Adult Acute Services absent vulnerable patient/missing inpatient (G90)

The National Missing Persons Framework¹ published in 2017 is the result of close collaboration between the Scottish Government, Police Scotland, local authorities, third sector organisations and NHSScotland. This framework promotes a shared approach which ensures an effective frontline response when someone goes missing and preventative measures to stop people going missing in the first place.

This NHS Ayrshire and Arran adult acute services absent vulnerable patient/missing in-patient procedure is aligned with the national missing persons framework.  The overall aims of this procedure are to:

• Prevent people from going missing from acute hospitals in the first place; and
• Limit the harm associated with people going missing.

Patients who are vulnerable and/or at risk of harm may be at risk of going missing and staff, in the course of their duties, should consider this risk and put in place preventative measures. Such measures may include taking practical steps to reduce the risk of the patient leaving the ward and getting lost for example asking them to let staff know if they want to leave the ward so someone may accompany them as appropriate.

When a patient is considered to be potentially at risk of going missing this must be known to all ward staff and shared with other hospital staff as appropriate. The care and treatment plan must have the risk recorded fully and this reviewed regularly as the risk may change depending on the patients’ treatment and/or condition.

Depending on individual circumstances it may be useful to refer to and enact the Higher Level Supervision procedure on the intranet.

For staff working in the Ayrshire Maternity Unit (AMU) please be aware of additional child protection guidance for the management of high risk pregnancies during stay in AMU as this guidance may be appropriate depending on circumstances.

A patient may be categorised as absent without authority when they have:

• left his / her ward without the agreement of the health care team or
• not returned at the agreed time or
• not attended a ward or is not where they should be.

Patients who fall into the ‘Absent’ category will be the subject of a continuous risk assessment by health care staff while they remain absent.

• Patients who are assessed as being no risk to themselves or others will be suitable for consideration in the absent category
• Their status may change to ‘Missing Person’ after an agreed period of time or if determined by the ongoing risk assessment. This must be a multidisciplinary health care decision with a minimum of nursing and medical staff involvement.
• Whilst the Patient’s status remains ‘Absent’ the Police will not be alerted.

The category will change when:

• The patient's whereabouts are unknown and there has been no phone contact from the patient for a period of time;
• Where health care staff have assessed the risk to have increased;
• There are other external factors that would seriously increase risk to health of the patient, e.g. adverse weather conditions.

A decision will be taken by health care staff regarding the length of time a patient may stay in the ‘Absent’ category, but will be no longer than 8 hours after which they would be deemed as missing.

A patient may be categorised as missing when their whereabouts is unknown and:

• the person is at risk of harm to themselves or another
• where the circumstances are out of character
• the context suggests the patient may be subject to crime.

 N.B. This is the national definition of a missing person.

A patient may also be categorised as a ‘Missing Person’ when he/she is absent from their ward for more than 8 hours without permission and / or when the ongoing risk assessment suggests a high level of risk.

When a patient is reported missing, a risk assessment will be undertaken by Police Scotland and thereafter categorised as high, medium or low.

Low Risk Status

Low Risk is deemed as any person that goes missing where there is low risk of harm to that person or others.

Medium Risk Status

Medium Risk is a missing person that is likely to place themselves in danger or they are a threat to themselves or others.

High Risk Status

High Risk is a missing person where the risk posed is immediate and there are substantial grounds for believing that the missing person:

• is in danger through their own vulnerability; and / or
• may have been the victim of a serious crime; and / or
• the risk posed is immediate and there are substantial grounds for believing that the public is in danger.

Owing to the changing nature of health and associated risk the level of risk is dynamic and individuals can move between these levels of risk and robust timeous communication between agencies is required to react in a proportionate and appropriate manner.

1. Realisation that the patient is missing:

   • ascertain when last seen
   • speak with fellow patients and all staff (person may have mentioned going out and forgot to communicate this)

2. If no one aware of whereabouts or reason for not being on ward

   • attempt to contact missing person by telephone.

3. Initiate a search of the immediate vicinity, including:

   • under beds and in cupboards
   • additional rooms and toilets
   • stairwells and fire escapes - N.B. this list is not exhaustive.

   Contact patient's nominated contact person / next of kin as per admission documentation and ask if patient has been in contact.

