Catherine Morgan

A481A481 review incidents, including to specialist missing person teams where there is uncertainty regarding the 
appropriate classification of incidents. 

3. 

Engagement with operational stakeholders 

The College has engaged with forces to understand how the current guidance is being interpreted in 
practice, specifically in relation to the exercise of professional judgement and thresholds for deployment. 

Further Action Proposed 

The College will implement the following actions to directly address the concern raised and strengthen 
national consistency: 

1. 

Revision of the Right Care Right Person toolkit guidance 

The College will revise the national Right Care Right Person toolkit to explicitly reinforce the requirement 
for professional judgement in all cases. This will include clear direction that risk to life and vulnerability 
must take precedence over process driven decision making, and that deployment should not be unduly 
delayed where a real and immediate risk to life or serious harm is identified. 

2. 

Development of interoperability guidance between RCRP and Missing Persons frameworks 

The College will produce additional guidance to support decision making in cases where it is not 
immediately clear whether an incident should be managed under the Right Care Right Person approach 
or as a missing person investigation. The guidance will incorporate the use of escalation routes, such as 
referral to specialist missing person teams, to ensure that complex or ambiguous cases receive timely 
review by appropriately trained staff. 

3. 

Dissemination and implementation support 

The College will communicate the updated guidance to all forces and provide a dedicated input within 
the national RCRP Tactical Delivery Board to support consistent implementation across policing. 

4.   Work with health and care partners to maintain a strong focus on prevention and early 
intervention 

The College will work to ensure risks are identified, assessed and managed at the earliest opportunity by 
the right agency responsible for an individual's care and treatment. This includes promoting the 
appropriate use of health, safeguarding and care powers to reduce escalation, minimise harm, and 
ensure individuals receive timely care, treatment and support before risks escalate to a level that may 
require an emergency response. 

The College will publish the revised guidance following the completion of the review of existing guidance 
which is currently underway. Updated materials will then be disseminated to forces, supported by clear 
communications and practitioner briefings to promote understanding, consistency and effective 
implementation of the revised guidance.  

These actions are intended to reinforce the role of professional judgement within national guidance and 
provide operational staff with greater confidence and support in making proportionate, risk-based 
decisions. By promoting a more flexible and informed approach to assessment and response, they aim 
to reduce delays in deployment that can arise from process-driven interpretations of policy. Ultimately, 
these measures will help ensure that vulnerable individuals receive a timely and appropriate response, 
improving outcomes while supporting effective and efficient use of resources. 

A482A482 
 
 
 A483A483

METROPOLITAN

POLICE

Mrs Patricia Harding Deputy Assistant Commissioner
His Majesty's Senior Coroner Metropolitan Police Service
Kent and Medway Coroners’ Service New Scotland Yard

Oakwood House Victoria Embankment

Oakwood Park London

Maidstone SWI1A 2JL

Kent

ME16 8EA

17" July 2026
Dear Mrs Harding

The Metropolitan Police Service (MPS) acknowledges the concerns raised within the Regulation 28 Report
to Prevent Future Deaths dated 19" May 2026, following the inquest into the death of Catherine Mary
Morgan. We recognisé the seriousness of the matters identified and are grateful for the opportunity to
respond.

We would also like to take this opportunity to express our sincere condolences to the family of Catherine
Morgan for their loss.

The first matter of concern is as follows:

“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a
delayed deployment. Even where call handlers have real concerns that someone not returning to a
mental health unit is a high risk missing person, the outcome of the toolkit not to deploy is the same
if the individual's address has not been visited, even when told that they would not go there. The
way in which the policy was applied removed any discretion by call handlers and despaichers to
deploy whilst check at the address were being conducted. Evidence was given at the inquest that
the call handler in the second call to MPS attempted to convey her concerns that there should be
immediate deployment to her supervisors in despatch and was advised the police would not

deploy.”
MPS Response

The MPS acknowledges the concerns raised in respect of the application of the Right Care, Right Person
(RCRP) policy and associated affinity protocols, particularly regarding delayed deployment and the
limitation of operational discretion.

Application of the College of Policing RCRP Toolkit within the MPS

The MPS is undertaking a review of the application of RCRP within Contact, Command and Control
functions. This work is focused on:

e Considering whether there is an over reliance on RCRP decision making tools

° Reinforcing the importance of professional judgement and dynamic risk assessment

e Strengthening the timely identification, grading and response to high-risk missing persons,
particularly where there is known vuinerability or prior suicide risk.

