Mansoor Zaman

From Baroness Merron 
Parliamentary Under-Secretary of State for 
Women’s Health and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

Our ref: PFD 26-02-06 – ZAMAN 

HM Coroner Graeme Irvine 
East London Coroner’s Court, Queens Road, Walthamstow,  
London E17 8QP 
020 8496 5000 

Coroners@walthamforest.gov.uk 

Dear Mr Irvine, 

25 March 2026 

Thank you for the Regulation 28 report of 6 February 2026 sent to the Secretary of State for 
the Department of Health and Social Care about the death of Mansoor Dawud Zaman. I am 
replying  as  the  Parliamentary  Under-Secretary  of  State  for  Women’s  Health  and  Mental 
Health.        

I would first like to express how saddened I was to read of the circumstances of Mr Zaman’s 
death  and  wish  to  extend  my  condolences  to  his  family.  The  circumstances  your  report 
describes are concerning and I am grateful to you for bringing these concerning matters to 
my attention in your Report.  

The report raises concerns over the following: 

1.  The  failure  of  nurses  on  the  ward  to  instigate an  authorisation under S.5(4) MHA  1983 
when Mr Zaman returned to the ward after absconding on the afternoon of 8th December 
2024.  
2.  The  failure  of  nursing  staff on the  ward  to  adequately document  observations and  care 
decisions.  
3. The failure of Trust staff to reappraise the level of risk presented by Mr Zaman to himself 
and others in light of his erratic behaviour on 8th December 2024, specifically,  
a. His escape from the ward by violently kicking the fire exit door.  
b. His aggression toward the duty doctor during assessment.  
c. His assault upon a member of ward staff.  

4. His second escape from the ward in identical circumstances to the first. The failure of Trust 
staff to re-assess the frequency and quality of observations that Mr Zaman should be subject 
to during the afternoon of 8th December 2024.  
5. The failure of the duty doctor to act decisively and impose an authorisation under S.5 (2) 
MHA 1983 having been presented with an agitated patient who had minutes before escaped 
from the ward.  

 
 
 
 
 
 
 
 
 
 
  
  
 
 6. The dilatory response of staff on the ward to report Mr Zaman as a missing person to the 
police, an action that did not happen for almost three hours after it was known that he had 
absconded.  
7. The categorisation of the risk presented by Mr Zaman as of a medium level by the nurse 
in charge when considering action to be taken after he absconded.  
8. The use of the police 101 number as opposed to the required emergency 999 number to 
make the report.  
9. The inadequacy of the Trust patient safety framework investigation which neither sought 
the recollections of treating staff, nor communicated the findings of the report to the same 
staff. 

My  officials  have  raised  this  case  with  the  Care  Quality  Commission,  responsible  for  the 
regulatory oversight of specified health, adult social care and mental health services, to seek 
assurances that the appropriate actions are being taken in response to this sad case. CQC 
have shared the following actions: 

CQC attended a regular engagement meeting with East London Foundation Trust on 18 
March. The trust updated CQC on their progress with investigating and learning from this 
specific incident. The trust recognised that the original PSII investigation report had not 
robustly covered one aspect of the incident and have commissioned a supplemental 
investigation and report relating to this incident. They are also reviewing governance 
processes to identify why this happened and reflect on learning in relation to this.  

The original PSII report identified two areas for improvement, and the trust have already 
made changes. They have reviewed processes in relation to the administration of the MHA 
on the ward, with refresher information provided to staff. Environmental safety and security 
in relation to accessing and leaving the ward, with a focus on fire doors, have also been 
reviewed. 

The supplemental investigation report and trust response to the coroner will be shared with 
CQC in early April. At this time the operational inspection team with support from the 
enforcement team expect to conclude their initial review of evidence in relation to this 
specific incident to inform a decision about whether further investigation work is needed. 

CQC carried out a comprehensive inspection of acute and PICU wards at the Trust in late 
2025, and are currently drafting the findings. CQC will continue to follow up on this incident 
through regular engagement with the Trust, looking at lessons learned and how these have 
been implemented and shared. They will also examine whether there are any emerging 
risks in relation to this incident and these can be followed up in a well led assessment 
planned for later in the year. 

CQC Mental Health Act review colleagues will use the information relating to the use of 
Section 5(2) powers as intelligence during their ongoing programme of MHA review visits. 

More widely, the changes we are making as part of the 10 Year Health Plan will improve 
quality and safety by making it clear where responsibility and accountability sits at all levels 
of the system. NHS England’s mental health, learning disability and autism inpatient quality 
transformation programme will support cultural change and a new model of care for the 
future across all NHS-funded mental health inpatient settings.  

 
 
 
  
 
  
 
 I hope the information provided has been of help. I am copying this response to Jim Mackay, 
CEO of NHS England, and look forward to the response from the East London Foundation 
NHS Trust (ELFT) Trust, whom I hope will thoroughly address the matters of concern set out 
in your Report.  

Thank you for bringing these concerns to my attention.   

Yours sincerely,  

BARONESS MERRON

Office of the Chief Medical Officer
Trust Headquarters
Robert Dolan House
5th Floor
9 Alie Street
London E1 8DE

Telephone: 
Email:  

Website: http://www.elft.nhs.uk

Private & Confidential 

For the attention of HMC Graeme Irvine 
East London Coroners Court 
124 Queens Road Walthamstow, E17 8QP 
Email: coroners@walthamforest.gov.uk 

06 April 2026 

Dear Sir,  

RE:  RESPONSE TO REGULATION 28  

1. 

I write to provide the Trust’s response to the concerns that you raised at the conclusion of 

the inquest touching the death of Mr Mansoor Zaman as set out below: 

Concern 1 – The failure of nurses on the ward to instigate an authorisation under s.5(4) MHA 
1983 when Mr Zaman returned to the ward after absconding on the afternoon of 8th December 
2024. 

Concern 2 –The failure of nursing staff on the ward to adequately document observations and 
care decision. 