4. If person still not located:

   Staff may consider the appropriateness of searching the wider environment, however, must consider the risks to self and others/ search in pairs/ keep a safe distance if needed and agree a method of calling for assistance from other ward areas to ask for assistance with the search, if required. Staff must also consider the wider impact of leaving the ward patients.

   Contact the following via hospital switchboard:

   • Police - provide description of the patient*
   • Security/ Porters - provide description of the patient, ask for a review of the CCTV The priority of the Security /Porter is to review and monitor the CCTV for evidence of the patient’s movements.

   *access relevant systems/records (e.g. eClipse, patient profile etc) for information and complete missing person information form and update police / security as appropriate. Consider vulnerability, risk to patient and risk to others and communicate the same.

5. If person still not located:

   • inform unit coordinator / management team / duty manager / medical team / maternity page holder
   • nurse to provide an update of the situation to the patient’s nominated contact person
   • complete a DATIX incident form and ASP referral if adult support and protection criteria has been met.

   Police coordinate search from this point:

   NHS provide police with information and support as required.

6. When patient found – de-escalation process:

   • inform all relevant parties of the person’s return e.g. security / police / porters / management
   • ensure missing person information form is completed and updated
   • complete DATIX to document how person returned and any associated adverse event, update ASP referral as appropriate
   • carry out an appropriate health assessment of the patient and record the outcome in the medical and nursing notes
   • agree a management plan, including supervision level
   • complete the return discussion/ debrief template.

Those coordinating the searches should:

• consider information in the patient's medical and nursing notes to identify whether it is safe for staff to search for the patient (risk of violence etc). Where a significant risk is highlighted and the patient has left the ward/department staff should contact the police for assistance.
• ensure that staff search the internal or external areas in pairs.

Those undertaking the search should ensure they have means of immediate communication, e.g. mobile phone contact with the area where the patient has gone missing and register their contact details with them. This is to ensure they can make emergency contact if necessary and for the Ward to give updates as appropriate.

All persons involved in searches should take into account prevailing conditions such as:

• patient risk
• weather
• time of day
• locations to be searched etc.

All persons involved in searches should take appropriate action and equipment considered necessary for the search e.g. torch, medical equipment etc.

When a staff member identifies an unsupervised and apparently vulnerable patient in or outwith the hospital grounds they should:

• approach the person in a calm unthreatening manner and ask “can I help you?”
• ask the person their name, which ward they are an inpatient in, where they are going and if anyone is with them
• check name on patient's wrist band
• if possible contact last known ward to alert them and summon assistance
• summon assistance:
  • in hospital grounds from staff / security
  • outwith hospital grounds from police / ambulance.

A return discussion can help to support a patient following their return, provide a platform to identify underlying issues and obtain information that could prevent future missing episodes. In all circumstances, it is important that there is an opportunity to identify the issues, and then help or ensure patients get the appropriate support or protection available. Those who are vulnerable in the community and without care or support around them may be the most in need of support or protection. Staff should consider the need for support and make any appropriate referrals including social work, adult support and protection or any other specialist services as relevant.

There is no set time for the discussion to occur - as soon as the patient is ready to do so, at a suitable time for the individual and with a trained professional of their choice where possible. It may not always be appropriate for Police Scotland to undertake a return discussion and a ‘safe and well’ check may suffice. In many circumstances, the discussion can be done informally as a conversation between the patient and ward staff.  Alternatively they may prefer to speak to a service provider they may already be engaged with, such as a social worker, a key worker in a care facility or a support worker from a third sector organisation.

Complete the return discussion/debrief template and retain in the patients records. This information may be valuable should the individual go missing on another occasion.

• Police will undertake investigation and will continue to be responsible for communication with family, carers and next of kin (as appropriate)
• liaison between duty manager and communications team to prepare possible communication briefing
• support staff - consider involving staff care
• record incident on Datix within 24 hours of event and initiate appropriate level of local adverse event review as per NHS Ayrshire and Arran Adverse Event Policy

Missing patient information sheet

1. Scottish Government. National missing persons framework for Scotland. May 2017. Available from: https://www.gov.scot/binaries/content/documents/govscot/publications/strategy-plan/2017/05/national-missing-persons-framework-scotland/documents/00517676-pdf/00517676-pdf/govscot%3Adocument/00517676.pdf