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A505

The MPS is reinforcing operational expectations through guidance and supervisory oversight to ensure that
deployment decisions are made in line with the College of Policing Right Care, Right Person toolkit. This
involves a particular focus on call handling, THRIVE+' assessment, deployment decision making,
supervisory escalation and reassessment where new information is received. This will ensure RCRP is
applied as a dynamic risk-based framework, not as a fixed non-deployment decision. Particular attention
will be given to incidents involving vulnerability, suicide risk, third-party concern and potential missing
person risk, where early supervisory oversight and clear recording of rationale are essential.

Implementation of Local Missing Hubs (LMH)

In addition, the creation and implementation of Local Missing Hubs (LMH) on each Basic Command Unit
(BCU) represents a significant development in how the MPS responds to missing person incidents. For the
first time, a dedicated and trained team of officers will assume control across the response to reported
incidents, including risk assessment and review, investigative progression and partnership and prevention
activity to safely reduce overall demand.

The MPS has already achieved a 30% reduction in total yearly missing person investigations over the last
four years, reflecting a shift toward earlier intervention and improved problem-solving approaches.

The 24/7 response model through LMHs will be streamlined through immediate ownership of incidents from
the point of professional triage and informant engagement.

This supports:

e Early decision making around necessity of response
e Accurate risk grading
e Proportionate development and progression of investigations.

LMH officers are empowered to make informed and accountable decisions in what are often complex and
risk-laden investigations. A blend of mandatory and enhanced training supports officers in undertaking
Officer in Case (OIC) responsibilities, setting bespoke investigative plans and applying appropriate tactics
to manage risk and locate vulnerable individuals.

Supervisory structures have also been strengthened:

* Sergeants provide active oversight, including flexible review timeframes, management of workloads,
and support in complex or high-risk cases

e A dedicated Detective Inspector provides strategic oversight of case progression, ensuring
appropriate resourcing and focus at BCU level

e Detective Sergeants embedded within the LMH model support investigative activity and drive
partnership working, including preventative initiatives such as Operation Resolute?

e The Missing Persons Coordinator role is aligned within the LMH structure, driving problem solving,
demand reduction and partnership engagement with local authorities, Ofsted and health and social
care services.

The MPS will review escalation arrangements within our control room to ensure that incidents involving
increasing vulnerability or deteriorating circumstances are subject to timely reassessment. This will include

' THRIVE+ is a risk assessment tool that supports the identification of risk and vulnerability
? Operation Resolute is an umbrella for planning and prevention strategies targeting specific sources of missing persons reporting.
Page 2 of 4

A505

enhanced supervisory review and access to specialist advice where information received during the lifetime
of an incident indicates a growing risk of serious harm, even where initial deployment thresholds were not
met. Particular focus will be placed on incidents initially assessed as health-led concerns where
subsequent information may indicate progression towards a missing person investigation or another
circumstance requiring a revised policing response.

The MPS is also actively engaging with national work led by the National Police Chiefs’ Council (NPCC)
and the College of Policing to ensure a consistent and appropriate approach. The NPCC Missing People
portfolio has been working with the national RCRP team to produce guidance on the overlap between
RCRP and Missing People policy.

A consultation meeting has been arranged in July 2026, which will provide forces, including the MPS, with
an opportunity to review and provide feedback on the draft guidance.

Details of Further Action Proposed
Subject to the outcome of the national consultation and the publication of updated guidance, the MPS will:

e Review and update local policies, procedures and control room practices to ensure clear alignment
between Missing Persons policy and RCRP

e Incorporate updated guidance into training, briefings and supervisory processes to support
consistent, risk led decision making

e Strengthen audit and governance processes to monitor the application of RCRP, particutarly in
cases involving vulnerable or high-risk individuals.

This includes oversight through the RCRP Governance Board, introduced in summer 2024, which provides
operational oversight, assurance and coordination for escalation relating to RCRP deployment decisions.

The Board:

e Reviews cases where deployment outcomes are disputed, complex or high risk

e Ensures decisions remain lawful, proportionate and aligned with national expectations

* Has an expanded remit to scrutinise the use of powers under the Mental Capacity Act and wider
mental health related concerns

e Maintains a clear focus on safeguarding, vulnerability and appropriate agency responsibility.

Operating within a wider partnership framework, the Board is integrated into the Joint Mental Health and
Policing Group, ensuring shared accountability, consistent practice and a clear route for organisational
learning and service improvement.

In addition, the MPS is developing an updated Concern for Welfare policy, supported by practical scenarios
to assist decision making. This will support increased clarity around when deployment is required or when

referral to LMHs is appropriate, particularly in circumstances involving vulnerability and potential missing
person risk.

Further Work
Further work will include:

e Ensuring that operational discretion is clearly supported where risk justifies early deployment

Page 3 of 4

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A507

¢ Reinforcing escalation pathways and supervisory oversight in cases involving high risk missing
persons

* Promoting a consistent understanding that the safety of vulnerable individuals remains the primary
consideration in all decision making.

The MPS recognises the seriousness of the concerns identified and is taking steps, both locally and in
collaboration with national partners, to ensure that the application of Right Care, Right Person supports
timely, proportionate and risk-based responses, particularly in cases involving vulnerable missing persons.

The second matter of concern is as follows:

“A call handler informed SLAM to call London Ambulance Service to do a welfare check at the home
address of the patient in circumstances where the ambulance service will only attend an address if
the resident is known to be there.”

MPS Response

The MPS has reviewed the circumstances of this aspect of the incident. We recognise the importance of
ensuring that advice provided by Met Command and Control (MetCC) staff is consistent with the
responsibilities and capabilities of partner agencies and reflects the processes set out within RCRP and
associated arrangements.

The MPS Right Care, Right Person policy and toolkit place responsibility on healthcare providers to
undertake initial reasonable enquiries when a patient leaves a healthcare setting. Those enquiries should
be progressed through the most appropriate agency or agencies based on the circumstances and should
not rely on referral to a single service as a default position. The MPS also recognises the importance of
clear escalation routes where there are concerns that the available arrangements are insufficient to
manage the presenting risk.

In response to the concern raised by the Coroner, the MPS will review guidance, training and quality
assurance arrangements to reinforce that where police are not the appropriate agency to respond, advice
provided to callers should be practical, achievable and consistent with the responsibilities of the agency to
which they are being directed. This will include reinforcing escalation and supervisory review where there is
uncertainty, disagreement or increasing concern regarding the most appropriate agency response.
Learning from this case will be incorporated into ongoing training, briefing and governance processes within
MetCc.

Please do not hesitate to contact me should you require further information from the MPS.

Yours sincerely,

Deputy Assistant Commissioner

Page 4 of 4

A507

South London and Maudsley NHS Foundation Trust 

                                                               Office of the Chief Executive             

Maudsley Hospital 
Denmark Hill 
London, SE5 8AZ 

Dear Mrs Patricia Harding, H.M. Senior Coroner for Kent and Medway  

Re: Catherine Mary Morgan  
Date of birth: 07.09.1986 
Date of death: 04.09.2024 

Thank you for your Regulation 28 Report dated 19 May 2026, setting out your concerns to be addressed by 
various organisations, including South London and Maudsley NHS Foundation Trust (the “Trust”), in relation 
to the sad death of Ms Catherine Mary Morgan.  

The Trust continues to offer its sincerest condolences to the family and profoundly regrets that deficiencies 
were identified by the jury in their conclusion in respect of the care provided to Catherine by the Trust.  The 
Trust is committed to ensuring that lessons are learned from this sad case.  

The concerns in respect of the Trust set out in the Learned Coroner’s report were summarised as follows: 

1.  Risk  assessments  in  respect  of  leave  were  not  being  conducted  in  accordance  with  NICE 

Guidelines 

2.  The  systems  in  place  for  recording  and  communicating  leave  for  a  voluntary  patient  were 

inadequate 

3.  The system for monitoring return from leave was inadequate 
4.  Ward staff appeared to take a different approach to leave and return depending upon the status of 

the patient as a detained or voluntary patient 

5.  A photograph of the patient was not included in the grab pack, unlike detained patients there was no 

checklist for voluntary patients as to the measures taken to locate the patient 

The Trust notes that the Learned Coroner has recognised that the Trust had identified and put in train work 
that needs to be undertaken to address these issues. However, the Learned Coroner also noted that much 
of the work has not yet been implemented or is not yet complete and that until this is done you remain 
concerned. We take this opportunity to provide further assurance and explanation with regard to changes 
implemented and ongoing at the Trust which are relevant to the above concerns including learning which has 
been implemented directly as a result of the Patient Safety Incident Investigation carried out following Ms 
Morgan’s death.  

1.  Risk assessments in respect of leave were not being conducted in accordance with NICE 
Guidelines, specifically evidence was given at the inquest that although dynamic risk 
assessments were undertaken in advance of leave being authorised, risk assessments were 
not consistent with NICE Guidelines. 

The Trust acknowledges that at the time of Catherine’s death the Trust’s approach to risk assessment was 
not yet consistent with NICE guideline NG225 Self-harm: assessment, management and preventing 
recurrence (2022).  

However, the Trust has now fully adopted NICE and NHSE guidance on individualised risk formulation and 
management planning. The Trust’s move to a personalised approach to risk has been launched in four 
phases: 

-  Phase 1: Listening and engagement (April – June 2025) 
-  Phase 2: Co-production and testing (July – September 2025) 

A484A484 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -  Phase 3: Implementation (October 2025 – January 2026) 
-  Phase 4: Evaluation  

To carry this out, the Trust established two groups to work in partnership with: 

1.  Personalised Approach to Risk of Suicide Steering group; and  
2.  Lived experience reference group. 

The Steering group provides strategic direction, approves major decision, ensures alignment with 
organisation goals and shares messages across staff groups and directorates. It includes representatives 
from across the organisation as well as external stakeholders. The lived experience group is a group of 
service users and carers as advocates for lived experience representation and had oversight of the Trust’s 
co-production work.  

Phase 1: Listening and engagement  

In Phase 1, the Trust explored staff and service user and carer experiences of risk assessment and safety 
conversations. The Trust reviewed best practice, learning from other organisations and existing work         
taking place in the organisation. 

As part of this phase, the Trust revised its Clinical Risk Assessment and Management of Harm Policy, which 
came into force in December 2025, and which was previously provided as part of the Trust’s evidence. The 
revised version updates previous Trust policy to reflect NICE guidance on self-harm: assessment, 
management and preventing recurrence (2022), statement from NHSE on risk assessment tools and NHSE 
Staying safe from suicide Guidance 2025. The policy provides staff with clear guidance on risk assessment, 
formulation, and the ongoing management of harm, emphasising the need for an individualised, 
patient‑centred approach moving away from traditional classifications of “low”, “medium” and “high” risk. It 
supports the development of a collaborative and proportionate risk management plan with the patient, aimed 
at reducing the likelihood of foreseeable harm. The policy further highlights the critical importance of safety 
planning as an integral extension of the risk management process, incorporating crisis and contingency 
planning for patients with a history of self‑harm or suicidal ideation, to mitigate the risk of recurrence and 
prevent avoidable future harm.  

Aligned with this the Trust’s risk assessment tool in the Trust’s electronic Patient Journey System (“ePJS”) 
has been updated to include a caveat that the tool should not be used to predict the risk of suicide and a tick-
box acknowledging that the user understands this. The Trust would like to make further changes to the risk 
assessment tool in ePJS to support the personalised approach to risk. However, there is a now a ‘changes 
freeze’ in relation to ePJS, as the Trust is in the process of moving to a new provider (further detail below).  

Phase 2: Cultural change programme  

The Trust has mandatory training for all clinicians on the management of Clinical Risk, which must be 
completed every 3 years. As part of Phase 2, this internal training was updated to include the revised Clinical 
Risk Assessment and Management of Harm Policy.  

In addition, all clinicians at the Trust have been given access to an NHS England eLearning module on 
Staying Safe from Suicide (which takes half a day to complete), which incorporates further training and 
guidance on delivering care in accordance with the revised NHSE and NICE guidance. The e-Learning 
module is designed to support all mental health practitioners to provide consistent high-quality approaches to 
suicide risk assessment and management.  The sessions provide evidence-based guidance on how to 
approach and support people to stay safe from suicide and feature case study based exercises that allow 
practitioners to develop their knowledge and apply the guidance in real-world scenarios. There is agreement 
for this eLearning module to be added to the Trust’s mandatory training schedule, using a staggered 
approach (with nurses prioritised), which is in line with NHS England’s National Suicide Prevention Strategy. 

Furthermore, the Trust has also been one of a handful of Trusts who have been working with the National 
Confidential Inquiry into Suicide as part of the journey towards a personalised approach to risk. The Trust 
has found it very helpful to learn from the experiences of other mental health providers and sharing the 
Trust’s own reflections.  

A485A485 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Phase 3: Implementation 

The Trust has recently completed a procurement in relation to a new Electronic Patient Record (“EPR”) 
system and work is underway with the appointed provider to develop a new EPR system with a plan for this 
to be in place by 2028.  

The Trust has identified this as a huge opportunity for re-designing through the new EPR procurement. The 
Trust has therefore been participating in the EPR re-design process informing the new procurement and has 
been exploring potential changes to how risk assessments and safety plans are documented on EPR. 
Further detail of these potential changes are detailed below. It is noted that the new system will have 
capacity to do reminders when actions have not been carried out to help ensure clinical tasks are carried out 
in a timely fashion.  

Phase 4: Evaluation 

The Trust continues to evaluate its transition towards a personalised approach to risk assessment and 
suicide prevention. In respect of the Inquest process, it was identified there is still some work to be done with 
respect to aligning all other policies with the transformed Clinical Risk Assessment and Management of 
Harm policy. In particular, there are aspects within the AWOL, Absent and Missing Persons policy which 
retain “old” low/medium/high classifications, i.e. the checklist used to guide decision making where a patient 
is identified as AWOL. This policy has now been marked as under review as was previously indicated in the 
Trust’s evidence in this case. The review, which is further explained below, is an overarching review of three 
interlinked policies namely, the s17 Leave Policy, the Leave for Informal Patients Policy, and the AWOL, 
Absent and Missing Persons policy which aims to strengthen consistency and clarity across these interlinking 
areas of practice whilst aligning Trust practices fully with the new clinical risk management approach and 
ensuring legal compliance with relevant Mental Health legislation. The review is being undertaken by policy 
leads under the supervision of the Trust Director for Social Work and the Trust Mental Health Lead and is 
planned to be completed and approved in the Trust’s Mental Health Law Committee by October 2026. The 
requirement for grab packs to have a photograph and the lack of a checklist for voluntary patients will be 
addressed as part of the policy review. 

2.  The systems in place for recording and communicating leave for a voluntary patient were 
inadequate and decisions were largely communicated by word of mouth which led to 
differences of understanding what had been agreed, the basis on which it had been agreed 
and by whom it was agreed. Documentation in respect of leave was incomplete and did not 
comply with policy. The nurse in charge was not informed of the decision for leave or the 
circumstances in which leave was granted. 

The Trust acknowledges the Coroner’s concerns in this respect and recognises the paramount importance of 
clear information sharing and shared understanding throughout ward teams to ensure the safe use of leave 
by formal and informal patients.  

Since Ms Morgan’s death, the Trust has made significant changes to the way in which discussion and plans 
from ward rounds, including in relation to patient leave, are noted within EPJS and how these are shared 
through EPJS template documents to assist with robust handover throughout the MDT and between shifts. 
There is a Ward Round template (Appendix A) which guides clinicians in noting the discussion and outcomes 
from ward round meetings. Of note, there is specifically a space under the “Safety” tab for clinicians to record 
agreement and discussions around leave, however it is also anticipated that discussion and planning of 
leave will feature prominently in ward round discussions and to this extent they should also be reflected 
within the recorded considerations around risk as well as plans and actions for the patient arising from the 
ward round review.  

The Trust’s Leave for Informal Patients policy having been disclosed in the course of this inquest, the 
Coroner will note that it is and remains to be Trust policy that relevant senior nursing staff are required at the 
beginning of every shift, in line with the Clinical Handover Policy, to ensure that they are fully informed of 
relevant information with regard to the patients under their care to include current legal status, mental state, 
potential risks, and leave status. Trust policy requires firstly, receipt of a verbal handover from the previous 
nurse in charge and allocated nurse and secondly review of “the ePJS MDT Handover tool and recent 
clinical records”.  

A486A486 
 
 
 
 
 
 
 
 
 
 
 
 In the time which has passed since Ms Morgan’s death, a substantial piece of work has been undertaken to 
create an MDT/DCCM handover tool within EPJS which pulls together, directly from the relevant parts of 
EPJS, information that is relevant to clinical handovers within the Trust (Appendix B). This directly pulls 
relevant information from the latest completed Ward Round template for the patient, as well as other recent 
clinical notes and prompts clinicians who are handing over patients to consider and record all relevant 
aspects of patient presentation, risk and legal status. As noted above, the Trust requirement is for this 
information to be verbally handed over between clinical colleagues and for the document itself to be read by 
the clinician receiving handover. The Trust will engage with the new provider to see if the above process of 
pulling information for the handover tool can be further refined with the launch of the new EPR.  

Since the incident, the hourly observation checks (which were completed incorrectly for Catherine at 12pm 
on 4 September 2024) have also been made electronic as part of the Trust’s work in respect of its new 
Enhanced Care policy. The introduction of the checks (now known as ‘well-being checks’)  in an electronic 
form (Appendix C) will make it easier for them to be cross referenced with the Leave Log to assist with 
monitoring patients on leave. It will also make it easier to audit the checks to ensure they have been correctly 
completed by staff.  

The Trust acknowledges that safe patient care not only requires a strong system to be in place for recording 
and sharing relevant clinical information within the MDT. Correct and relevant information must be inputted 
into these systems. In this case, it has been identified within the Trust’s PSII that there was a failure to 
document discussion around the recommended timing of leave – in particular that a suggested time of 15 – 
30 mins for negotiated unaccompanied leave for Catherine was discussed during the ward round on 3 
September 2024, however, this was not included in the note of the meeting on ePJS. On the 5 March 2026 
this matter, along with broader considerations regarding management of informal leave and failure to return 
from planned leave were addressed within a Patient Safety learning article which has been published 
centrally and has been disseminated by Directorate governance teams to all relevant staff. A copy of this has 
previously been shared with the Coroner. As a point of clarity, it is not Trust policy (and it would also be 
contrary to the legal framework) to mandate time limits for informal leave given the legal right of informal 
patients to take time off the ward as they choose. It is accepted that for some individuals, safety planning in 
relation to time taken off the ward might encompass suggestions around the amount of time which would be 
and feel safe, and where this is the case it is the Trust’s expectation made plain within the aforementioned 
Patient Safety learning article, this discussion should be documented.  

With respect to other specific aspects of the Coroner’s noted concern, 

• 

It has been discussed as a learning point from this case at the Trust’s Patient Safety Committee 
meeting on the 11th June that ward policies around the taking of leave including informal leave and 
the documenting of the same must be followed (for example if a form is required to be signed by a 
Registered Mental Health Nurse (RMHN) it cannot be done by a different professional such as a 
Nursing Associate).  The learning was also discussed in the directorate learning event on 15th June. 
Having said that, the Trust considers it may need to update its policy in respect of registered nursing 
associates being able to sign patients out for leave, in light of the fact that registered nursing 
associates can coordinate shifts and the shift coordinator is able to sign people out.  

•  The Ward Risk Assessment for Section 17/Informal Leave form that was in use when Ms Morgan 
was a patient on the ward was not included in any Trust policy but was produced by the ward by 
combining the Section 17 leave risk assessment checklist and the Daily Leave Log to produce a 
new form. Because of the reference to section 17 leave it was not felt that this was appropriate to 
both detained and informal patients and thus a new standardised Leave Log has been developed 
that is appropriate to both detained and informal patients (Appendix D). With respect to the Section 
17 leave risk assessment checklist, it has been identified that this is not in accordance with NICE 
guidance 2022 which does not recommend the use of risk assessment tools to predict the risk of 
suicide or to decide which patients receive treatment or are discharged.  It is recognised that it 
would be helpful to capture within the standardised Leave Log/Leave Form that the patient’s time off 
the ward has been discussed with either the Nurse in Charge or the Patient’s Allocated Nurse (Trust 
policy allows both) who has confirmed in line with policy that there is no reason not to permit time off 
the ward as per the patient’s request.      

•  The Trust  is currently investigating options for producing the Leave Form  electronically potentially 

within the Trust’s “Enhanced Care on E-Obs” system, which is an electronic platform integrated with 
ePJS to enable recording wellbeing checks. Enhanced Care on eObs is a secure digital system that 
helps hospital staff record wellbeing checks and engagement during periods of enhanced care. It 

A487A487 
 
 
 
 
 
 
 replaced paper forms with a more efficient digital system using iPads. As mentioned above, the 
Trust has recently procured a new EPR system and will be exploring with the new provider the 
possibility of producing the Leave form electronically, in a similar way to Enhanced Care on E-Obs, 
so that the form would be easier to access for the purpose of recording and monitoring leave.  