Concern 3 – The failure of Trust staff to reappraise the level of risk presented by Mr Zaman to 
himself and others in light of his erratic behaviour on 8th December 2024, specifically,  

a – His escape from the ward by violently kicking the fire exit door;  
b – His aggression toward the duty doctor during assessment;  
c – His assault upon a member of ward staff  

Concern 4 – His second escape from the ward in identical circumstances to the first. The failure 
of Trust staff to re-assess the frequency and quality of observations that Mr Zaman should be 
subject to during the afternoon of 8th December 2024. 

Concern 5 – The failure of the duty doctor to act decisively and impose an authorisation under 
s.5(2)  MHA  1983  having  been  presented  with  an  agitated  patient  who  had  minutes  before 
escaped from the ward. 

Concern 6 – The dilatory response of staff on the ward to report Mr Zaman as a missing person 
to the police, an action that did not happen for almost three hours after it was known that he 
had absconded. 

Concern 7 – The categorisation of the risk presented by Mr Zaman as of a medium level by the 
nurse in charge when considering action to be taken after he absconded. 

Chief Executive: 

Chair:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 8 – The use of the police 101 number as opposed to the required emergency 999 
number to make the report. 

Concern 9 – The inadequacy of the Trust patient safety framework investigation which neither 
sought  the  recollections  of  treating  staff,  nor  communicated  the  findings  of  the  report  to  the 
same staff.  

2. 

I gratefully note your observations and seek to assure HM Coroner and the family of Mr 

Zaman  that  the  Trust  has  undertaken  a  great  deal  of  reflection  and  learning  since  Mr 

Zaman’s very sad death on 29 December 2024.  

3. 

I asked the Trust’s Risk and Governance Team to complete an addendum to the Patient 

Safety Investigation (the ‘Addendum’) into Mr Zamon’s death. The purpose was to provide 

additional context and clarification on aspects of care that were not explored in the Trust’s 

PSII as well as to support Newham Centre for Mental Health (NCfMH) to put into place 

robust and meaningful actions to address these concerns and prevent future deaths.  

4. 

I understand the Addendum has been disclosed with this response and provided to the 

family of Mr Zamon. 

5.  Please  find  our  response  to  each  concern  under  the  themes:  Risk  Assessment, 
Observations,  Holding  Powers,  AWOL  response,  Record  Keeping  and  Patient  Safety 
Investigation response.   

RISK ASSESSMENT 

•  Concern  3  –  The  failure  of  Trust  staff  to  reappraise  the  level  of  risk  presented  by  Mr 
Zaman  to  himself  and  others  in  light  of  his  erratic  behaviour  on  8th  December  2024, 
specifically,  

a – His escape from the ward by violently kicking the fire exit door;  
b – His aggression toward the duty doctor during assessment;  
c – His assault upon a member of ward staff  

•  Concern 7 – The categorisation of the risk presented by Mr Zaman as of a medium level 

by the nurse in charge when considering action to be taken after he absconded. 

6.  The  Addendum  highlights  that  identifying  risk  in  service-users  requires  clinical  staff  to 

consider  a  combination  of  structured  assessment,  ongoing  observation,  and  dynamic 

clinical judgement in real time. Relevant factors included in this process are the service 

user’s history of violence, self-harm, suicide attempts, and previous AWOL episodes. 

Chief Executive: 

Chair: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7. 

It is not clear that this was done consistently and in real time on the day Mr Zamon left 

Ruby Triage Ward (the ‘Ward’). There was a significant delay in updating the RiO Adult  

Risk Assessment after Mr Zamon’s first unauthorised absence. It also did not identify that 

he was high risk. The telephone call to the duty/resident doctor to attend Ruby Triage 

Ward (the ‘Ward’) indicates that there was an appreciation by staff that Mr Zaman’s risk 

was increasing. However,  when the duty resident  doctor stopped the clerking process 

due  to  Mr  Zaman’s  increasing  aggression  to  discuss  the  use  of  Section  5(2)  with  the 

senior on-call doctor, then Mr Zamon assaulted a member of ward staff and left the ward 

for a second time, it is not clear that ward staff appreciated Mr Zaman’s increased risk. 

Whilst actions were undertaken, they did not reflect the appropriate level of risk. 

8. 

It does appear that the senior nurse did not appreciate that Mr Zaman’s risk was high 

until the police were called three hours later and that level of risk was considered by her 

to be due to the amount of time that had passed since he absconded from the Ward, not 

his presentation during the incident. 

9. 

I  discuss  the  actions  the  Trust  is  taking  to  improve  the  quality  of  its  risk  assessment 

amongst staff in the section on observations below as the two issues are inter-linked.  

OBSERVATIONS: 

•  Concern 4 – His second escape from the ward in identical circumstances to the first. The 
failure  of  Trust  staff  to  re-assess  the  frequency  and  quality  of  observations  that  Mr 
Zaman should be subject to during the afternoon of 8th December 2024. 

10.  The  Addendum  also  notes  that  Mr  Zaman’s  observation  levels  were  not  increased  to 

reflect the heightened risk following his first unauthorised exit. Continuous 1:1 eyesight 

observation should have been considered at that time. Additionally, zonal observations 

on the fire exit would have been appropriate and would have illustrated an appreciation 

of increasing risk. It appears that zonal observations were considered, though they were 

not implemented because of the rapidly changing clinical situation. 

11.  To improve staff risk assessment and observation practice the Ward staff will undertake 

mandatory  refresher 

training  on  completing  structured  risk  assessments  and 

documenting  dynamic  changes  in  risk.  This  includes  practical  guidance  on  when 

observations should be increased and when zonal observations should be used. It will 

also highlight clear expectations for recording changes in presentation in real time. This 

will take place within the next two months. 

12.  Compliance with training will be monitored by monthly audits of 10 randomly selected risk 

Chief Executive: 

Chair: 

 
 
 
 
 
 
 
 
 
 
 
 
 assessments.  Audits  have  an  expected  compliance  rate  of  at  least  90%  for 

documentation of key risk factors and dynamic risks. 

