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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

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Executive Summary
Patients who go missing from • Understanding the problem
mental health wards present a
continuing challenge to mental
• Developing entry/exit policies
health services. They may place • Providing meaningful engagement
themselves and others at risk, while • Structuring the day
significant amounts of health service • Engaging key stakeholders
time and resources are spent in Good practice examples are provided for each
seeking to ensure their safety. strategy, together with contact details and a list
This workbook explains the background to the of useful references.
challenge of missing patients and offers the A self-assessment tool is included as an appendix
following five practical strategies which can so that acute services can measure their own
help to reduce the numbers who go missing: progress and develop local action plans.

Introduction
The problem of patients going missing Patients present a high risk of going missing within
without permission from acute wards is the first 2-3 weeks of admission (Bowers et al,
an important challenge for mental health 1999. b). This is when they may be experiencing
an acute phase of their illness and will often need
care. In a study by Bowers et al (1999)
a period of time to settle into the ward and
4% of people harmed themselves or familiarise themselves with the staff and the ward’s
others in some way following their boundaries and expectations. Some patients may
absence from the ward, while a more not believe that hospital admission is beneficial to
recent report (Man Univ, 2006) found them or in their best interests. It is therefore a key
that no less than 27% of inpatient priority to ensure that staff begin to form a
suicides take place off the ward, often meaningful, therapeutic and collaborative
relationship straight away (DH, 2006). One of the
after the person has gone missing
main reasons why patients leave the ward without
Absence also prevents therapeutic input permission is because they have social
from staff, and is anxiety provoking for responsibilities to address, like paying bills or to
those involved. Such incidents also ensure their property is secure. Staff will need to
create time-consuming work for nurses assess and recognise these issues early on in
and other professionals (eg police) order to prevent further anxiety and worry that
(Bowers et al, 1999.c) would then lead to the patient choosing to leave.

Research has also shown that missing patient Other reasons for going missing include
incidents can affect carer and relative views, symptoms of mental illness, or discontent with
and faith, in mental health services. ward environment and care (Bowers et al,

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1999.a). Interventions to prevent missing patients 1999.b). Around half of patients who go
should target people who are newly admitted or missing whilst already off the ward, possibly
are experiencing an acute phase of their illness. whilst on section 17 leave, are attending
This involves assessing all new patients and activities off the ward, at handover or at meal
identifying the most likely patients to leave, then times. The remainder use alternative means
implementing prevention strategies before this such as removing glass from bedroom
can happen. Patients who have gone missing windows, and climbing out or leaving via fire
previously are at greater risk from the same exits (Bowers et al, 1998.e).
behaviours again in the future (Meehan et al,
1999). Some inpatient units are not adequately Ensuring the safety of service users, staff and
equipped with staff who are trained to manage visitors, was highlighted as a key priority area
and address these needs and therefore for service improvement in Pathway to
experience high rates of missing patients. Recovery (HC, 2008) the Healthcare
Commission’s recent review of inpatient care. It
Avoidable Deaths (Univ Man, 2006), a 5 year found that, although the frequency with which
report of the national confidential inquiry into detained patients were absent without leave
suicide and homicide by people with mental was relatively high, this was generally for brief
illness highlighted a number of key risk factors in periods and that the rate varied considerably
those patients who had gone missing without between trusts. It recommended that
staff permission, and subsequently committed commissioners and providers of mental health
suicide. They were more likely to be young, services need to focus on: promoting a more
male, unemployed and homeless with high rates positive therapeutic environment and better
of schizophrenia, previous violence and alcohol engagement with service users to meet their
and drug misuse. They were also more likely to diverse needs; ensuring that risk management
have had over 5 previous admissions and been systems are implemented in practice; and
non-compliant regarding their medication in the looking at ways to minimise the likelihood of
last month. However, 81% of this group had patients going missing, using national guidance
been estimated as low or no immediate risk and best practice approaches.
and 48% had been estimated as being low or
no long term risk – with consequent lower City University London published a self-training
observation levels being applied prior to them package for staff (City Univ, 2003) on how to
going missing. The report therefore raised reduce the numbers of patients going missing
concerns about the robustness of risk from acute wards, based upon three research
assessment processes and recommended a studies which they had carried out. Their “anti-
joint management review of high risk patients absconding intervention” suggested the
with other clinical teams as well as aligning CPA following key actions:
and risk management. It also highlighted issues • Rule clarity regarding entrance and exit policies
re staff training, staffing levels and
communications and advocated the need for
• Identify those at high risk of going missing
closer contact with patients’ families and carers. • Target nursing time for those at high risk
In the past, one intervention to help reduce • Careful breaking of bad news
missing patient incidents was to simply lock the • Post incident debriefing
doors. However, it has been suggested that
“physical security measures alone are not a
• MDT review following 2 episodes of
going missing
sufficient answer to the problem of absconding,
and nurses need to work harder to develop This material can be downloaded from
supportive alliances with patients” (Bowers et al, www.citypsych.com

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Seven steps to patient safety in mental health This workbook is intended to address this gap
(NPSA, 2008) provides a step-by-step process and assist staff in their day-to-day work.
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
Scope and structure
going missing, have complex systemic causes of the document
which require actions on an individual, team,
The document explains the background to the
directorate and organisational level.
challenge of missing patients and then offers five
key strategies to help reduce the numbers of
people who go missing. Each strategy is explained
Aims of the workbook and accompanied by a practical task checklist
When patients go missing from acute mental and a range of good practice examples. Finally, a
health wards, they potentially place themselves self-assessment tool is included in Appendix 1 so
and others at risk. The purpose of this that wards can measure progress against each
workbook is to provide acute mental health staff strategy and develop their own action plans.
with a number of practical ways in which they
can effectively reduce the number of patients
who go missing from acute mental health How to use this document
wards. It aims to:
Read through the document and then measure
• enable staff to view the ward as a whole system the effectiveness of your own clinical areas
• reduce the potential for patients to go missing using the assessment tool in Appendix 1. This
can also be downloaded as a user friendly
• improve the inpatient experience during Word template from www.virtualward.org.uk.
their stay, and
By following up the references and examples
• make the ward a place which patients value of good practice, you should be able to develop
and find therapeutic. and implement a practical action plan to reduce
the number of missing patients on every ward.

