On 23rd April 2022, the family of Rachel Jones took her to A&E at East Surrey Hospital due to suicidal thoughts and superficial self-injury. She was assessed under the Mental Health Act (MHA) at East Surrey on 26th April 2022 and having been subsequently detained under s2 MHA, was transferred to Langley Green Hospital in Sussex. Rachel made progress whilst in hospital and was removed from her MHA section by 5th May but she remained at Langley Green as a voluntary patient. Her discharged was planned for 6th May however she disclosed to a support worker she intended to end her life after discharge so this was reported to ward staff the hospital. No action was taken and her risk assessment was not updated.
Later on the 5th May, Rachel was signed out for 15 minutes for a cigarette but did not return at the agreed time. The hospital did not realise she was missing for around one hour and Rachel eventually turned up at her mother’s house. Hospital staff drove there drive there to bring her back and her mother informed staff she was agitated and distressed, claiming to have tried to kill herself twice the previous night whilst in the hospital. Again, her risk assessment was not updated.
On 6th May 2022, the hospital received an email from Rachel’s mother, expressing concerns about the plan to discharge her, given ongoing suicidal thoughts and they received a further email from the support worker, reiterating her concerns from the day before. Rachel was signed-out for a 15 minute cigarette break at 1040am and after initially going to reception, Rachel went back to the ward door and asked a member of staff for some money. This should have been seen as a ‘red flag’ and the Nurse in Charge should have been informed, but this did not happen. Rachel left the building and did not return at her agreed time. Staff did not realise she had not returned until the police arrived at 14:30, more than three hours later. The Senior Coroner found that this was a serious failing because it meant the AWOL* procedure was never triggered and no steps were taken to find her.
In the meantime, Rachel turned up at a friend’s house, behaving strangely and her friend returned her Langley Green, dropped her at 1150. Rachel did go back inside and speak with the receptionist before leaving again but because the AWOL procedure had not been triggered, the receptionist did not know that she was a missing patient.
Following an inquest under Senior Coroner Penelope Schofield, it was found that Rachel’s death was contributed to by neglect in circumstances where hospital staff allowed her to leave for 15 minutes for a cigarette and then failed to realise she did not return for more than three hours. Tragically, during that time, Rachel ended her life.
It was found by the Coroner if AWOL procedure had been triggered as required, this would probably have saved her life.
FINDINGS
HM Coroner found the following missed opportunities were possibly causative:
- Response to the report on 5th May 2022 that Rachel intended to hang herself upon discharge.
- Failure to update her risk assessment with those concerns.
And the following failures were probably causative:
- Failure to notify the Nurse in Charge when Rachel returned on 6th May 2022 (asking for money).
- Failure to check on Rachel’s whereabouts when she did not return from leave on 6th May 2022.
- Failure to trigger the AWOL Policy on 6th May 2022.
As a result, she concluded that Rachel’s death was contributed to by neglect.
*AWOL POLICY
It’s worth noting as an aside, the name of the policy that wasn’t triggered: it was referred to in coverage of the inquest as an “AWOL policy”. Rachel was not “absent without leave” as defined by the Mental Health Act because she was not a detained, sectioned patient at the point where she failed to return from her 15-mins leave. Policies covering absence or absconding are often wider in their application than simply being restricted to those patients who are subject to the MHA, but as a point of law, someone who is a voluntary patient cannot be absent without leave.
As various cases have shown, this does not mean such patients are at lower risk when absent and such matters have had to be considered in the Supreme Court where arguments were put that voluntary = lower risk. The Supreme Court disagreed, describing “the differences between the two categories of psychiatric patient [voluntary and detained]” as “one of form, not substance.”
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 