The recent conclusion of an inquest in to the death in 2016 of Mr Luke Leggatt in Canterbury has given rise to a social media debate amongst police officers about the East Kent Hospitals NHS Foundation Trust’s reaction to Coroner’s process. Mr Leggatt had been taken to the hospital by his brother after taking cocaine and having resisted assessment or any treatment for this, had left the hospital. The police were not called when he walked out and he tragically died of a heart attack, caused by a fatal level of cocaine toxicity. Faced with an obvious degree of criticism, the East Kent Hospitals spokesperson announced that they have changed their policy on patients who walk out of A&E to make sure that every such patient is subject to a ‘safeguarding call’ to the police irrespective of any assessment of ongoing risk to that person.
Job done – over to the police. Settles everything, doesn’t it? I have at least few dozen questions and observations about this, not least because of how it appears to have been done.
Whilst missing patient / missing person investigations can often be frustrating to officers, the potential seriousness of each case is widely understood and most officers are told that one of the easiest routes to disciplinary procedures, is to be casual about them. What is more likely to promote casualness than a number of investigations in to people who are not at risk, reporting, it would obviously seem, to create the impression that another organisation has ‘done something’ to cover it’s back after a tragic, adverse event?
Here is just some of what a police officer would want to know from an A&E Department or any hospital reporting a patient absent, absconded or missing. Even if a person is at immediate and obvious risk where you start with crews looking for people nearby and making the urgent and obvious enquiries like “Did they go straight home” or “are they nearby to the A&E?”, the force would still try to have one officer gathering this information whilst a search begins, to maximise information and lines of enquiry if searches have to widen and investigations deepen. This stuff can be critical in the ‘golden hour’ of a vulnerable person being missing.
What has the reporting organisation done prior to ringing the police? – if nothing, why not?! … missing patients are still a hospital’s responsibility to a degree, certainly until the police are sufficiently briefed to take over the matter as a missing person’s investigation. It should always be borne in mind that missing patients and missing people are NOT the same thing, for what should be obvious reasons. The starting point is that hospitals owes a duty of care and that this cannot be entirely passed to the police with one phone call which says, “Michael Brown walked out: here’s his date of birth and address”. This is also about not duplicating effort, especially in more urgent cases.
- Name of the person who is being reported missing
- DOB / address / phone number / description
- Details of anyone known to them – Next of Kin; person who brought them in.
- Circumstances in which they went missing – this means more than “walked out of A&E”:
- Why were they thought to have come to A&E?
- What condition were they complaining of?
- How long did they remain there?
- Is there any reason at all to question in law their mental capacity to take their own decision to leave? – who did that capacity assessment, when and why?
- What are thought to be the medical risks to this individual? – not just on this presentation, but from any hospital records, is anything else relevant to the investigation or risk assessment?
- If no assessment of capacity, because there was no reason to question their capacity; why is the report being made to the police, given that people are entitled to leave if they wish and, although it’s rude and inconvenient, they’re not obliged to ask permission or tell the hospital.
- What are thought to be the medical risks to that individual of having left?
- Given that there are some limited situations in which A&E departments and hospitals can hold people, why was this not done in this case? – again, this is not a criticism: it is about the police understanding whether it is because the hospital themselves believe that no legal grounds existed … that, in turn, may influence how the police make their legal decisions.
- Precise circumstances of leaving: did they tell staff they were leaving and leave against advice; did they slip out unobserved? – because this begs further questions.
- What direction did they go? – are they known to have left hospital grounds or could they still be on hospital grounds?
- Extent of any search of hospital undertaken by hospital staff / security – if we can’t rule out the patient leaving the hospital, I’d be asking security and staff to search it (because we have had patients turning up dead four days later in toilets that weren’t searched).
- Any available CCTV of what the person last looked like when they went missing.
- Bearing in mind that the police will often be entirely unable to make an assessment of whether or not a person is ‘safe and well’ (medically speaking), and given an obvious lack of legal powers over people in a lot of circumstances, what exactly are the police being asked to *do*, strictly speaking?
