Safety in mental health

Programme Lead: Eileen Dudley

Patient Safety Manager, Oxford Academic Health Science Network

Mental Health Resources

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Programme Aim

For each ward to reduce failure to return from Section 17 leave or agreed time away from the wards by 50% within 12 months of the start of their project.

Programme Focus

The development and spread of a Failure to Return to the Ward Project. This project was initiated at Oxford Health NHS Foundation Trust and has extended to include Berkshire Healthcare NHS Foundation Trust.

Programme Details

Absconding and failure to return to wards following periods of leave have a wide range of consequences for patients, their families, staff, the public and other agencies. These may include:

  • interruption to care plans
  • breakdown in working alliances
  • loss of trust
  • possible risks to the patient or others’ wellbeing.

Absconding and failure to return also disrupt the therapeutic environment on the ward and increase time spent ensuring the patient’s welfare and safe return.

The Failure to Return to the Ward Project focuses on both detained and informal patients to support timely, safe return to the ward following a period of agreed leave or time away and to reduce incidents of Absence Without Leave and missing patients.

The project employs Institute for Health Improvement (IHI) methodology to test interventions directed towards the introduction of:

  • books for signing in and out
  • new patient information leaflets detailing ward expectations
  • the therapeutic planning of leave or time away
  • the use of business cards with messages of care
  • intentional rounding
  • visual staff procedure information.

The work has also informed a change in the local policy guidance. Following testing on a pilot ward, the interventions were extended across seven wards five of which have achieved and sustained the target 50% reduction in failure to return rates. The remaining two are continuing to work towards this target.

Teams from Berkshire Healthcare and Central and North West London trusts took parat in an Oxford AHSN quality improvement training programme with NHS Improving Quality. Berkshire Healthcare has started a project on Bluebell Ward, Prospect Park Hospital, and return-on-time rates have risen to 91% from 20%.

Further information

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