13.   Further, MDT communication will be strengthened by the continued implementation of 

the Relational Security Initiative at NCfMH (the ‘Initiative’).  Relational security refers to 

clinicians’ knowledge and understanding of service users and their environment, and the 

translation of that information into meaningful care. Since August 2024, several phases 

of the Initiative have been completed including training facilitators, unit-wide events and 

on-ward  'bite-size'  sessions  with  staff  teams.  At  the  next  session,  the  application  of 

Relational Security to this incident will be considered. It is anticipated the training will aid 

clear team--based discussion, documentation, and shared decision-making whenever a 

patient’s risk level changes or escalation is being considered 

HOLDING POWERS 

•  Concern 1 – The failure of nurses on the ward to instigate an authorisation under s.5(4) 
MHA 1983 when Mr Zaman returned to the ward after absconding on the afternoon of 8th 
December 2024. 

•  Concern 5 – The failure of the duty doctor to act decisively and impose an authorisation 
under s.5(2) MHA 1983 having been presented with an agitated patient who had minutes 
before escaped from the ward. 

14.  I have discussed HM Coroner’s concerns surrounding the use of section 5(4) and s.5(2) holding 
powers  with  the  Trust’s  Associate  Director  of  Mental  Health  Law  and  the  Trust’s  external 
solicitors. In relation to Concern 1 it is helpful to set out section 5(4) of the Mental Health Act 
1983 (MHA).  

“If, in the case of a patient who is receiving treatment for mental disorder as an in-patient in a 
hospital, it appears to a nurse of the prescribed class— 

(a)  that the patient is suffering from mental disorder to such a degree that it is necessary for 
his health or safety or for the protection of others for him to be immediately restrained from 
leaving the hospital; and 

(b)  that it is not practicable to secure the immediate attendance of a practitioner or clinician for 

the purpose of furnishing a report under subsection (2) above” 

15.  Section 5(4)  is clear that the power should  only be invoked if the  immediate attendance of a 
doctor may not be secured. It is the Trust’s expectation that a nurse should be able to secure 
the immediate attendance of a doctor or approved clinician. During the day, regular medical staff 
will generally be present on the ward. At night or “out of hours” there is a medical staff member 
on duty for this purpose. 

16.  It is possible that a situation may arise where immediate attendance is not possible. An example 
of this would be where the ‘out of hours’ duty doctor is attending to an emergency on another 
ward. In that case it is appropriate for the nurse to invoke section 5(4) for up to six hours after 
they first carry out an assessment in line with paragraph 18.29 of the MHA Code of Practice.  

Chief Executive: L

Chair: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 17.  In the present case, the immediate attendance of a doctor was secured. Therefore, section 

5(4) powers were not lawfully available for the nurse to invoke. 

18.   In relation to Concern 5, I set out section 5(2) of the MHA. 

‘If, in the case of a patient who is an in-patient in a hospital, it appears to the registered medical 
practitioner or approved clinician in charge of the treatment of the patient that an application 
ought to be made under this Part of this Act for the admission of the patient to hospital, he may 
furnish to the managers a report in writing to that effect; and in any such case the patient may 
be  detained  in  the  hospital  for  a  period  of  72  hours  from  the  time  when  the  report  is  so 
furnished.’  

19.  The MHA Code of Practice is also relevant and it further states at paragraph 18.4, set out 

below:.  

‘Doctors should not be nominated as a deputy unless they are competent to perform the role. If 
nominated deputies are not approved clinicians (or doctors approved under section 12 of the 
Act), they should wherever possible seek advice from the person for whom they are 
deputising, or from someone else who is an approved clinician or section 12 approved doctor, 
before using section 5(2). Hospital managers should see that arrangements are in place to 
allow nominated deputies to do this.’ 

20.  The Mental Health Act Manual 28th Edition, by Richard Jones further states,  

‘the nominated clinician, who could be a junior doctor, should exercise her own judgement 
when exercising the power under s5(2). She can be advised but not required to consult with a 
senior colleague before exercising the power.’ 

21.  The junior doctor in this case was the nominated deputy. They are not an approved clinician 
nor approved under Section 12 of the Act. They promptly sought the advice of a more senior 
doctor, who was section 12 approved. This was the arrangement in place on 8 December 
2024 for nominated deputies. They were not required to consult the senior doctor. However, it 
is the Trust view that it was good practice (and in line with the MHA Code of Practice) for them 
to do so considering the situation was high risk but did not yet present with an immediate life-
threatening emergency. 

22.  It is important to note, that neither Section 5(2) or 5(4) provide the same powers to clinicians 
as section 2 or 3 of the MHA. It is only a holding power and does not allow for treatment 
(including rapid tranquilisation). Under section 5(2) or 5 (4) rapid tranquilisation would require 
consent of the patient as per section 4 (3)(b) of the MHA and paragraph 18.41 of the MHA 
Code of Practice. The latter states: 

“Detaining patients under section 5 does not confer any power under the Act to treat them 
without their consent. The rules in part 4 of the Act do not apply to these patients. In other 
words, they are in exactly the same position as patients who are not detained under the Act in 
respect of consent to treatment.” 

23.  The Trust is of the view that rapid tranquilisation is generally not an appropriate method for 

enforcing detention. In rapidly escalating emergency situations, the Mental Capacity Act 2005 
or possibly the common law may be available to clinicians to support the use of rapid 
tranquilisation. It may not be appropriate to wait for holding powers in those situations. 
However, without further detailed exploration of those options, it is unclear to me if they would 
have been appropriate in this instance. 

Chief Executive:

Chair:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 24.  That said, I was appraised of the oral evidence heard at inquest. The explanations provided by 
some (but not all) of the staff as to how section 5(4) or 5(2) are used were not in-line with the 
legal requirements set out in the MHA. This is a matter of concern to the Trust. Consequently, 
at the time of inquest, I requested that the ward staff undergo refresher training in relation to 
their holding powers. This took place on 25 February 2026. Within the next 6 months, the 
Associate Director of Mental Health Law is going to hold a further refresher session with the all 
the ward staff to include situations when the MCA may be used in an emergency. They will 
also update the rapid tranquilisation policy to ensure it restates this position with clarity.  