Who should use


this document? Five strategies to reduce
This guide is primarily targeted to all clinical staff missing patients
responsible for the care of people in acute The available evidence indicates that strategies
mental health wards. regarding missing patients are needed which take
into account the fact that a mental health inpatient
service is a whole system. This workbook outlines
Why this document is needed the following five key strategies to assist staff in
reducing the chance of patients going missing:
Although a significant amount of research has
been carried out as to why patients go missing 1) Understanding the problem
and a number of important initiatives have been 2) Developing entry/exit policies
developed, there has been no brief,
3) Providing meaningful engagement
straightforward practical guidance readily
available for staff who work in clinical settings. 4) Structuring the day
5) Engaging key stakeholders

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Strategy One
Understanding the problem
When a patient goes missing, this 3) There may be times of the day at which
should be recorded as a clinical patients choose to leave sometimes because
incident. By seeking out this information there are less nursing staff about. Find out at
what times the incidents occur more
and analysing it, we can learn lessons
frequently and whether they are associated
about who might leave, how they leave, with specific situations on the ward. An
where they go to, the reasons they example of this is could be at handovers, in
leave and when this occurs. From the the evening or at the weekend.
analysis, we can then look to develop
4) Find out if the incidents are associated with
preventative measures to help reduce the same patient. If they are, seek the
missing patients incidents. patient’s view of why they are going missing –
Below are suggested questions that, when this may be related to dissatisfaction or
answered, will help identify the areas of your social/equality issues. Clear management
service which need addressing in order to plans for such patients should be discussed
reduce the number of missing patient incidents. and developed at a multidisciplinary team
(MDT) meeting.. Check what management
plans have been implemented to address
the problem and whether they are evaluated
Task Checklist for effectiveness.

1) Contact your information services department 5) Management of the environment will need
and collate the information relating to to be considered. Patients will often use fire
missing patient incidents over the last twelve exits as a point of exit from the ward.
months. Ensure that any information is Consider how the patients are leaving and by
disaggregated by race, disability, gender, age, what route? Are they leaving covertly or
sexual orientation, religion or belief so that through the main entrance? How many fire
you can see whether there are any underlying exits do you have? Are they alarmed? Do
equality issues which need to be addressed. areas accessible to patients off the ward, e.g.
exercise area or garden, allow unrestricted
2) You can supplement this information by access/exit out of the hospital/unit?
contacting your local police missing persons
lead. You can request data on how many 6) Are patients leaving the ward without the
patients have been reported missing from your knowledge of staff or are they not returning
ward or unit in the last 12 months. Information from agreed periods of leave? Have patients
can be collected from the police that ‘run away’ following escorted leave?
demonstrate how many times they have been
7) Following the patient’s return to the ward, do
contacted and whether they were required to
the nursing staff update the risk assessment?
return the patient back to the ward. More
Are triggers for the incident recorded? All
detailed information can then be sought from
relevant information including any equality
the incident forms themselves.
issues needs to be obtained from the patient,

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so that if it does occur again then staff 1) Understand the problem Through analysis of
would have reliable information on the the missing persons data it was possible to
habits of the individual, i.e. where they go, identify particular patterns:
who they see etc.

8) Are all incidents discussed within the MDT?


• Defining those service users that had gone
missing and those that had not returned
Are clear management plans formulated? Is
from leave.
the patient involved in or informed of future
management plans? What are the obstacles • Understanding those service users repeatedly
to implementing the plan? going missing (20% of service users
9) Look at whether the reported incidents accounting for 60% of incidents).
resulted in a review by the clinical team and
whether an action plan was developed to
• Establishing the time of day at which service
users were most frequently going missing.
reduce a repetition.
2) Inter-agency Collaboration It was important
10) Are unsuccessful attempts at leaving the
ward reported as ‘near miss’ incidents?
to focus on stakeholders who have influence
and are influenced by the problem of service
11) From the results obtained consider how users going missing. The Police played a
many incidents could have been potentially major role and were involved and informed of
prevented if one or more of the 5 strategies in the specific actions being taken to address the
this workbook were in place. Identify how problem. Sharing the information from Stage 1
many of these incidents could have been with the Police promoted a collaborative
prevented by initiating section 17 leave and/or
approach with good understanding of the
escorted leave with staff, relatives or friends.
context of the problem.
3) Action and Intervention This stage was
implemented simultaneously with Stage 2 and
worked around four general themes:
EXAMPLE1
The Salford Absconding • Targeting the needs of those service users
who were repeatedly going missing (60%
Project (SAP) identified in Stage 1). A common characteristic
of this group was that they were delayed
Greater Manchester West Mental
discharges awaiting secure accommodation. It
Health NHS Foundation Trust
was therefore necessary to engage the PCT
Issue(s) addressed re missing patients: and Secure Commissioners to support
There was a disproportionately high incidence transfers to appropriate services.
of service users going missing from the
• Effective and timely use of the Psychiatric
Inpatient Unit. Intensive Care Unit (PICU) to support open wards
in the assessment and management of service
Approach adopted to reduce the number users identified as at risk of going missing.
of missing patients:
The SAP approach was to address the problem • Targeting the peak times that service users
within three stages: were going missing through increased activity
and engagement at these times.

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• Introduction of “Plan Your Day” meetings with missing which projected over a 12 month period
service users in order that individuals were would have been 268, (16% higher than the
involved in setting out at the start of each day national average). In a 5 month evaluation period
the specific activities and groups that they following this there was >80% reduction
would be involved with. projecting under 50 such incidents over a 12
month period.
What worked well?
• Addressing the needs of the 60% group that Lessons learnt:
were repeatedly going missing led to an • In order to plan effective interventions to
immediate reduction in incidents through reduce incidents of service users going
proactive management. missing, it was essential to analyse the
information of previous incidents.
• Service users were positive about the Plan
Your Day meetings and the collaboration with • Inter-agency relationships are key.
the Ward Teams that this enabled. • Reducing incidents of service users
going missing is more than about locking
What did not work so well? doors. Collaboration and engagement has
The challenge for this initiative was the a major influence.
sustainability. The delayed discharge of
service users awaiting specialist
accommodation has re-occurred. For more details contact:
David Bartholomew, Senior Manager Adult
Key benefits or outcomes: Services David.Bartholomew@gmw.nhs.uk
Within the initial period analysed (9 months)
there were 201 incidents of service users going

