Adult Acute Services absent vulnerable patient/missing inpatient

The National Missing Persons Framework¹ published in 2017 is the result of collaboration between the Scottish Government, Police Scotland, local authorities, third sector organisations and NHSScotland. This framework promotes a shared approach ensuring an effective frontline response when an adult inpatient goes missing and the preventative measures in place to prevent adult inpatients going missing.

The SOP for When an adult inpatient is missing or absent is aligned to the national missing persons framework.  The overall aims of this SOP are:

• Prevent adult inpatients from going missing from hospital environments
• Limit harm associated with people going missing.

Staff  should consider risks associated with adult inpatients, who are considered vulnerable and/or at risk of harm, who may be at risk of going missing or be absent from the healthcare environment and ensure preventative measures are in place.  Measures can include:  

• Take practical steps to reduce the risk of the patient leaving the ward and getting lost, i.e. asking the person to advise staff if they want to leave the ward so someone may accompany them as appropriate. 

When an adult inpatient is considered to be at risk of going missing, this should be communicated to all healthcare environment staff as appropriate. The care and treatment plan should have the risk recorded fully and be under regular review and update to reflect any changes relating to the patients’ treatment and/or condition.

It may be useful to refer to the Higher Level Supervision guidance on the intranet.

Additional child protection guidance for the Management of High Risk Pregnancies during stays in AMU applies for staff within Ayrshire Maternity Unit. 

An adult inpatient may be recorded as absent when they have:

• left the healthcare environment without discussion with the health care team
• not returned at the agreed time
• not attended a ward or is not where they were expected to be.

Patients who are assessed as being no risk to themselves or others will be suitable for consideration in the absent category.

A decision should be taken by healthcare staff regarding the length of time an adult inpatient may stay in the absent category, this will not be longer than 8 hours, after this time they would be deemed as missing person. 

The status may change to missing person after the agreed period of time mentioned above as 8 hours, 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 adult inpatient's whereabouts are unknown and there has been no contact from them 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 adult inpatient, i.e. adverse weather conditions. 

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 they are absent from the healthcare environment for more than 8 hours without prior discussion with the healthcare staff 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 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 risks, the level of risk is dynamic and individuals can move between these levels of risk and robust timely communication between agencies is required to react in a proportionate and appropriate manner.

Realisation that the patient is missing or absent:

• ascertain when last seen
• speak with fellow patients and staff 
• consider adult inpatient may have mentioned going out and forgot to communicate.

If no one aware of whereabouts or reason for adult inpatient not being on ward

• attempt to contact by telephone.

Initiate a search of the immediate vicinity, consider including:

• under beds and in cupboards
• additional rooms and toilets
• stairwells and fire escapes

Contact adult inpatient's nominated contact person / next of kin as per admission documentation.

If adult inpatient not located:

• consideration to be given to searching wider environment
• consider the risks to self and others in doing so
• search in pairs/keep a safe distance if required
• agree a method for calling for assistance from other areas to ask for support with search 
• consider impact of leaving ward area.

Contact the following via hospital switchboard:

• Police - (provide description of missing person)
• Security/ Porters - ask for review of CCTV (provide description of missing person)
• 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 and any risks to missing person and others and communicate this.

If adult inpatient still not located:

• inform unit coordinator / management team / duty manager / medical team / maternity page holder
• nurse in charge to provide an update to the adult inpatient’s nominated contact
• complete a DATIX incident form and ASP referral if adult support and protection criteria is met.

When adult inpatient is located

• inform all relevant parties 
• ensure missing person information form is updated
• complete DATIX to document return and any associated adverse events
• update ASP referral as appropriate
• undertake health assessment of the adult inpatient and record the outcome in medical and nursing notes.

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. Where a significant risk is highlighted and the patient has left the ward, the Nurse in Charge should contact the police for assistance. They should ensure staff search the internal or external areas in pairs, ensuring there are sufficient staffing levels on the ward.

Those undertaking the search should ensure they have means of immediate communication, i.e. mobile phone with contact details for 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 to receive 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.

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 missing adult inpatient within or outwith hospital grounds:

• approach the person in a calm unthreatening manner and ask “can I help you?”
• ask the person their name (if they are able to tell you), which ward they are an inpatient in, where they are going and if anyone is with them
• ask the person for permission to check their wristband
• if possible contact last known ward to alert them and summon assistance.

If assistance required:

• within hospital grounds - contact staff / security
• outwith hospital grounds - contact police / ambulance.

A return discussion can provide a platform to identify underlying issues and obtain information that could prevent a repeat event.

In all circumstances, it is important that there is an opportunity to ensure patient gets 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 ensure appropriate referrals are made i.e. social work, adult support and protection or any other specialist services.

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 this can be with a service provider they may already be engaged with i.e. 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 patient's records. This information may be required should there be a repeat event in future.

Police will undertake investigation and continue to be responsible for communication with family, carers and next of kin (as appropriate)

• Liaison between Director of Site Operations and Communications Team to prepare possible communication briefing. During the in-hour period the site Director should be made aware in order to liaise with communications team.  During the out-of-hour period this will be the Duty Manager who will contact the communications team after discussion with the Director on call.
• 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 (only available on intranet)

At all times the safety of the adult inpatient and staff is paramount.

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