AWOL RESPONSE 

•  Concern 6 – The dilatory response of staff on the ward to report Mr Zaman as a missing 
person to the police, an action that did not happen for almost three hours after it was 
known that he had absconded. 

•  Concern 8 – The use of the police 101 number as opposed to the required emergency 

999 number to make the report. 

25.  The Addendum sets out that the Trust’s AWOL Policy in place at the time of the incident, requires 
the nurse in charge to take immediate action. Accordingly, the Duty Senior Nurse and the junior 
doctor was notified that Mr Zaman absconded. The on-call doctor asked the nurse in charge to 
contact the police and to inform medical staff if he returned. This was repeated to the ward staff 
after the junior doctor spoke to the senior doctor again and confirmed that the police should be 
called. 

26.  The nurse in charge proceeded on the basis that further local actions were appropriate before 
police escalation. This was in line with the AWOL policy, including initiating a search of the ward 
and surrounding external areas and making several calls to the nearest relative. The incident 
was reported to police around 3 hours after Mr Zaman left the ward for the second time.  

27.  It appears the nurse in charge was still working on the basis that Mr Zaman was medium risk. 
This explains why the police were called via 101. Under the AWOL policy, 101 would normally 
be  used  for  a  medium-risk  absence,  while  999  would  be  expected  where  the  patient  is 
considered high risk. However, with time, Mr A was described as high risk when the 101 call 
was made. 

28.  I agree that Mr Zaman was a high risk, missing person. His absence should have been reported 
via  999,  and  an  AWOL  Grab  Pack  should  also  have  been  completed  to  support  the  police 
response in line with the  London AWOL and Missing Persons Policy and the Pan-London Joint 
AWOL Policy, 

29.  You heard at the inquest that the Trust’s AWOL policy has been refined and makes it clear when 
999  should  be  called.  Additionally,  within  the  next  two  months,  the  ward  staff  will  undergo 
refresher training on both policies and understand how they apply together in practice, so that 
AWOL procedures are followed consistently and safely. 

30.  The senior clinical team will also develop and implement mandatory AWOL policy training for all 
clinical staff, including a competency assessment covering both the Trust AWOL Policy and the 
Pan-London Joint AWOL Policy. 

Chief Executive: 

Chair:

 
 
 
 
 
 
 
 
 
 
 
 
 
 DOCUMENTATION AND COMMUNICATION 

•  Concern 2 –The failure of nursing staff on the ward to adequately document observations 

and care decision. 

31.  The addendum makes it clear that information on risk, observations and care decisions were  
not  consistently  documented.  This  included  telephone  calls  made  to  the  nearest  relative,  the 
one-to-one discussions with the nurse in charge, and the absence of a dedicated LFPSE report 
for the second absconsion. 

32.  The  Relational  Security  Initiative  outlined  under  the  Observations  section  above  will 

reinforce the importance of accurate and timely documentation.  

PATIENT SAFETY INVESTIGATION RESPONSE  

•  Concern 9 – The inadequacy of the Trust patient safety framework investigation which 
neither sought the recollections of treating staff, nor communicated the findings of the 
report to the same staff.  

33.  I understand it is frustrating that recollections of all staff are not always sought in PSIIs 
nor the findings communicated to all staff. Unfortunately,  it  is sometimes a balance of 
trying  to  obtain  all  clinician  accounts  (due  to  things  such  as  sick  leave)  versus  timely 
completion  of  the  investigation.  The  same  applies  to  feedback  sessions.  Though,  to 
mitigate  these  issues,  when  staff  are  unable  to  attend  feedback  sessions  they  are 
routinely provided with a copy of the final report via email and asked to comment on it. 

34.  The Risk and Governance team has been apprised of your concerns and asked to keep 
it in mind to ensure when these situations arise they are achieving the correct balance. 

Conclusion  

35.  I hope this response provides sufficient reassurances to you and to the family of Mr Zaman 

about the learning that has taken place at the Trust since his sad death.   

36.  I would like to offer my sincere and heart-felt condolences to his family at this difficult time.    

Chief Medical Officer 

Chief Executive: 

Chair:

Patient Safety Incident Investigation (PSII) 

Addendum to Final Report 

Incident ID number: 

Date incident occurred: 

30th December 2024 

Incident type 

Death of an Adult Service User 

Directorate 

Service 

Report Author 

Newham Centre for Mental Health 

Ruby Triage Ward 

Report approved date: 

1st April 2026 

Approved by: 

Director of Nursing, Mental Health, London 

Reason for Addendum: 

To support the response to the Prevention of Future Deaths 
(PFD) Regulation 28 report and address the coroner’s 
concerns regarding risks and delays in notifying the police. 

Report Version: l  

Final  

Date of Addendum: 

1st  April 2026  

Contents: 

Addendum………………………………………………………………………..Page 2 

Appendix 1. Timeline of events ......................……………………………….Page 10 

Appendix 2 Timeline of events chart………………………………………......Page 12   

References……………………………………………………………………….Page 13      

1 

 
 
 
 
 
 
 
 
 
 
 
 
 1. Purpose of this addendum 

This addendum provides additional context and clarification on aspects of care that were not 
explored  in  detail  in  the  main  report.  It  focuses  on  post-admission  care,  including  the 
management  of  events  following  the  first  unauthorised  exit  from  the  ward,  the  second 
unauthorised exit, and the escalation process that followed. 

2. Ward clinical context 

Weekend staffing was reviewed and considered appropriate for ward activity, with two Band 
5 RMNs and four Band 3 social therapists on shift. One of the RMNs was acting as nurse in 
charge  and  shift  coordinator.  Weekend  MDT  presence  was  reduced,  with  a  single  on-call 
doctor covering the unit and responsible for new admission clerking. 