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Strategy Two
Developing entry and exit policies
Patients are admitted to adult acute 5) Identify a workable system that allows the
inpatient units for a variety of different monitoring of patient’s movements to and from
reasons. The function of an inpatient the ward. A discussion group with ward staff
and or patients could achieve this. Ensure that
unit is to provide care in the least
the system chosen is benefiting the patients
restrictive environment. The needs of the and not just for the convenience of staff.
individual may range from 1:1 on a PICU Challenge any custodial roles and attitudes
to minimal observations on acute wards. (Rae, 2007). Examples of potential policy
It is for this reason that entrance/exit include ‘signing in and out policy’, ‘locked
policies need to be flexible to the needs door policy’. Explore new technologies for
of all patients whilst acknowledging doors, e.g. swipe cards, keypads and fobs.
varying degrees of individual risk. 6) Arrange a consultation meeting. Inform
patients, advocates and Patient Advice and
An entrance and exit policy allows staff to
Liaison Services (PALS) at community
monitor the flow of patients in and out of the
meetings (or similar) about the proposed
ward or mental health unit. Just as importantly,
system and why it is being considered.
it also allows staff the opportunity to engage,
Encourage discussion and feedback. A simple
assess and, if necessary, intervene with
questionnaire could be handed out to staff,
patients. (Rae, 2007)
patients and relatives asking for their views on
how to improve the safety on inpatient wards.

7) Decide when to implement a trial period.


Task Checklist Enough time needs to be be allowed, for its
1) Collate and analyse the current missing implementation, review of function and an
person figures (see Strategy One above) audit of missing patient incidents to occur.

2) Identify from data collected if your service 8) Train all staff on how to implement and use
would benefit from an entrance/exit policy in the new system.
your clinical area.
9) Staff will need to explain to patients the value
3) The ward manager will need to ensure and necessity of policies, making it clear that
that the absence of entrance/exit policy it is for their own safety. This could include:
is recorded on the risk register or acute care “Keeping inappropriate people out” (Rae,
forum agenda in order for senior managers 2007). For new patients, provide policy
to review. information in both written and verbal format
as part of the admission process.
4) Consider using the Missing Patients Toolkit:
A resource for acute hospitals, community 10) At the end of the trial period, collect
hospitals and mental health units for ideas missing patients data again. Audit and
in creating policy or the City University’s evaluate the data by comparing it against
Anti-Absconding self-training package for the previous figures. Collect subjective
ward staff (See Reference section for details). feedback from all involved.

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EXAMPLE2 Key benefits or outcomes:


• 75% reduction in the numbers of patients
Use of Electronic Key Fobs missing from the ward.
on an Acute Mental Health Ward • Reduction in nursing observations solely for the
Cheshire and Wirral Partnership purpose of patients going missing.
NHS Foundation Trust • Increased time for nurses to engage in
Issue(s) addressed re missing patients: therapeutic activity on the ward.
• The numbers of patients leaving the ward • Initiative extended to Juniper Ward at
without prior agreement. Bowmere Hospital.
• The time spent on managing level two
observations on the ward Lessons learnt:
• Daily risk assessment • A need to focus on a daily risk assessment
• Allowed the ward to be locked without • To check that patients have not been asked to
preventing patients who were able to leave the change room for any reason without the fob
ward doing so. being changed as well.
Approach adopted to reduce the number
of missing patients: For more details contact:
• Entry and exit to Beech Ward is by the use of Gill Edwards, Ward Manager, Beech Ward
an electronic key fob (Salto). gill.edwards@cwp.nhs.uk
• 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 EXAMPLE 3
and exit to the ward. Introduction of swipe
card system
What worked well? Leeds Partnerships NHS Foundation Trust
• Communication throughout the project with
patients and staff at daily community meetings. Issue(s) addressed re missing patients:
• Reduced the number of patients on close/
• Patients who did not receive an exit fob on intensive observations.
admission understood why and how it linked to
their intervention plan whilst on the ward. • Reduced the number of patients leaving the
ward without staff knowledge.
• Use of the swipe care generated an electronic
What did not work so well?
record check of who is in and out of the ward
On three occasions patients without a fob
did leave the ward without prior agreement. • Created short timed delay on exit from the
This occurred when the door was open for ward giving staff further opportunity of seeing
others to leave. people as they leave.

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Approach adopted to reduce the number • The swipe card in isolation is not an attempt to
of missing patients: reduce the number of missing persons. It is used
• All Adult Acute Inpatient Wards have been in conjunction with having the following in place:
electronically locked (in and out) using a • Having a care plan to address what action
monitored swipe card mechanism. should be taken where a history of going
• Staff from each ward are issued with electronic missing is known at start of admission.
swipe cards that are programmed to access all • Building better partnership relations with other
areas of the unit (not just their own ward, in agencies. We have regular meetings with the
case of unnecessary delay in emergency). local police who feedback on the number of
• Patients are individually assessed with a view missing persons per month and outcomes. A
to deciding who should not have a swipe card. joint missing person’s protocol has also been
• Patients subject to detention would not generated between the two services (This is
normally have a card. currently under further review).

