Recommendations - West Yorkshire Police, June 2023

The IOPC recommends that West Yorkshire Police (WYP) review its interpretation of the Hospital Absconder Policy and the way it is communicated to operational staff to ensure that appropriate consideration is given to the 'immediate, real and substantial risk to life and/or serious injury' that exists at the time the request for assistance is received even when the calling hospital may have failed in its own responsibility to take reasonable care of the vulnerable person.

This follows an IOPC review where a person took their life having absconded from a hospital whilst waiting to be allocated a bed in the mental health ward. The hospital considered the person to be at risk of self-harm and asked WYP to take primacy in locating them. WYP twice refused to take primacy. The IOPC felt the call taker and inspector may have attached to much weight to the actions and failings of the hospital to appropriately care for the person instead of focusing on, and attaching weight to, the risk factors that were pointing to an immediate, real and substantial risk to life.

Accepted

Since the initial update the Force’s Safeguarding Governance (SG) have updated the Missing Persons Force policy section on ‘Hospital Absconder’ which under the Right Care, Right Person national framework has been renamed ‘Hospital/Healthcare Walkout’.  It is less a policy and more guidance as it sits within the Missing Person policy which works hand-in-hand with the Welfare Check Force Policy. The issue of ‘immediate, real and/or substantial risk to life’ has been incorporated in missing person training as a specific point of discussion during interactive scenario-based training undertaken for front line sergeants and inspectors by the Missing Person DI in SG. Policy has been amended to specifically state that a failure on the part of another agency to discharge a duty of care must not stop police from doing the ‘right thing’ to protect people. This is not however a clause that permits another agency to abrogate its responsibility where the duty of care properly sits with them. It is meant to ensure that a vulnerable person does not suffer, as a consequence. These training sessions and other sessions offered by SG have continued into 2024.

An important issue raised during the inquest was however the joint understanding of responsibility in the case of [REDACTED] and in other scenarios. WYP have reflected that in addition to fuller information being sought by police (albeit not exhaustively) when contacted by HCPs about the individuals concerned, and fuller information being provided by those HCPs, clarity needs to exist around who is best placed to deal and what incident type agencies are dealing with. Agencies need to know clearly which partner has a duty of care and responsibility to then inform what will be done with that situation.  It was clear that there were still some misunderstandings.

In [REDACTED]’s case, he was not actually a ‘missing person’ at the time the report was made and wouldn’t have been unless he had not been located at his home address through normal prudent checks by those responsible for this – at the time the MH professionals working in the HRI. His case was therefore at that time a Welfare Check policy issue.  

Whilst further clarity is therefore needed in terms of the interface between the Missing Person and Welfare Check policies, the understanding of these policies by partner agencies is critical so that appropriate action and responsibility can be taken and effective escalation undertaken when disagreements arise. The Missing Person DCI and DI at SG are continuing this work with the Force’s Organisational Policing Improvement Team (OPIT) to ensure that there is clarity around specific scenario-based situations and there are no omissions or gaps in our joint understandings. This clearly has to involve hospital, mental health and ambulance partners.

The main recommendation however is for WYP completed.

The IOPC recommends that West Yorkshire Police (WYP) engage with Huddersfield Royal Infirmary Hospital to reinforce the advice that has been given previously in respect to WYP’s absconder policy and to identify whether this case highlights any learning for the hospital or WYP.

This follows an IOPC review where a person took their life having absconded from a hospital whilst waiting to be allocated a bed in the mental health ward. The hospital considered the person to be at risk of self-harm and asked WYP to take primacy in locating them. WYP’s death and serious injury investigation into the person’s death identified possible failings on the part of Huddersfield Royal Infirmary Hospital in respect to the information they provided when asking WYP to take primacy in locating them.

Accepted

Whilst much work had been done around recommendation 1, it became apparent that due to an administrative error recommendation 2 had not actually been specifically actioned. Discussions had taken place with the C&H NHS Foundation Trust around Right Care, Right Person and inputs shared around training with all Force MFH Coordinators and relevant HCPs in all WY NHS FTs, but SG had not specifically spoken to the HRI. HM Coroner was advised of this by the temporary head of SG.

Contact was made with the Head Nurse for Urgent & Emergency Care at C&H MHS FT and a meeting held to ensure that the respective agencies understood one another’s definitions and polices around risk, to ensure it was embedded. Actions were agreed. Again however based on recommendation 1, this professional link and the involvement of OPIT is required to ensure that the understanding of the risk is complemented by a clear understanding of the responsibilities to act and who is the agency best placed to this. As a consequence, although this action is completed the principles of recommendation 1 still need further work but will form part of the ongoing development of understanding.