 Four patients on physical health observations; this required enhanced monitoring of their vital 
observations. Two of these patients required twice daily checks, 1 was 4 times daily and 1 
was once a day. There were 3 sets of mental health intermittent observations including Mr. A. 
This  required  checks  to  be  completed  every  15  minutes  of  their  whereabouts  and  general 
safety.  Enhanced care was provided to four patients requiring physical health observations 
and three patients on intermittent (15-minute checks) mental health observations, including 
Mr A.  At 13:30, the Emergency Nursing Team (ENT) attended the ward to support restraint 
and depot administration for another patient.  

AWOL Policy instructs staff to confirm a person’s absence, search in and around the unit and 
inspect CCTV. 

3. Admission and initial risk assessment 

The Clinical Risk Assessment and Management Policy requires risk assessments to focus on 
a  person’s  needs  and  support  their  immediate  and  longer-term  psychological  and  physical 
safety.  Information  may  be  gathered  through  patient  interview,  record  review,  collateral 
information, and engagement with the patient. Expected practice is that a risk assessment is 
completed at inpatient admission and documented on the RiO Adult Risk Assessment Form. 
For  patients  already  known  to  services,  Dialog+  should  be  updated  within  72  hours  of 
admission. 

Following admission at 10:05, Mr A was orientated to the ward environment. He then went to 
his bedroom and was asleep by 10:53. As he was asleep, staff were unable to complete the 
risk assessment collaboratively at that time. In line with expected practice, staff did not wake 
him and instead planned to continue and refine the assessment once he was awake and able 
to engage. As Mr A remained asleep from 10:53 to 14:30, it was reasonable that admission 
assessments  and  clerking  were  only  partially  completed  during  this  period.  The  ward  staff 
followed policy. 

Following admission at 10:05, Mr A was orientated to the ward environment. He then went to 
his bedroom and was asleep by 10:53. As he was asleep, staff were unable to complete the 
risk assessment collaboratively at that time. In line with expected practice, staff did not wake 
him and instead planned to continue and refine the assessment once he was awake and able 
to engage. As Mr A remained asleep from 10:53 to 14:30, it was reasonable that admission 

2 

 
  
 
 assessments  and  clerking  were  only  partially  completed  during  this  period.  The  ward  staff 
followed policy.  

Mr  A’s  initial  risk  assessment  review  was  initiated  at  11:53.  Risks  to  self  and  others  were 
documented,  including  a  known  history  of  aggression  when  his  needs  were  not  met 
immediately.  At  the  time  of  admission,  however,  he  had  not  displayed  any  aggressive 
behaviour on the ward and was asleep. This would have been updated once Mr A had been 
seen and clerked by the doctor after he awoke.  

The risk of self-harm reflected the circumstances of the current admission, specifically that Mr 
A had been found near Southwark Bridge with reported intentions to enter the water. Risks of 
escape and absconsion were also recorded, as it had been reported that he had attempted to 
leave  the  Section  136  place  of  safety.  This  information  was  appropriately  documented  to 
inform ongoing assessment and observation. Overall, the approach was clinically appropriate 
and consistent with standard practice, balancing the need for ongoing risk assessment with 
respect for Mr A’s immediate presentation and wellbeing. 

Intermittent  15-minute  observations  were  prescribed  when  Mr  A  arrived  on  Ruby  ward  at 
10:05, and records show these were completed with no missed recordings. 

Mr  A’s  initial  risk  assessment  was  completed  at  11:53.  Risks  to  self  and  others  were 
documented,  including  a  known  history  of  aggression  when  his  needs  were  not  met 
immediately.  At  the  time  of  admission,  however,  he  had  not  displayed  any  aggressive 
behaviour on the ward and was asleep. 

The risk of self-harm reflected the circumstances of the current admission, specifically that Mr 
A had been found near Southwark Bridge with reported intentions to enter the water. Risks of 
escape and absconsion were also recorded, as it had been reported that he had attempted to 
leave  the  Section  136  place  of  safety.  This  information  was  appropriately  documented  to 
inform ongoing assessment and observation. Overall, the approach was clinically appropriate 
and consistent with standard practice, balancing the need for ongoing risk assessment with 
respect for Mr A’s immediate presentation and wellbeing. 

4. First unauthorised exit from Ruby ward 

At  14:26,  Mr  A  left  his  room  and  approached  the  nursing  office  to  speak  with  staff.  He 
requested  to  leave  the  ward  to  smoke.  At  this  point,  staff  had  ongoing  concerns  about  his 
presentation, given the circumstances of his admission and the fact that medical clerking had 
not yet been completed. 

In line with expected practice, staff explained that he could not leave the ward until he had 
been reviewed by a doctor as part of the admission process. This decision was proportionate 
to the risks identified at that time and consistent with standard inpatient admission procedures. 

At 14:33:56, Mr A exited the ward through the fire door, which is not visible from the nursing 
office.  His  departure  was  unwitnessed,  as  staff were  carrying  out routine  observations  and 
had no indication that he had left the ward. 

3 

 
 
 
 
 At  14:35,  staff  completing  routine  observations  were  unable  to  locate  Mr  A.  Once  it  was 
established  that  he  was absent from the  ward,  staff  acted  promptly  by  initiating  a full  ward 
search, including bedrooms, communal areas, and accessible ward spaces.  Mr A could not 
be located.  A member of staff went out in their car, located Mr A offsite, and returned him to 
the  ward  at  15:17:38.  The  ward  staff  followed  the  Trust’s  London  Absent  without  Leave 
(AWOL) and Missing Persons Policy. 

On  return to  the  ward, Mr  A  was  searched  by  two  members  of  staff in  line  with  the Trust’s 
Searching Service Users and Property Policy. He cooperated with the search and voluntarily 
handed over cigarettes, which were retained for safekeeping.  The search was proportionate, 
respectful, and limited to what was necessary to manage immediate safety risks following an 
unauthorised  absence.    An  InPhase  incident  record  (ID  24543)  was  completed  for  the  first 
unauthorised absence at 16:44. 