• Informal patients would normally have a • Clinical team managers work with individual
swipe card to come and go. This would be ward clinicians to identify from police
their default position as legally, informal feedback how missing person’s cases could
patients should be able to leave when they have been managed differently.
want to without hindrance or delay. • Having clearer local guidance on what
• However all informal patients are assessed for actions clinicians should take for missing
their level of risk and should the risk action persons which considers the assessment.
plan determine it appropriate, they would be E.g. Often patients are not actually missing,
formally asked to consent (in writing) not to but are absent from the ward without
have a swipe card. Should an ‘at risk’ patient permission e.g. section 17 authorised leave.
refuse to accept this option (as would be their • The above local actions would include going
right) then the clinical team would have to into the community to pick up our patients
reconsider their treatment plan. This would as we know where they are, rather than
broadly have 3 options. draining police resource unnecessarily.
• Accept the patient’s perception of their own
risk and plan care accordingly sharing risk What worked well?
with the patient. • Staff have an immediate system of being able
• Consider the patient for discharge on the to identify who has authorisation to leave the
grounds that they are not willing to comply ward. E.g. if a patient asks to be let out of the
with reasonable treatment request and could ward, then staff can immediately question why
be safely supported elsewhere. they do not have a key. This prompts them to
stop and find out why before opening the door.
• Consider use of the Mental Health Act on the
grounds that the patient is refusing • It reduced the necessity to have staff ‘door
treatment for their own safety. watching’ and promotes the use of direct
engagement.
• This approach introduced a level of
transparency that was not possible under • We no longer unnecessarily and unlawfully deny
pre-existing open door arrangements. 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 This was found to remove the ‘meet and greet’ of
that the swipe card would be used as welcoming visitors. The switch has now been
‘currency’ and those patients would bribe, removed and staff now need to go to
persuade or intimidate those who were entitled the door to swipe it open. This gives staff an
to have a card. opportunity to make face to face contact with
• Patients report feeling safe as this system is those entering the ward and clarify their
also useful to make it easier to exclude reason for visiting.
unwelcome visitors, especially those with
criminal intent. Key benefits or outcomes:
• Systems are in place to ensure that missing • A reduction in the number of occasions service
patients are reviewed clinically and users leave the ward without permission.
managerially following an episode where a • A reduction in missing persons
patient has left the ward without permission reporting average.
or agreement from staff. We have developed
a missing patient action plan, for those at • Continuous development of staff
highest risk, and post missing episode assessment and risk management skills.
interview process to help staff, and the • Clear information for service users and
service user, understand the reasons for their families regarding how to enter and
going missing. leave the ward.
• Improved relationships, joint working and
What did not work so well? shared protocols with our partner agencies
• Swipe card were initially placed on the inner including West Yorkshire Police, families
ward door. However we found that the time and carers.
delay was not sufficient. Swipe card system • Staff are better able to manage visitors by meeting
are now also in place on the outer ward door and greeting them at the door (and redirect
to enable an ‘airlock’ time delay. people who do not need to enter the ward).
• Staff initially needed further education • Service users value the use of the swipe card
regarding the system to ensure that there was system and are able to contribute to the
documented evidence that patients without decision making process regarding their own
keys had gone through an assessment process safety and wellbeing.
of showing consent not to have a key.
• It is a system that our service users have been
• The entrance to the unit (building) is now also consulted on and have reported having a
awaiting the swipe card system as there have positive experience of.
been issues regarding people being able to
leave the building.
Lessons learnt:
• Those without cards needing to enter The main entrance to our unit should have been
the ward (this could include visitors or a key consideration in implementing the swipe
community clinicians) needed to ring a card system. It was considered further along the
buzzer to be let in. The switch to open the process, when it became apparent that this was
door was behind the nurses’ station. the key area that

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patients were able to use to leave (as opposed to • At the point of each entry, service users and
the initial thoughts that the ward exit doors were visitors use an intercom system to either the
the main security issue). reception desk or ward
• The entrances are all managed on a magnetic
For more details contact: lock to both enter and leave the wards
Linda Rose, Acute Care Pathway Clinical • These principles are supported by ongoing
Governance Lead linda.rose@leedspft.nhs.uk 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,
EXAMPLE 4 and any changes in their mental health is
Managing entry and exit to the documented and is reflected in the assessment
acute wards in Doncaster acute taken prior to them leaving the ward.
inpatient wards
What worked well?
Rotherham Doncaster and South Humber
• Service users and their carers supported
Mental Health NHS Foundation Trust.
this change.
Issue(s) addressed re missing patients: • The mechanics of putting magnetic locks on
• In December 2007 the adult acute unit for the doors did not make it appear like a
Doncaster services moved from a no longer ‘fit secure/locked ward.
for purpose’ district general hospital site to a
newly built and refurbished unit.
What did not work so well?
• Within the new wards the layout resulted in
• Other services, community teams and visiting
service users being able to enter and leave the
professionals sometimes have a lower
wards without the knowledge of staff.
understanding about the issues and can see
the managed doors as an inconvenience.
Approach adopted to reduce the number • Publicity was limited to the immediate areas
of missing patients: and services whereas a wider programme of
• Principles around service delivery were communication would have improved the
reviewed against the backdrop of maintaining implementation process.
and respecting a person’s autonomy and also
keeping them safe during an acute mental
health episode. Key benefits or outcomes:
• The wards have a ‘safer’ feel to them – service
• As a result of this brief review the unit now
users/carers feel safer when on the unit and
operates the following principles:
are not likely to go missing from the wards.
• The entrance to the unit is via a single entrance
• Staff have greater confidence in the ward
• Each ward is also then only accessed by a layout and are more able to spend time
single route engaging with service users, rather than
watching and managing the doors.

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• People who do not have a legitimate reason to even a small number of clients being reported
be on the unit/wards do not gain access. as missing had a large impact on resources.
• There is greater staff focus and consequent • Staff were concerned by the fact that a
skill and knowledge regarding risk assessment. tiny number of clients would repeatedly
• All staff are aware of the whereabouts of each leave the ward.
service user and whether they are able to • Solihull had historically used its High Dependency
leave the ward. Unit (HDU) at times to manage clients who
• There has been a reduction in the number of frequently left the ward for unauthorised periods.
those who go missing from the wards. This unit had been under review due to its level of
occupancy reducing over the last couple of years.

Lessons learnt:
• Be brave, having managed doors does not Approach adopted to reduce the number
make the wards into a ‘secure’ unit. of missing patients:
A new approach was adopted using a service
• Publicise the change the a wide audience for user signing in and out whiteboard on one of
greater community sign up to the changes. the wards in order to:
• Encourage engagement/assessment and
For more details contact: interaction on leaving and returning to the ward.
Deborah Wildgoose, Nurse Consultant • Enable clearly identified times for leaving the
Deborah.wildgoose@rdash.nhs.uk 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
EXAMPLE 5 adhering to leave arrangements by
encouraging greater collaboration between
Empowering Service Users to staff and service users.
manage their leave by using a • Attempt to address the issues of boredom by
signing in and out board reviewing the model of care and significantly
Birmingham and Solihull Mental Health increase the number of occupational therapists
Trust – Solihull Directorate. and activity workers on the wards. This has
enabled an extended engagement and activity
Issue(s) addressed re missing patients: program to be developed.
• The Solihull wards had remained unlocked and • Currently the wards doors have remained
staff had historically avoided “door watching”, unlocked, although there has been consultation as
and focused, instead, on high levels of to whether service users would prefer the ward
therapeutic engagement to actively manage risk. entrance to be locked. The general feeling was
• Whilst the frequency of service users going that the current situation should remain with
missing from the wards was minimal, it was regards to leaving the ward, although access to
apparent from discussions with the police that enter the ward may be restricted due to the wards
being located within a main general hospital.