3.  The system for monitoring return from leave was inadequate, reliance being placed on hourly 
checks. The nurse conducting the hourly check at 12.00 when Catherine was due to return was 
not aware that she was on unescorted leave and did not escalate the matter to the nurse in 
charge with the result that the ward only became aware that she had not returned when her 
mother arrived at 12.50. Consideration was not given to the appropriate amount of leeway to 
be given to the patient before escalating the fact  of them not having returned, with patients 
being given 30 minutes or more; 

It is also relevant to consider under this heading the Coroner’s additional concern: “Ward staff 
appeared to take a different approach to leave and return depending upon the status of the 
patient as a detained or voluntary patient” 

As noted above, the Trust has identified the procurement and re-design of its Electronic Patient Record 
system presents an opportunity to incorporate recording and monitoring of patient leave (for informal as well 
as formal patients) within the patient’s electronic record, for example by making the Leave Form an 
electronic document and therefore easier to access and monitor, as opposed to being solely reliant on a 
paper log.  

In the meantime, additional measures are in place on the ward to which Ms Morgan was admitted where 
they have now introduced a whiteboard in the main nursing office with leave and return times written on it. 
This means that it is now much easier for nursing staff to keep track of whether a patient has returned from 
leave at the expected time. The board is updated when a patient is signed out and then on their return. This 
aspect of learning from the incident was part of the presentation at the Patient Safety Committee so that 
other wards within the Trust can consider implementing the same system.  

Reminders and reflection to staff about accurate completion of leave logs/hourly leave checks have also 
been emphasised in a directorate learning event. It is also noted that if Leave Form can be recorded             
electronically, as is hoped, then this will provide a much clearer audit trail, including names of users and time 
stamps, so it will be easier to monitor compliance and promote learning compared with the existing paper      
systems. 

The Trust notes the Coroner’s specific concern with respect to the “leeway” given to  informal patient’s when 
they do not return from leave as planned, and a difference in approach to leave and return from leave applied 
between informal and detained patients. Whilst it is already Trust policy that staff should promptly escalate to 
the nurse in charge in the event of an informal patient failing to return from leave as planned and agreed (in 
accordance with the Trust’s Leave for Informal Patients Policy), it is the intention that the planned review of 
that policy, alongside the review of the AWOL and Absent and Missing Persons policy, will ensure that relevant 
measures  and  considerations  from  the  AWOL  policy  will  be  incorporated  and  reinforced  within  the  revised 
Leave for Informal Patients Policy, to reduce discrepancies between the two approaches.  

The aforementioned Patient Safety article circulated to staff on 5 March 2026 reinforced the following: 

-  That it is the responsibility of the member of staff allocated to the hourly checks to check whether the 

patient has returned from leave at the expected time; and  

-  Staff must act promptly if a patient fails to return from leave, setting out 5 steps to be taken including  
escalation  to  the  Nurse  in  Charge,  contacting  the  patient  to understand the delay, contacting 
family and friends where appropriate, considering a welfare check or contacting the police if there is 
an immediate risk; and completing a Datix incident report.  

A  Blue  Light  Bulletin  to  share  learning  from  the  patient  safety  incident  was  issued  on  10  March  2026  and 
emphasises that a serious incident had occurred due to staff being unaware that an informal patient had not 
returned from leave as expected. The bulletin highlights “the value of promptly checking on patients who do 
not return from  leave”  and  sets out the relevant checks. The Bulletin  has been  raised  in Trust governance 
committees, discussed with team business meetings and been made available to all staff (clinical and non-
clinical).   

A488A488 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition, there was a Lewisham Quality Meeting held on 13 April  2026 chaired by 
, 
Deputy Head of Nursing and Quality with attendance by front line clinical staff, including Band 5 and 6 nurses 
who carry out nurse in charge role. Learning and discussion was held in relation to the nurse in charge role, 
including the key role they play in relation to leave, expectations of those in that role and in light of the clearly 
set parameters of the role set out within the Trust policies and procedures. 