5. Actions following the first unauthorised exit 

The AWOL Policy states that, on return to hospital, the patient must be reviewed by the nurse 
in  charge  as  soon  as  possible.  This  post-return  review  should  include  mental  and  physical 
state,  current  level  of  risk,  required  level  of  observation,  and  any  specific  care  needs. 
Information gathered should then be used to reassess future risk and inform any necessary 
changes to the care plan. 

The review identified that the nurse in charge contacted the on-call doctor following Mr A’s 
first unauthorised absence.  Although staff were unable to recall the exact time the call was 
placed, there is corroborating evidence that the on-call doctor acknowledged the request and 
attended the ward at 15:20. This supports that escalation to medical staff occurred in a timely 
way following the incident. 

The nurse in charge was aware of Section 5(4) of the Mental Health Act 1983, which allows a 
nurse to prevent an informal inpatient from leaving hospital where there is immediate concern 
about safety and no doctor with Section 5(2) authority is immediately available. In this case, 
Section 5(4) was not used because the on-call doctor had already been contacted and was 
immediately available to assess Mr A. Although this reasoning was not formally recorded, it 
was clinically understandable in the circumstances. 

When the on-call doctor arrived, clerking commenced in a separate room.  Mr A remained on 
intermittent 15-minute observations.  During this time, he was visible to staff from a respectful 
distance.    The  nurse  in  charge  explained  that  maintaining  some  distance  was  intended  to 
avoid  causing  further  distress  while  still  allowing  staff  to  observe  him  safely.  Therapeutic 
observations and zonal observations were not reviewed at that stage, as the nurse understood 
there to be an active medical assessment underway.  

6. Medical review and interrupted clerking 

During  the  admission  clerking,  the  doctor  observed  that  Mr  A  appeared  tense,  emotionally 
withdrawn, agitated and aggressive. He repeatedly stated that he wanted “nature to take its 
course.” The doctor interpreted this as an expression of emotional distress and potential risk, 
rather than a neutral statement. 

4 

 
  
 
 In response, the on-call doctor made the clinical decision to stop the clerking at 15:25:12.  This 
was done because Mr A was showing signs of distress and disengagement, and continuing 
the assessment was unlikely to be clinically useful and may have increased risk. The doctor 
was also concerned by Mr A’s aggressive behaviour and considered that sedation might be 
required. The doctor then went to the nursing office to consult the second on-call doctor by 
telephone about possible use of Section 5(2). The nurse in charge did not recall being told 
that  the  clerking  had  been  terminated,  although  she  did  witness  the  staff  member  being 
assaulted. 

7. Second unauthorised exit from the ward 

CCTV  shows  that  at  15:31  Mr  A  became  physically  aggressive  towards  a  staff  member, 
prompting another staff member to intervene. The Duty Senior Nurse and Emergency Nursing 
Team were not contacted, and the situation was managed by the ward team. 

Over the next few minutes, Mr A was seen pacing near the fire exit and moving between his 
bedroom and the corridor. At 15:37:06, while the on-call doctor was still in discussion in the 
nursing  office,  Mr  A kicked the fire  exit  door  and  left  the  ward for  a  second time. The  door 
closed behind him at 15:37:10. The sound of the fire exit door alerted staff, who responded 
immediately and attempted to locate Mr A in the surrounding area. 

8. Actions and escalation following the second unauthorised exit 

In  accordance  with  the  AWOL  Policy,  the  nurse  in  charge  was  required  to  take  immediate 
action. The Duty Senior Nurse was informed, and at 15:39:18 the on-call doctor was notified 
that Mr A had left the ward for a second time.    

At 15:59, the on-call doctor documented concerns about Mr A’s risk to others, noting that he 
had previously assaulted a staff member and had repeatedly reported suicidal thoughts. The 
on-call doctor asked the nurse in charge to contact the police and to inform medical staff if Mr 
A returned. The nurse in charge did not call the police at the time and it appears the nurse in 
charge  proceeded  on  the  basis  that  further  local  actions  were  appropriate  before  police 
escalation  in  line  with  policy.    This  included  actions  staff  took  once  they  confirmed  Mr  A’s 
absence – they initiated a search of the ward and surrounding external areas.  CCTV was not 
reviewed immediately because ward staff did not have direct access to it and access required 
matron  support.      Mr  A  was  not  contacted  by  phone  because  it  was  known  that  he  had 
destroyed his phone while in the Health Based Place of Safety.  

A RiO entry at 16:04 states that several calls were made to Mr A’s nearest relative, his mother. 
The review found that contacting his mother was reasonable and proportionate at that stage. 
Although documentation could have been clearer, this appears to be more a record-keeping 
issue than a failure to act.  A clearer record of the calls and any subsequent conversations 
with the family would have provided better evidence of information shared and actions taken 
to locate Mr A.  

5 

 
   
 
 
 
 Medical  escalation  was  already  underway  when  Mr  A  left  the  ward  for  a  second  time,  and 
events moved quickly, meaning there was limited opportunity to implement Section 5(2) before 
he  left  again.    However,  although  risk  was  being  reviewed  and  police  contact  had  been 
advised, there is no clear evidence that this updated view of risk was explicitly communicated 
across the MDT at the time. This reflects the challenges of timely communication amongst the 
MDT when managing an immediate/emergency clinical situation, than to a failing by any one 
individual.  

A RiO entry at 16:41 states that the risk assessment had been updated. However, the Adult 
Risk Assessment was not updated on RiO until 18:12.  

At 17:54, the on-call doctor spoke to the more senior on-call doctor for a second time to update 
her that Mr A had left the ward again before Section 5(2) could be initiated. She also advised 
that nursing staff should inform the police and contact his family.   

9. Risk documentation and recording 

When the risk assessment was updated, it reflected staff actions, searches, and escalation to 
both medical staff and the Duty Senior Nurse. The review concluded that the risk assessment 
documentation was updated within a reasonable timeframe.   