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• Activities offered have tried to focus on a • Incidents of frustration associated with leave
mixture of ward based and community activities, are minimal as service users report not feeling
for example striders and strollers and also locked in.
Retired Greyhound Walking which have proved • Feedback from service users identified that
very popular in reducing feelings of confinement they do prefer the wards to remain unlocked
and promoting the healthy living agenda. as they find this comforting.
• Service users do utilise the board and take
What worked well? responsibility for their leave.
• The majority of admissions to Solihull have
• The use of the HDU function has reduced to
been informal admissions. This has been in
part due to the fact that service users report such an extent that the 7 beds are no longer
required and this unit has been replaced with a
not feeling “locked in”.
single bedded extra care room on each ward.
• When staff have encouraged service users
to take responsibility for leave this has been
quite successful. Lessons learnt:
• There have been good examples of discussions • Developing a robust activity programme which
prior to and when returning from leave. focuses on exercise and community activities
reduces feelings of containment.
• The number of missing service user incidents
has remained low. • Using a signing in and out board can prove
effective when the whole team adopts an
approach of encouraging service users to take
What did not work so well? responsibility for leave.
• The signing in/out board has been used on one
of the wards for a number of years. At certain • There must be adequate staffing to ensure
times it tends to revert back to Staff recording there is engagement and discussion prior
on the board which could adversely impact to and returning from leave. Staffing levels
service users managing their leave. were reviewed using the NIMHE Acute
Workload Calculator.

Key benefits or outcomes:


• The wards currently remain unlocked. For more details contact:
• The numbers of patients taking unauthorized Martin Luke, Acting Deputy Director of
leave have remained minimal. Nursing martin.luke@bsmht.nhs.uk

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Strategy Three
Providing meaningful engagement
‘Meaningful engagement’ covers the Many issues that might lead to the patient going
broad spectrum of assessment, missing can be resolved quickly and easily by
planning, implementation and recognising the context of their lives and
understanding that individuals may have
evaluation of care, through the use of
different needs depending on their age, gender,
1:1 contact with the patient. This should disability, race, sexual orientation, belief or
be achieved collaboratively and needs religion. This needs to be understood in order to
to be meaningful to both the member of respond to them as individuals appropriately.
staff and the service user. The 1:1’s Attention also needs to be given to the patient’s
should continue throughout the feelings about their care and their environment,
patient’s admission. since discontent with this can also lead to the
patient choosing to leave over remaining in
Meaningful engagement is clearly evidenced hospital (Bowers et al, 1999). Good complaints
through the ‘Re-focusing’ work by Nick Bowles procedures need to be in place, as well as a
(2002), and ensures that all patients have the working culture of accepting and welcoming
opportunity once a day to discuss, explore and criticism and suggestions for improvement.
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 Task Checklist
as encouraging effective communication 1) Review risk management strategies including
between staff and service user. Engagement is effectiveness of observation and engaging
more likely to be successful and meaningful for policies. Consider the quality of any
both the nurse and patient, once trust and interactions during such times, as this is likely
rapport has been established. to have an impact on the patient’s experience
Assessment is a vital way of identifying and choices they make.
behaviour that could lead to the patient not 2) Check that training and instruction on issues
remaining on the ward, early on in a patient’s of risk assessment and positive meaningful
admission. Some risk factors to look out for engagement should “promote a sense of
include: early stages of admission, social personal responsibility on the part of the
responsibilities that need completing, patients service user” (Rae, 2007). This should be
who present a high risk to themselves or others, included on any trust induction package.
symptoms associated with illness and patients
with a history of going missing from mental 3) Consider replacing the term special
health units (Bowers, 1999). Good assessment 'observation' with special 'engagement', as it
skills are paramount in order to gather relevant would be preferable for the patient to have
information and interpret it accordingly. 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.

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4) Clearly identify, through risk assessment, 10) Check that all patients are made aware of
potential issues that might result in the who their nurse is for the shift/day. This
patient going missing (e.g. worried about could be done verbally by staff, possibly at a
their cat, property needs securing). patient’s ‘plan your day’ meeting, or through
Negotiate with patient a solution to their the use of a ward orientation board. All
concern, which benefits the patient and puts nursing staff need to ensure they know who
their mind at ease. If any actions are agreed their allocated patients are, and this can be
staff must follow it through to the end, or risk done via the handover at the
losing the trust that was established. commencement of the shift.

5) Recognise the importance of ensuring that 11) Regularly check that nursing staff approach
the patient understands the rationale for their allocated patients and offer 1:1 time, or
being admitted to the mental health unit. All arrange a time later in the shift. If a patient
aspects of their care and treatment needs to does not want to engage, then nursing staff
be explained and efforts made to ensure will need to enquire as to the reason why
continuity of their care whilst an inpatient. and document this accordingly.

6) Check that patients are regularly seen 12) Develop use of ‘protected time’ to ensure
by their primary, named or allocated nurse. that patients get undivided attention by ward
Ensure the engagement is needs related. staff. This period of time best occurs when
Try to match the skills of your staff to the there are no ward rounds and before
needs of the patient, whilst maintaining relatives visiting hours.
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 EXAMPLE 6
Therapy, Family Therapy, Cognitive The use of protected time
Behavioural Therapy, and Psycho-
Social Interventions. All of these therapies Greater Manchester West Mental
would help to increase the quality of 1:1 Health Foundation Trust
engagement and help to promote
Issue(s) addressed re missing patients:
recovery rates.
• Proactively engaging service users during
8) Staff need to be able to demonstrate inpatient admission.
evidence of any interactions with their
• Improved risk assessment.
patients, ensuring accurate record keeping (if
it hasn’t been written down, it didn’t happen!) • Increased ward based activity.
9) The shift co-coordinator needs to
allocate individual patients to staff members Approach adopted to reduce the number
at the commencement of the shift. Those of missing patients during protected time:
patients that have leave from the ward need • The nursing team gives all their time to the
to be assessed that morning prior to any patients on the ward.
leave, in order to assess for changes in
presenting risk. • Visitors are not allowed on the ward

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• No interdisciplinary work is conducted except What did not work so well?


in cases of emergency. • Nursing staff felt under pressure to ensure
• Telephone calls are diverted to the ward office-based tasks were completed.
administrator. • It is important to continually evaluate the
• All nursing staff are required to spend time progress and benefits through team meetings
with patients in communal areas, engaging in and individual supervision.
meaningful 1:1 or group sessions.
Key benefits or outcomes:
What worked well? • There is no empirical evidence to demonstrate
• This has proved to be a simple but effective that this approach has had a direct impact
method of promoting meaningful engagement. upon the reduction of service users going
Protected time is targeted to take place missing from hospital. It has however been
at times when an increased number of recognised that during the periods of protected
service users are likely to go missing and time there is a reduction in incidents on the
it complements a number of approaches ward that have previously been associated with
to address this problem. stress leading to service users going missing.

