Scope / Reason for development
To assist Emergency Physicians to manage patients who leave the Emergency Department unexpectedly, without the knowledge of clinical staff, and in whom there remains a potential risk of harm to self or others either through neglect or deliberate means. This guideline does not refer to those patients who ’Did Not Wait’, who ‘Left without Being Seen’, or who ‘self-discharge’.
Summary of Recommendations
- Emergency Departments should prioritise the clinical assessment of patients at high risk of absconding.
- An essential action to be performed as soon as the risk of absconding has been identified is to assess capacity, ideally as part of a mental health triage tool.
- Emergency Departments should have a specific form for detailing a patient’s physical features, if at risk of absconding.
- Emergency Departments should have written policy to address management to help prevent absconding when risk has been identified. This should involve capacity assessment, if the patient attempts to leave, and best interest decisions.
- Emergency Physicians requesting that a patient be restrained must be clear regarding the legal justification of their request and document this in the clinical notes. At all times this must be the least restrictive.
- Restraint to prevent absconding should be a proportionate response and in the patient’s best interest.
- Acute trusts should have written agreements with the security team regarding when restraint can be applied and how it is applied.
- Acute trusts should work with local partners to devise pathways and responsibilities as to who should be contacted when patients abscond. This should be based on immediacy of risk of that patient coming to harm. This may be Police, Ambulance, Social Care or mental health services.
- Any children who abscond with or without an accompanying adult should trigger local safeguarding procedures.
- Emergency departments should record the number of patients who abscond and those cases in which the Police Service have been contacted in order to facilitate service improvement.
Key Information
- Patients who abscond and lack capacity or who potentially lack capacity (formally unassessed but the manner of their presentation causes concern) may be a risk to themselves or others and may be detainable under the Mental Capacity Act (MCA) 2005 or the Mental Health Act (MHA) 1983.
- A duty of care exists once a patient is booked in.
- If a patient has capacity their right to act on a decision must be respected, even if it appears ‘unwise.’ However, if the decision to leave ED appears unwise, be cautious before concluding that the decision is reached with capacity.
- If a patient’s actions put others at immediate risk of significant harm, it is lawful under common law to intervene to prevent that harm, irrespective of the patient’s capacity.
- Patients who lack capacity to leave can be restrained so long as that restraint is necessary and proportionate to the risk of harm they would suffer otherwise (s6 MCA 2005). If physical restraint is needed for more than 10 minutes, then chemical restraint (Rapid Tranquillisation) should be administered.
- Preventing a patient from leaving for more than a short time becomes a deprivation of liberty. Lawful deprivation of liberty requires formal authority, which ED personnel do not have. Options under the MHA 1983 are limited to requesting the assistance of the police who can use a section 136 in the ED.