- This question is about way more than pedantry: it goes to clinical leadership of a clinical situation that the police cannot fully absorb. If the answer is “once found, call an ambulance”, fair enough – but any request the person be ‘brought back’ to hospital will invite questions about what legal powers are open to the police in that medical situation, especially if a person has not been assessed as lacking capacity.
CAPACITY & UNWISE DECISIONS
This list is not exhaustive – I can think of other questions and issues that would be relevant in some cases. I wonder if the hospital, described in the press article, as “under extreme pressure due to staff shortages” actually has the organisational capacity to sit down with officers and answer these questions for everyone who walks out who is not thought to be at specific risk?!<
And it invites this obvious question:
Are we saying that this process will be what the hospital attempts to initiate if a sober adult man attends on a Friday night because of a cut to his hand from a DIY accident but becomes bored of waiting whilst appreciating that A&E are struggling to see him in four hours because of all the critical, trauma and alcohol related cases coming in like heart attacks, car crashes and assault injuries? Surely, once it’s noticed he’s not there, you get reception to ring him on his mobile number (which you took during booking in) to wonder where he is and he’ll say something like, “Just appreciated you’re really busy on a Friday night – I’ll bear with it tonight and come back in the morning when you’re less busy.” Are we seriously saying that this means the hospital will phone the police to make a ‘safeguarding call’?!
Frankly and bluntly, what on EARTH for?!!? … a capacitous adult, exercising a lawful choice – even if it’s unwise, it’s still lawful. What would the police do on arrival that a phone call couldn’t try to do? Nothing – it’s this aspect of this sudden change of policy by East Kent Hospitals that risks being labelled ‘back-covering exercise’ … and it is being labelled as such on social media by officers reading the article. It also invites the other question, was this policy change discussed with an agreed with Kent Police so that the kinds of questions I’m raising here were raised with hospital managers? – and if not, why not?! It is my current understanding this wasn’t discussed with them and it amazes me to contemplate that because of the number times in my work the NHS stress that consultation is everything and working in partnership is key.
There is also one question that arises for me here that has niggled at me all my service. I have dealt with reports like this, during all of my operational roles. What is always missing in those reports from the various NHS hospitals I’ve worked near, is two things –
- Any obvious consider at the triage stage of mental capacity to take decisions, including that to walk out, for whatever reason – it strikes me that where there is no reason to question capacity (and bearing in mind that capacity in adults must be assumed unless there is reason to question it), this should influence how hospitals respond to adults making choices.
- Any contingency planning for those who might leave, whether indicated or not – this article does not cover what the hospital thought the risks to Mr Leggatt would be if he left and on the one hand they called security but on the other hand didn’t stop him leaving.
As a hospital manager, I’d be interested in why staff were reporting people ‘missing’ to the police – another public organisation that I would also know by watching the news are “under extreme pressure”, unless there was an obvious reason to do so. But in fairness, Mr Leggatt presented whilst acutely intoxicated by cocaine and we know that consumption of cocaine can affect mental capacity to take decisions – it is, for example, listed as a mental disorder in the medical manuals and no attempt appears to have been made to keep him there prior, or to call the police at all. It’s all very well comments being made to say that hospitals can’t force people to things, but actually the law provides a framework for that, in extremis. Whether or not those frameworks apply in a given situation is a far finer judgement, but if you read the Kent OnLine article for yourself, you may form the view that I did: that there are a lot of things going on between the lines that are important and not being made plain.
There reasons to suppose a cocaine intoxicated, distressed adult man may be vulnerable on various grounds and that the police should have been called when he left – it strikes me that is the problem here: risks and vulnerability were under-estimated and a call that probably should have been made, wasn’t made .. one can only imagine why. I’d be interested to see what the Coroner’s verdict was or what any Preventing Future Deaths report may say (if there is one), but this stuff doesn’t stack up to a unilateral amendment that everyone who gets bored waiting in a busy A&E and makes a capacitous decision to leave should be subject to a ‘safeguarding call’ to the police.
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