• Each protected period of time varies and is


dictated by the patient’s needs and desires: Lessons learnt:
Sometimes staff and patients have a general • Protected time provides an ideal opportunity
chat and everyone joins in, and on other for nurses to spend time with patients where
occasions people engage in quizzes with mixed by they are not distracted by other task
staff/patient teams. Protected time allows orientated duties.
nursing staff the opportunity to engage with • This adds to the service user experience
their allocated patient in a 1:1 if they have not and also supports the development of clinical
already done so. skills of nurses.
• Documentation and other office based activity
is important in the delivery of care on acute
inpatient wards. Protected time has helped For more details contact:
improve the balance between this and the Sheila Hulme, Deputy Ward Manager
opportunity for nurses to provide therapeutic Sheila.hulme@gmw.nhs.uk
engagement.

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Strategy Four
Structuring the day
Bowers et al (1999) reported that presenting symptoms (e.g. poor self esteem,
patients often leave mental health units anxiety, trauma). This will enable you to identify
because they feel trapped and a suitable activity or therapeutic programme.
claustrophobic, or disinterested and 3) Liaise with other professionals such as
bored whilst on our wards. Occupational Therapy, Psychology or
Support, Time and Recovery (STR) worker
A structured day provides patients with the to develop a range of therapeutic activity
opportunity to engage in meaningful and programmes for positive engagement, which
therapeutic activity. Examples of these include can be tailored to meet the diverse and
recovery groups, self esteem groups, and cultural needs of the individual. You can also
community meetings. We can also reduce ward develop links within the local community,
disturbances, and the tendency for violence by looking at drop-ins or volunteers to run
adequately structuring and resourcing our groups, service users to identify and facilitate
wards to enable diversional, recreational, and special interest groups. An employment
social activities to take place. worker could volunteer to attend a morning
A structured day not only occupies the patient, session and look at social inclusion work.
but helps with their symptoms by engaging 4) A patients meeting can be arranged to occur
them in therapeutic activity. It also encourages every weekday morning. This meeting can
social interaction. Patients are more likely to feel inform patients of the groups and activities
valued, because nursing staff are putting time for that day or the week ahead. Try to ensure
and effort into their recovery. attendance of as many patients as possible.
“We must ensure opportunities for exercise and 5) Staff need to maintain involvement in groups/
fresh air, or the need for observation, continuous activities. It not only offers staff a valuable
risk assessment, communication and giving of opportunity to build a therapeutic alliance
information, responsibility, and the development with patients, but also demonstrates that
of therapeutic alliances and effective personal nursing staff value the initiative.
support and care” (Rae, 2007 p15).
6) Display information about activities and groups
around the communal areas of the ward,
promoting available activities for the week
Task Checklist ahead, whilst ensuring that issues of translation
1) Positively promote activities to patients and and forms of communication that address the
staff. Encourage all patients and staff partially sighted etc are addressed. Ensure that
members to take part in therapeutic groups these activities include activities both on and off
and activities. the ward. Include this information in the
patient’s handbook, which is given to each
2) Through meaningful engagement and patient upon admission.
assessment, identify the patient’s interests and
needs. This can be achieved according to 7) Any identified group/activity needs to be
interest (e.g. music, sport, embroidery) or care planned, and regularly reviewed
according to changing needs.

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8) During 1:1 time with allocated staff members, • The project was to provide social and
assess the suitability for the day’s activity/ recreational activities between the hours of
group. 4.00pm and 8.0pm each weekday evening and
9) Ensure that activities also include those all day on Saturday and Sunday.
outside normal working hours (including • Workers were employed on a sessional basis.
evenings and weekends). Patients are more They had a variety of skills and experience in
likely to go missing when there is limited providing social and recreational activities.
activity on the ward.
• They were given a largely free hand to arrange
10) Document attendance at such activities. flexible and responsive programmes with
This information needs to be fed into service users on the wards.
the MDT meeting.

11) Groups and activities need to be


What worked well?
continuously reviewed, by seeking the
opinions of those involved. Seek service
• The pilot was evaluated as successful in that it
user suggestions for alternative groups. 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
EXAMPLE 7 service users in the identified ‘out of hours’ times.
Out of hours activities • The activity workers focus on the provision of
in Doncaster’s acute activities that are socially inclusive and support
service users maintaining contacts with their
inpatient wards communities. Working alongside the OT and
Rotherham Doncaster and South Humber nursing staff, they facilitate out of hours
Mental Health NHS Foundation Trust. activities on the wards that may then be
continued within the community once a
Issue(s) addressed re missing patients: persons’ hospital stay has ended.
It is well documented that the underlying social
and therapy needs of service users on acute • The Out Of Hours service is now a highly
wards have not been well met. Acute Problems regarded embedded component of acute care
(SCMH, 1998) suggested that 40% of service within the Doncaster adult inpatient service.
users received no social or recreational activity at
all during their stay. This results in long episodes What did not work so well?
of boredom and a disconnection for service users As a result of the hours worked by the out of
with their own social communities. When bored hours activity workers, there was a feeling of
and discontented service users leave the ward in being disconnected with the ward staff. This is an
search of other connection and recreation. ongoing issue that requires particular attention to
ensure their integration within the ward teams.
Approach adopted to reduce the number
of missing patients: Key benefits or outcomes:
• A pilot was run for 3 months within the two • The numbers of those who go missing from the
Doncaster adult acute admission wards and PICU. Doncaster wards was initially low. However as

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part of the project evaluation the most inspector tasked with tackling the problem.
commonly reported outcome for service users The result of the process was a revised multi-
was reduced levels of stress, both on a personal agency response to patients going missing
level as well as that of the environment. from hospital.
• The project was described as having provided • Patients feeling bored in hospital.
comfort, enjoyment and a sense of fun in an • Lack of therapeutic engagement.
acute inpatient setting.
• Lack of support for female service users.