At  18:13,  the  nurse  in  charge  completed  an  InPhase  incident  record  (Non-LFPSE  10063) 
relating to the incident in which Mr A knocked off a staff member’s glasses. This report also 
recorded that Mr A had kicked the fire door and left the ward for a second time. 

The incident report stated that the risk assessment had been updated and that the police had 
been notified. However, this was not clearly recorded in Mr A’s medical records on RiO. 

10. Police notification 

The incident was reported to the police at 18:35, around two hours and 58 minutes after Mr A 
left the ward for the second time.  Although the ward was busy, this alone does not fully explain 
the timing. If Mr A had been clearly understood by the ward team to be high risk at the point 
of the second absence, police contact would likely have been prioritised earlier.  

The evidence suggests that the nurse in charge was still working on the basis that Mr A was 
medium risk when he first arrived on the ward and left the ward.  By the time she contacted 
police,  her  perception  of  risk  had  changed,  in  part  because  Mr  A  had  then  be  off the  ward 
longer than his previous absence, which is why Mr A was then reported to police as high risk. 
This suggests that the main issue was not simply workload, but that the changing level of risk 
and the need for escalation were not clearly shared in real time. 

A RiO entry at 18:35 states that the incident was reported to the police via 101.  Under policy, 
101 would normally be used for a medium-risk absence, while 999 would be expected where 
the patient is considered high risk.  However, Mr A was described as high risk when the 101 
call was made.    

6 

 
 
 
 
 
 11. Conclusion 

The shift  coordinator  has  reflected  on  the  events  of the  day, the factors  contributing  to  the 
identified omissions, and the lessons learned from the incident. This addendum reaffirms the 
concerns outlined in the PSII and highlights additional matters requiring attention. 

11.1 Documentation 

Key information was not consistently documented. This included telephone calls made to the 
nearest  relative, the  one-to-one  discussion  with  the  nurse  in  charge,  and  the  absence  of  a 
dedicated LFPSE report for the second absconsion. 

11.2 Risk assessment and observation 

Risk was not clearly identified as high immediately following the first unauthorised absence, 
as reflected in the delay in updating the RiO Adult Risk Assessment, which was not amended 
until 18:12.  Observation levels were also not increased to reflect the heightened risk following 
the first unauthorised exit.  Although zonal observations for the fire exit were considered, they 
were not implemented because of the rapidly changing clinical situation. 

11.3 Escalation 

There was a delay of almost three hours in notifying police following the second unauthorised 
absence. As also identified in the PSII, the timing of police notification fell outside what would 
be expected for a clearly recognised high-risk patient missing from the ward. The addendum 
also identified uncertainty about the reporting process, with Mr A being described as high risk 
while reported via the 101 line.  Staff were unfamiliar with the Pan-London Joint AWOL Policy, 
and the police Grab Pack was not completed. 

The PAN London Policy which was introduced after the Right care Right Person. There is a 
dedicated section titled “Making the decision to inform the police.” It states that regardless of 
a person’s legal status, if they were at risk of serious harm, there absence should be reported 
to the police via 999.  Staff should also complete a Required Information ("Grab Pack")  

•  Trusts must provide a standardised information pack that includes:  
•  Patient identifiers and photographs  
•  Risk factors  
•  Mental/physical health concerns  
•  Details of last sighting  
•  Search actions already completed  
• 

7 

 
 
 
 
 
 
 
 
 
 
 This was not considered at the time, and it was still felt that Mr A was not a missing person 
and would be around the grounds. The Nurse in Charge felt this was an oversight on her part.   

The  review  recognises  that  the  doctor  instructed  the  nurse  to  contact  the  police  on  two 
separate  occasions.  However,  there  is  no  documented  evidence  of  a  coordinated  MDT 
discussion or shared decision-making process that clearly established Mr A’s level of risk at 
that time and what action was required under the AWOL policy. This suggests that escalation 
was not fully managed as a shared team responsibility but instead appears to have been left 
mainly to the nurse in charge to interpret and act on alone. 

12. Further learning and recommendations 

12.1 AWOL and missing person’s process 

The on-call doctor stopped the clerking process because of increasing concern about risk and 
to discuss possible use of Section 5(2) with the senior on-call doctor. During this period, Mr A 
left the ward for a second time. Although the on-call doctor recognised the risk and requested 
police notification, there was a delay before Mr A was reported missing. By the time police 
were contacted via 101, Mr A was reported as high risk because he had not been located and 
time had passed. 

A high-risk missing person should have been reported via 999, and a Grab Pack should also 
have been completed to support the police response. This was not done. The London AWOL 
and Missing Persons Policy and the Pan-London Joint AWOL Policy were therefore not fully 
followed. 

It is recommended that all Ruby Triage Ward staff are made fully familiar with both policies 
and understand how they apply together in practice, so that AWOL procedures are followed 
consistently and safely. 

It would also be beneficial for the senior clinical team to develop and implement mandatory 
AWOL policy training for all clinical staff, including a competency assessment covering both 
the Trust AWOL Policy and the Pan-London Joint AWOL Policy. 

12.2 Risk assessment and dynamic observation 

Identifying risk in high-risk patients requires structured assessment, ongoing observation, and 
dynamic  clinical  judgement.  Relevant  factors  include  history  of  violence,  self-harm,  suicide 
attempts, and previous AWOL episodes. 

Ruby  Triage  Ward  staff  would  benefit  from  a  mandatory  refresher  session  on  completing 
structured  risk  assessments  and  documenting  dynamic  changes  in  risk,  including  practical 
guidance on when observations should be increased and when zonal observations should be 
used. This should include clear expectations for recording changes in presentation in real time. 

8 

 
  
  
 
 
 
 Compliance  could  be  monitored  through  a  monthly  audit  of  10  randomly  selected  risk 
assessments, with an expected compliance rate of at least 90% for documentation of key risk 
factors and dynamic risks. 

Strengthen  MDT  communication  and  relational  security  by  requiring  clear  team--based 
discussion,  documentation,  and  shared  decision-making  whenever  a  patient’s  risk  level 
changes or escalation is being considered.   