This reflective session emphasised the role of the nurse in charge as not only the most senior nurse on duty 
but the clinical leader, risk manager, coordinator and decision-maker responsible for keeping patients and staff 
safe  while  ensuring  high-quality,  lawful  mental  health  care.  It  was  stressed  that  the  nurse  in  charge  holds 
overall accountability for patient care on the shift and their role  in relation  to  escalating  emerging  risks  on  
the  ward,  including  making  real-time decisions about calling the police.  

In addition, nurse in charge performance of these responsibilities is assessed through monthly supervision and 
annual appraisal processes. Ward managers and matrons undertake direct observation  of  practice on  the  
wards.    Any    concerns    will    be    raised    with    staff    immediately.  Supervision    is    a    space    for   continued  
reflection  and  learning,  consideration  of  feedback, discussion of cases and case-based scenarios to test 
and  enhance  individual’s  understanding  of  the  expectations  and  requirements  of  role,  mandatory  training 
completion is reviewed during supervision and additional training and support needs can be considered. 

4.  A photograph of the patient was not included in the grab pack. Unlike detained patients there 

was no checklist for voluntary patients as to the measures taken to locate the patient 

The issue of a checklist is addressed above. With respect to the requirement to include a grab pack, policy 
requirements with respect to this will be reviewed as part of the Mental Health Law Committee’s 
aforementioned tripartite Policy Review.  

The Trust acknowledges the Coroner's concern that a photograph of the patient was not included within the 
grab pack and that,  unlike  detained patients, there was no standardised checklist documenting the actions 
taken  to  locate  an  informal  (voluntary)  patient  who  failed  to  return.  The  Trust's  Leave  for  Informal  Patients 
Policy already sets out the actions that staff must take when an informal patient does not return from agreed 
leave,  including  risk  assessment,  attempts  to  contact  the  patient,  liaison  with  family  or  carers  where 
appropriate, and escalation to senior clinicians and the police where required. Nevertheless, it is accepted that 
a standardised checklist of actions would be beneficial. In relation to patient identification, whilst a photograph 
was  not  available  in  this  case,  the  grab  pack  contains  detailed  identifying  information,  including  physical 
description and distinguishing features, which could assist police in locating and identifying the individual.  

As  part  of  the  Trust's  policy  review  and  learning  arising  from  this  incident,  arrangements  are  being 
strengthened to ensure a more consistent and robust approach for informal patients. The revised policy will 
introduce a standardised checklist, aligned to the processes already in place for detained patients, to provide 
clear documentation and assurance that all reasonable steps have been taken to locate a patient who is absent 
and considered at risk.  

The requirement in the Trust’s AWOL policy for there to be a current photograph associated with a patient’s 
grab pack derives from the Mental Health Code of Practice’s guidance that detained patients should have a 
photograph included in their notes (27.22). The Trust acknowledges that its policy does not make clear that 
this guidance relates to detained patients rather than voluntary patients. 

The review will also consider requirements relating to the availability and maintenance of patient photographs 
within  grab  packs,  subject  to  appropriate  consent,  information  governance,  and  legal  requirements.  These 
changes will support consistency of practice, improve record keeping, strengthen assurance regarding actions 
taken, and enhance the information available to partner agencies, including the police, during missing person 
investigations.  

Conclusion  

The Trust regrets that the work that it has undertaken to address the learning that has arisen from this sad 
case and through the inquest process has not yet been completed. Nevertheless, the Trust hopes that the 

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 information provided in this response provides reassurance to the Coroner and the family that work is 
underway and there is a timeline for action.  

The Trust acknowledges that the principal outstanding actions at this stage are (1) the tripartite policy 
reviews to bring the policies in respect of leave up to date with NICE guidance and (2) the discussions with 
the new provider to explore how the Trust’s systems in respect of documenting, communicating and 
monitoring leave might be strengthened under the newly-procured EPR – both of which are actions that will 
inevitably take some time to complete and embed.  

In the meantime, the Trust has taken action through various forums to reinforce to its staff its expectations 
around the recording, communicating and monitoring of leave for informal patients, and the key role played 
by nursing staff in this, as well as continuing to embed NICE guidance and the individualised approach to 
risk assessment and safety planning. 

The Trust would once again like to offer its sincere apologies and condolences to Ms Morgan’s family for the 
shortcomings that were identified on the part of the Trust.  

Yours sincerely 

Interim Chief Executive Officer 

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