Lessons learnt:
• Running the project as a pilot gave the Approach adopted to reduce the number
opportunity to see it work in practice and of missing patients:
measure the outcomes prior to rolling it out. • Proactive risk management plans considered
the proportional response to individuals should
• ‘Therapy’ should be defined by patient need they become missing, based on risk and past
and as such can range from formal 1:1 work patterns of behaviour.
to an informal shopping trip.
• The policy also recognised the difference
• A small investment can make massive changes. between those absent without leave
(whereabouts known) and those who were
truly missing (whereabouts unknown) and
For more details contact: introduced an escalation of welfare checks
Deborah Wildgoose, Nurse Consultant to identify whereabouts before triggering the
Deborah.wildgoose@rdash.nhs.uk 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
EXAMPLE 8 associated increased awareness of the issue
led to a reduction of cases logged with the
Multi-agency policy development police in the subsequent year (below 300).
for missing patients • When the hospital was first opened in 2001 a
North Staffordshire Combined team of diversional activity workers was
Healthcare NHS Trust developed across the acute inpatient service to
offer direct engagement with patients in group
Issue(s) addressed re missing patients: or individual sessions offering a range of ‘low
• In 2002-4 the Harplands Hospital, a provision key’ activities particularly designed to tackle
of nine mental health wards located close to the need to occupy patients in meaningful
the acute care hospitals of the city of Stoke- activities (in line with ‘Acute Concerns’). This
on-Trent, had a disproportionate amount of service together with a ‘central therapies’
missing person incidents logged with the police provision has evolved into our current provision
(around 400 incidents a year). of therapeutic programmes offering a layered
• This problem acted as the trigger for joint approach to meaningful engagement in
working between the hospital and a local police activities and therapies.

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


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

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• patients benefit from a full programme of The heart of Star Wards’ work is inspiring a full
daily activities programme of daily activities for inpatients.
• patients retain and build on our community ties. • While we don’t have specific data on our
Star Wards was created following the impact on reducing the numbers of patients
experiences of Bright’s Director, Marion Janner, going missing, our fist national members’
as a detained inpatient. We are constantly survey showed that 50% had experienced a
discovering NHS hospitals which are providing an reduction of violence as a result of taking part
exceptionally high quality of service to inpatients, in Star Wards.
including those with the most complex and • As the factors related to violence and missing
challenging needs. Over 500 wards are patients are similar (eg quality of relationships
members, including forensic, eating disorder, with staff), it is likely that involvement with Star
learning disability, elderly and children and Wards has a positive effect on enabling
adolescents wards. They are providing a fabulous patients to remain on the ward.
range of meaningful therapeutic, social and • The problem-solving and creativity skills that
recreational opportunities for enriching staff deploy through their involvement can be
inpatients’ experiences. applied with great effect to addressing the
individual factors motivating potential incidents
Key benefits or outcomes: of patients leaving the ward when it’s not safe
• “Better client feedback, increased staff for them to do so.
satisfaction, less aggression and violence,
more therapeutic contact”
For more details contact:
• The pioneering research on missing patients by
Len Bowers and colleagues at City University
www.starwards.org.uk or
identified that providing meaningful activities for
marion@brightplace.org.uk
patients is a key element in reducing this risk.

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Strategy Five
Engaging stakeholders
If initial assessment and interventions Missing patient incidents take up many hours of
have failed, and the patient goes valuable nursing and police time. Any
missing from the mental health unit or opportunity to save time and resource need to
be seized, while still maintaining patient and
fails to return from leave, effective
public safety.
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 Task Checklist
such as the police of each other’s roles 1) Develop a missing person’s policy, with
and responsibilities. Therefore, it is integrated joint protocol with local police
good practice to have a policy for force. Consider using Missing Patients
Toolkit: A Resource for acute hospitals,
missing patients which includes a
community hospitals and mental health
locally agreed integrated protocol of units (see Reference section for details).
what can and cannot be done, in
relation to locating and returning those 2) Have pertinent information about patients to
patients back to the ward. hand. Gather this information upon admission
to the ward. It should include a full
In reporting a missing patient, the police will description of the patient, the name and
require certain information about the patient. contact details of next of kin, the patient’s
Such information needs to be readily available in present and past risks (if relevant), contact
the patient’s notes, prior to such an incident details of family and friends, also any
occurring (e.g. a description of the patient information of where the patient may go.
should be gathered upon admission). This
ensures good communication with the police, 3) Services will need to make sure that services
and help to achieve a timely and safe return of users, relatives and carers are aware of the
the patient. purpose of acute care, ie to provide safe and
sound interventions, to assess and respond to
Other people who are often involved when acute manifestations, and for relatives/carers
patients go missing are carers and relatives. to understand inherent risks (Rae 2007).
We often rely on relatives to inform us if a
patient turns up at their home. This can put 4) Arrange regular meetings with police to
them in compromising positions, as patients address and update issues. Seek agreement
can then believe that their relatives are with local police force for the effective joint
‘informing’ on them rather than helping to management of missing patient incidents.
ensure their safety. It is often upsetting and 5) Invite the Police to visit the unit to understand
worrying for relatives and carers to find out that how mental health units operate. Develop a
their loved ones are missing. shared understanding of each other’s roles and
responsibilities in relation to missing patients.

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6) Attempt to develop a good working What did not work so well?


relationship with family members or carers. Initially these meetings took place on a quarterly
This could be done by inviting them to MDT basis. This was not frequent enough and was
meetings, or by encouraging regular contact therefore increased to monthly.
with nursing team. Clearly, this would need to
be done within the boundaries of
confidentiality. Make carers/relatives aware of Key benefits or outcomes:
the role of nursing staff, the ward • Prior to the regular police liaison meetings, the
environment, including the limitations of service operated in a reactive manner to issues
nursing strategies. 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
EXAMPLE 10 operational staff within both services.
Police Liaison • Through the regular meetings, with missing
Greater Manchester West Mental Health patients as a regular agenda item, a shared
Foundation Trust understanding of the problem was developed.
Whilst this cannot be evidenced as reducing
Issue(s) addressed re missing patients: incidents, it formed an essential component of
• Inter-agency Collaboration the “Salford Absconding Project” highlighted in
• Information Sharing. Good Practice Example 1.

