Running Away Causes Delay

Published 23 October 2017. Last updated 6 November 2017.

This project reduced the number of patients who absconded (ran away) from the Coffs Harbour Mental Health Inpatient Unit, by implementing an environmental review, courtyard supervision, flexible visiting hours, multidisciplinary team reviews, leave prescriptions and capital works.


To reduce the rate of absconding patients in Coffs Harbour Mental Health Inpatient Unit by 50 per cent, by June 2017.


  • Increases the supervision of patients in mental health inpatient units.
  • Allows staff to spend more time with patients, delivering patient-centred care.
  • Improves communication of absconding risks between teams.
  • Reduces the number of absconding incidents in mental health inpatient units.
  • Improves communication between clinicians and patients, family and carers.
  • Provides a better understanding of rules and responsibilities in the unit.
  • Allows teams to understand the reasons why patients abscond.


In 2016, NSW Health issued a safety notice1 to all local health districts and Specialty Health Networks, following a number of incidents where patients absconded from mental health inpatient units. As a result, a rigorous process was put in place to support the safe and appropriate assessment of involuntary patients before they were granted leave from a mental health inpatient unit.

To achieve this, a number of tasks were allocated to each local health district, as follows:

  • distribute the safety notice to all stakeholders and mental health inpatient units
  • conduct a safety audit of the physical environment of mental health inpatient units, with recommendations to reduce the risk of absconding patients provided to NSW Health by 1 August 2016
  • review absconding incidents and identify areas for improvement, with results reported to NSW Health by 1 August 2016
  • audit and revise the process for providing leave to patients in mental health inpatient units, including risk assessment protocols that outline the patient’s history of absconding and current absconding risk, due by 1 August 2016
  • ensure that any leave decisions are considered by a multidisciplinary team and outcomes are documented, with written advice to the family or carer about the risk of harm to self and others, how to manage risks during leave and what to do in the event of a crisis.

Review of clinical incidents found that Coffs Harbour Mental Health Inpatient Unit accounted for 49 per cent of all absconding incidents in Mid North Coast Local Health District (MNCLHD) between July 2015 and June 2016.


  • A project team was established and a driver diagram developed to identify primary and secondary causes of absconding incidents.
  • An environmental review was conducted in conjunction with Work Health and Safety, with recommendations provided to increase safety and security. These recommendations included an air lock area at the entrance of the unit, changes to fences in the courtyards and reduced access to the inpatient unit from the rear doors. Recommendations were approved and capitol works were completed in July 2017.
  • It was identified that 68 per cent of patients absconded over the fences of the courtyards.  As a result, a new supervision schedule was put in place where staff monitored the courtyards.
  • Flexible visiting hours were introduced, to allow family and carers to visit outside the standard visiting hours. This provided increased support to the patient and reduced the risk of them running away.
  • Multidisciplinary team reviews were reintroduced, as it was identified that patients did not have any opportunity to contribute to their care planning.
  • It was identified that leave prescriptions were inconsistent. A leave procedure was developed as part of the clinical review, with documentation standardised.
  • An analysis of absconding incidents revealed that there was no clear reason why patients absconded. As such, incident debriefing tools were developed to help staff discuss the incident with patients and from their point of view.
  • A smoking cessation program implemented by MNCLHD was introduced to inpatients, to reduce the amount of leave granted for smoking purposes.

Project status

Sustained – The project has been implemented and is sustained in standard business.

Key dates

September 2016 – May 2017

Implementation sites

Coffs Harbour Mental Health Inpatient Unit


Clinical Leadership Program


  • Absconding incidents were reduced by 21 per cent, which did not achieve the aim of the project. This was due to the fact that all solutions were not implemented at the time of evaluation, in particular capitol works to the courtyard area.
  • The number of repeat absconders reduced by 11 per cent.
  • The number of absconding incidents from the courtyard reduced by 45 per cent.
  • The number of absconding incidents directly from the unit reduced by 12 per cent.
  • The number of visitors accessing the unit outside of standard visiting hours increased by 40 per cent.
  • 100 per cent of leave prescriptions were achieved.
  • Two patient stories were captured as part of the project.
  • 100 per cent of patients had multidisciplinary reviews.
  • The number of patients who were identified as smokers and provided support to quit smoking increased from 12 per cent to 53 per cent.
  • The number of patients who were readmitted to the mental health inpatient unit within 28 days reduced from 37.5 per cent to eight per cent.

Lessons learnt

The most important lesson is to listen to as many patient stories as possible. Teams can raise fences, produce policies and increase observations, but the reality of each consumer who absconds is unique and must be considered when developing solutions.


  1. NSW Ministry of Health. Safety Notice SN004/16: Assessment and Management of Risk of Absconding from Declared Mental Health Inpatient Units. North Sydney: NSW Health; 2016.

Further reading


Tanya Dugard
Quality Manager, Mental Health Services
Mid North Coast Local Health District
0459 821 797


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