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Mental health patients in transit | Signal

Reference number
1162 H
Issue date26 February 2010

This Signal relates to the safety of mental health patients in transit, due to inadequate transport or escort.


Mental health trusts are aware of the risks of severely-ill inpatients going missing and many have put measures in place to improve security of their units. However, appropriate steps may not be taken to ensure the safety of patients when they are transferred. These include risks of self-harm or injuries due to vehicles without secure locks, potential ligature points and lack of staff escort to prevent harm.  


A typical incident reads:
“I was driving and [patient name] was a passenger in the back with [patient name 2]. Both [patient name] and I both thought [patient name 2] was adjusting his seat belt. However, we both realised the seriousness of the situation. [Patient name 2] began to sit with his back toward [patient name] and this is why we both did not realise he was strapping the full length of the seat belt around his neck about six times. Then he began jumping forwards to hang himself. We released the seat belt from his neck. Once we stopped the car, [he] was unconscious so we phoned 999."


The National Reporting and Learning Service (NRLS) was alerted following a trigger incident where a patient with depression was transferred from an acute emergency department to a mental health facility by taxi and then exited the vehicle and died from a collision with other traffic. A search of the Reporting and Learning System (RLS) database showed 17 similar incidents, seven of which resulted in patient death. However, it was difficult to determine the preventability of these incidents from the reports as key issues, such as presence of escort, was not always clear. Risk factors included lack of central locking mechanisms in the car as well as lack of trained staff (for instance, one incident related a voluntary driver only with no nurse escort).


A related issue concerned patients absconding from a mental health tribunal (neutral location), during or after tribunal hearing. Eleven incidents were identified in the wider RLS database; although there was no evidence of serious harm, the distress of patients (especially after an unfavourable hearing) makes this a high-risk situation.


There are many risks to consider when transporting mental health patients. The Mental Health Act Code of Practice gives clear guidance on conveying patients detained under the Act. Although it does not strictly apply to the transport of voluntary patients, many of the same principles do apply.


Other useful resources on the wider issue of absconding include a national handbook with strategies and practical advice to reduce missing patients. Mental health trusts should develop local policies for transporting patients in collaboration with primary care, acute care and ambulance services, and these should feature in commissioning plans. 


Have you had any incidents like this?
Do you have any protocols for assessing at risk patients and providing safe transport?




Short Survey on the value and effectiveness of Signals

This is the last issue of the pilot project. To assess the value and effectiveness of Signals, we would be grateful if you and your staff could take a few minutes to answer a short survey. We would like to know if you have found Signals useful and how it could be developed further to suit your needs.


Relevant to: Mental health and other settings where mental health patients transported to and from