Since  August  2024,  the teams  in  Newham  Centre for  Mental  Health  have  been  part  of the 
Relational Security initiative in ELFT.  Relational security is the knowledge and understanding 
we have of a service user and of the environment, and the translation of that information into 
meaningful  responses  and  care.  The  roll-out  in  NCMH  has  involved  a  number  of  phases 
including training up facilitators, unit-wide events and on-ward 'bite-size' sessions with staff 
teams.  These  sessions  encourage  staff  to  discuss  and  reflect  on  relational  security  when 
applied  to  a  number  of  key  areas  including  boundaries,  risk  awareness,  patient/staff  mix, 
visitors, the personal world (i.e. what has happened to people and what is most important to 
them) of patients and staff. 

12.3 Shift coordination and delegation 

On the day of the incident, shift coordination did not function as effectively as it should have, 
resulting in some key duties being delayed or overlooked.   Shift coordinators on Ruby Triage 
Ward would benefit from additional support and opportunities to build confidence in delegation, 
escalation, and risk identification. The Ward Matron has already implemented a support plan 
and mentoring for the nurse in charge who was on duty that day, and is also seeking wider 
confidence-building support for the broader ward team 

9 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 1. Chronological Timeline of Events on Sunday 8 December 2024 

Time 

10:00 

11:53 

14:26 

Event / Description 

Intermittent 15-minute observations were initiated. Mr A was orientated to the 
ward and then went to sleep. Staff could not complete the collaborative risk 
assessment because he was asleep. Staff planned to complete the assessment 
once he was able to engage. 

Initial Adult Risk Assessment completed on RiO. Risks recorded included a 
recent incident at Southwark Bridge indicating self-harm risk, risk of 
escape/absconsion, and a known history of aggression when needs are not met, 
although no aggression was observed on admission. Assessment was judged 
proportionate. 

Mr A left his room and approached the nursing office requesting to leave the 
ward to smoke. Staff explained he could not leave until after medical review due 
to the circumstances of admission, incomplete medical clerking, and immediate 
safety concerns. 

14:33:56 
 First 
unauthorised 
absence 

14:35 

Mr A exited the ward via the fire door, unseen by staff. 

Staff could not locate Mr A during observations. A full ward search was initiated, 
including bedrooms, communal spaces and accessible areas. Mr A was not 
found. 

15:17:38 

External search conducted. A staff member located Mr A offsite using a car and 
returned him to the ward. 

Approx. 15:17–
15:20 

Mr A was searched by two staff in accordance with the Searching Policy. He 
cooperated and handed over cigarettes for safekeeping. 

15:20 

The on-call doctor attended following staff escalation. Nursing and medical staff 
jointly assessed Mr A, with a staff member present throughout for support and 
observation. 

18:21 

Risk assessment updated on RiO to include the first absence. 

Post-first 
incident 

Staff were aware of potential use of Section 5(4) but did not apply it because a 
doctor was already confirmed as attending. Escalation to the on-call doctor was 
considered appropriate and timely. 

15:25:12 
Clerking and 
emerging 
concerns 

During clerking, Mr A appeared tense and withdrawn and repeatedly stated he 
wanted “nature to take its course.” The doctor interpreted this as emotional 
distress and possible risk. Clerking was ended early to avoid further escalation. 
The doctor consulted the second on-call doctor regarding the possible need for 
Section 5(2). 

15:31  

Mr. A was seen engaging with a staff member before he grabbed their glasses 
from their face and threw them to the ground 

15:37:06 
Second 
unauthorised 
absence 

Mr A kicked the fire exit door. 

15:37:10 

The door closed behind him and he had left the ward. Staff were alerted by the 
noise and responded immediately. 

15:37–15:39 

Staff began immediate external searching in accordance with AWOL Policy. 

15:39:18 

The on-call doctor was notified that Mr A had absconded for a second time. 
Medical escalation was already in progress regarding possible Section 5(2). 

15:59 

The on-call doctor documented concerns including risk to others, a previous 
attack on staff, and recurrent suicidal thoughts. The doctor instructed nursing 
staff to contact police and notify the doctor when Mr A returned. 

10 

 
 
 16:04 

16:41 

16:44 

17:54 

Staff did not record any of the attempts that were made to contact the police 

RiO entry recorded several attempts to contact Mr A’s mother, but no outcomes 
or details were documented. 

RiO entry stated that the risk assessment had been updated (actual update 
recorded at 18:12). 

InPhase Incident ID 24543 completed for the first unauthorised absence. 

On-call doctor documented discussion with the senior second on-call doctor. 
Advice given was to contact police, contact family, and allow the police to use 
professional judgment. 

18:12 

Adult Risk Assessment on RiO updated to include both unauthorised absences. 

18:13 

18:35 

Nurse in charge completed Incident ID Non-LFPSE 10063, recording the 
aggression incident, the second absconsion, the risk assessment update, and 
police notification. 

Staff contacted police via 101, approximately 2 hours and 58 minutes after Mr 
A’s second absconsion. No separate LFPSE incident was created for the second 
absence. Review team noted that both incidents were reported on InPhase 
about two hours after each event occurred. 

11 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 2. Timeline of events 

Timeline of Events on the 8th December 2024

15 minute observations 
commenced  

Risk assessment 

Left his room  

First unauthorised 
absence via fire exit 

Returned to the ward, searched 
and On-call clerking  and On-call 
arrived

Clerking 
in 

Clerking 

terminatedKicked through fire exit for 

second time 

Police notified

10:00 

11:53 

14:26 

l4:33 

15:17-15:20

15:20

15:25

15:37

18:35

12 

 
 
 References  

Clinical record keeping Policy 2.1  

East London NHS Foundation Trust Therapeutic Engagement and Observation Policy 9.0 

London Absent Without Leave (AWOL) & Missing Persons Policy 6.0 

Pan

London Mental Health Trusts Joint AWOL Policy 

East London NHS Foundation Trust Clinical and Risk Management Policy 5.2 

‑

13