Approach adopted to reduce the number Lessons learnt:


of missing patients: • Where there is a problem that causes a drain
Establishment of regular Police Liaison Meetings. on another organisation’s resources,
relationships can become strained when
reactive approaches are employed.
What worked well?
• It created a regular opportunity to discuss the • Through the regular liaison meetings it has been
problems experienced by both services in order possible to develop a more proactive approach
to identify collaborative solutions. to problem solving with longer term benefits.

• It provided the opportunity to resolve issues


at a strategic level. For more details contact:
David Bartholomew, Senior Manager Adult
Services David.Bartholomew@gmw.nhs.uk

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Appendix One
The five strategy self-assessment tool
The self-assessment tool template can You may find it useful to share the tool in
be downloaded as a user friendly word advance and encourage members of staff to
document from www.virtualward.org.uk think about the statements before the meeting.

Scoring and
Introduction Incident evaluation
Each of the five good practice strategies has a To understand the effectiveness of the strategies
self-assessment tool linked to it. The purpose of within the guidance it is necessary to look at
this tool is for you to assess where you are in changes in the nature of incidents within the
relation to the strategy. service. One way of doing this is to complete a
quarterly evaluation of the score. It is anticipated
Complete red, amber or green as appropriate that there will be a positive correlation between
for the statement, which most nearly matches understanding the degree to which the strategies
the situation on your ward. are being implemented and the number of
Choosing red indicates that you are not reported incidents: i.e. if a service is achieving
achieving this strategy. Therefore you would 100% green on all strategies, they could expect to
move to the development planning stage. How have a reduction in incidents, both serious and
you go about planning and implementing is none serious. Conversely, a service that has 100%
entirely up to you. We would recommend group red could expect to have a high level of incidents.
discussion with colleagues, patients and carers. It is not necessary to measure against all
Enter in the Development Plan what is required incidents but is suggested that information on
to achieve the strategy. the following categories are used:
Choosing amber highlights that the strategy is only 1) Incidents of patients going missing.
partially being achieved, and that more planning
2) Incidents of self harm
and developmental work needs to be done in this
area to achieve the full strategy. Again you should 3) Incidents of verbal abuse/threatening behaviour.
enter in the Development Plan what is required to 4) Incidents of actual violence.
meet the strategy. Evidence demonstrating partial
achievement would also need to be present. 5) Incidents of property damage.

If green is chosen this means that you are Through completing a quarterly evaluation
achieving this strategy. Evidence to support this against incidents reported, it is possible to track
need be documented. progress not only with regard to reduction in
missing patients but also the overall impact.
Each tool will not take too long to complete, but it
will be important to allow enough time for This information can be used to generate
discussion. Your team should ideally complete the a report as needed as one means of
tool collectively, having met and discussed it fully. evaluating effectiveness.

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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.

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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.

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

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

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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.

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Literature Review. Journal of Psychiatric and Mental A review of NHS Acute Inpatient mental health services.
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/The_pathway_to_recovery_200807251020.pdf
Bowers L., Jarrett M., Clarke N., Kiyimba F., and
McFarlane L. (1999, a) Absconding: Why patients leave, Meehan T., Morrison P., and McDougall S., (1999)
part 1. Journal of Psychiatric and Mental Health Nursing 6, Absconding Behaviour: An Exploratory Investigation in
199-205. an Acute Inpatient Unit. Australian and New Zealand
Journal of Psychiatry 33:533-537.
Bowers L., Jarrett M., Clarke N., Kiyimba F., and
McFarlane L. (1999, b) Absconding: How and when National Institute for Mental Health in England (NIMHE)
patients leave, part 2. Journal of Psychiatric and Mental (2006) National Suicide Prevention Strategy for England:
Health Nursing 6, 207-211. Annual audit report on progress.
www.nimhe.csip.org.uk/silo/files/national-suicide-
Bowers L., Jarrett M., Clarke N., Kiyimba F., and McFarlane prevention-strategy-for-england-annual-report-on-
L. (1999, c) Absconding: Outcome and risk, part 3. Journal progress-2006.pdf
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National Patient Safety Agency (NPSA) (2008): 7 Steps to
Bowers L , Simpson A (2004). Runaway Success. Nursing patient safety in mental health
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Bowers L., Simpson A., and Alexander J. (2005) Real
World Application of An Intervention To Reduce North East Yorkshire and North Lincolnshire Strategic
Absconding. Journal of Psychiatric and Mental Health Health Authority/National Patient Safety Agency (2007).
Nursing 12, 598-602. Missing Patients Toolkit: A Resource for acute
hospitals, community hospitals and mental health
Bowles N., Dodd P., Hackney D., Sunderland C., and
units, developed by trusts in the North and East
Thomas P. (2002) Formal Observations and Engagement:
Yorkshire and Northern Lincolnshire area.
A Discussion Paper. Journal of Psychiatric and Mental
http://www.nimhe.csip.org.uk/silo/files/neynl-sha-missing-
Health Nursing 9, 255-260.
patients-toolkitdoc.doc
Clark N., Kiyimba F., Bowers L., Jarrett M., and McFarlane L.
Rae, M (NIMHE 2007) Review of open door policy in
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acute inpatient wards: A discussion paper.
Journal of Psychiatric and Mental Health Nursing 6, 219-224.
http://www.nimhe.csip.org.uk/silo/files/reviewofopendoorsfi
Care Services Improvement Partnership: National Institute nalapril20072doc.doc
for Mental Health in England (2005) Acute workload
Sainsbury Centre for Mental Health (SCMH) (1998) Acute
calculator. http://www.westmidlands.csip.org.uk/mental-
Problems; A survey of the quality of care in acute
health/mental-health/acute-inpatient-programme-for-2007-
psychiatric wards
-08/acute-workload-calculator.html
http://www.scmh.org.uk/publications/acute_problems.aspx
City University Department of Mental Health and Learning ?ID=187
Disability Anti-Absconding self-training package for ward
Star Wards – a service user led initiative to improve
staff. http://www.citypsych.com/index.html
positive user engagement www.starwards.org.uk
Department of Health (2006) From Values to Action: The
The University of Manchester (2006). Avoidable Deaths.
Chief Nursing Officer’s review of mental health nursing.
Five Year Report of the National Confidential Inquiry
http://www.dh.gov.uk/en/Publicationsandstatistics/Publicati
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Health Illness.

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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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