested that information on
the following categories are used:
1) Incidents of patients going missing.
2) Incidents of self harm
3) Incidents of verbal abuse/threatening behaviour.
4) Incidents of actual violence.
5) Incidents of property damage.
Through completing a quarterly evaluation
against incidents reported, it is possible to track
progress not only with regard to reduction in
missing patients but also the overall impact.
This information can be used to generate
a report as needed as one means of
evaluating effectiveness.
ReducingMissingPatients.qxd 27/3/09 09:33 Page 28

Strategy One: Analysis of Missing Person Data

Criteria R A G Where we Development Evidence of By By

are now Plan Achievement Who? When?

1.1 There are systems in place that

effectively record all incidents of missing
patients.

1.2 There is a feedback mechanism for

data on incidents which is forwarded to
senior managers/matron for the service.

1.3 Data has been obtained on missing

patient incidents for the previous 12
months and includes:
• Disaggregation by race, gender, age,
sexual orientation, religion and disability
• Time of day incidents occur.
• Individuals who frequently go missing.
• Specific points of exit. (i.e. Fire exits)
• Particular themes as to why. (i.e. to
secure property, post MDT meeting)

1.4 Contact has been made with the

Police for their data on missing patient
incidents over the last 12 months.

1.5 There is evidence that all missing

patient incidents result in a review by the
clinical team.

1.6 Risk assessments are updated and

collaborative management plans are
developed to prevent further incidents.

Strategy Two: Entrance and Exit Policy

Criteria R A G Where we Development Evidence of By By

are now Plan Achievement Who? When?

2.1 An Entrance and Exit policy is in

operation within the clinical area.
(If RED go to 2.5).

2.2 The current policy clearly identifies

who is on or off the ward at any time.

2.3 Information on the policy is

routinely given to patients upon
admission to the ward.

28
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Strategy Two: Entrance and Exit Policy continued . . .

Criteria R A G Where we Development Evidence of By By

are now Plan Achievement Who? When?

2.4 All staff have been trained in and

demonstrate understanding of the
Entrance/Exit policy.

2.5 Absence of an Entrance/Exit policy is

recorded on the risk register/Acute care
forum agenda, (or appropriate forum to
take to senior level).

Strategy Three: Meaningful Engagement

Criteria R A G Where we Development Evidence of By By

are now Plan Achievement Who? When?

3.1 The shift co-ordinator allocates

patients to staff at start of every shift.

3.2 Staff arrange 1:1 time with their

allocated patients, and demonstrates
evidence of this.

3.3 Primary nurses and allocated staff

members are aware of their
responsibilities to their patients.

3.4 All ward staff are trained in

risk assessment.

3.5 All patients who can have leave from

the ward have a daily risk review.

3.6 Through risk assessment

patients who are likely to go missing
are identified.

3.7 Current risks are discussed and

management plans agreed with patient.
Patient signs care/management plan)

3.8 All patient 1:1 interactions are

clearly documented.

3.9 Patient engagement is encouraged

and protected time occurs regularly in
the week.

29
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Strategy Four: Structuring the Day

Criteria R A G Where we Development Evidence of By By

are now Plan Achievement Who? When?

4.1 All patients can access a range of

therapeutic activities, either group or
individual (including recreational), both
on and off the ward.

4.2 Activities are tailored to meet

individually assessed needs.

4.3 There is a daily patients meeting,

where daily/weekly activities can be
promoted to all patients.

4.4 Patients are able to plan their week

with their named nurse.

4.5 Ward staff become involved in ward

based group activities.

4.6 Information is displayed around

the ward promoting therapeutic groups
and activity.

4.7 Weekend and evening activities are

consistently available.

4.8 Patients are encouraged to give

feedback on groups or activity attended

4.9 Patients are needs assessed and

referred for Occupational Therapy.

Strategy Five: Engaging Stakeholders

Criteria R A G Where we Development Evidence of By By

are now Plan Achievement Who? When?

5.1 The trust has an up to date missing

person policy.

5.2 An integrated joint protocol with the

local police force is established and
agreed within this policy

5.3 All staff are clear on their

responsibilities in relation to missing
patients and trust policy

30
ReducingMissingPatients.qxd 27/3/09 09:33 Page 31

Strategy Five: Engaging Stakeholders continued . . .

Criteria R A G Where we Development Evidence of By By

are now Plan Achievement Who? When?

5.4 A system exists where nursing staff

has easy access to all relevant
information required for the reporting of
a missing patient.

5.5 A senior manager is trained in liaison

and holds regular meetings with the
local police/missing person’s lead.

5.6 The police provide annual figures on

reported missing persons from your
ward or unit.

5.7 The police have been to the unit

or ward and are aware of the nurse’s
role in helping people with mental
health problems.

5.8 All clinical staff are clear about the

Police’s role when reporting an incident.

5.9 All relevant information upon

admission is routinely given to
relatives/carers i.e. Contact details for
ward, name of Primary nurse etc…

5.10 Relatives and carers are routinely

invited to Multi Disciplinary Meetings.

5.11 Whilst ensuring confidentiality,

relatives/carers are kept informed of
decisions made at MDT meetings.

31
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Literature Review. Journal of Psychiatric and Mental
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Bowers L., Jarrett M., Clarke N., Kiyimba F., and
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Bowers L., Jarrett M., Clarke N., Kiyimba F., and
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Bowers L., Jarrett M., Clarke N., Kiyimba F., and McFarlane
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Healthcare Commission (2008) The Pathway to Recovery:
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ReducingMissingPatients.qxd 27/3/09 09:33 Page 33

Glossary
DH Department of Health

HC Healthcare Commission

HDU High Dependency Unit

MDT Multi-Disciplinary Team

NIMHE National Institute for Mental Health in England

NPSA National Patient Safety Agency

OT Occupational Therapist

PALS Patient Advice and Liaison Services

PCT Primary Care Trust

PICU Psychiatric Intensive Care Unit

SAP Salford Absconding Project

SCMH Sainsbury Centre for Mental Health

STR worker Support, Time and Recovery Worker

Univ. Man University of Manchester

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