Kristian Allen

I am Gareth JONES, Assistant Coroner, for the coroner area of West Sussex, Brighton and Hove.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Section 4 contains the jury’s findings as revealed in the Record of Inquest. I am concerned that s17 leave is being authorised by staff in ignorance of the leave conditions. In this particular case, the responsible clinician granted leave on the 13th of February 2025, a condition being that Kristian had to test negative for drug use before leave was allowed. On the 15th of February 2025, the nurse in charge granted escorted leave despite Kristian having tested positive for cocaine use. He was unaware of the restrictions on Kristian’s leave. Evidence was heard during the Inquest that this was a frequent problem and I am concerned that nursing staff are unaware of leave conditions and this is not being properly monitored. This runs a risk of future fatalities if leave is being granted inappropriately. I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken.