'Multiple systemic failings' before patient death
Family HandoutConcerns have been flagged about a hospital which allowed a mental health patient to leave before he ran away to take heroin and cocaine, which led to his death.
An inquest ruled Kristian Allen, 36, from Shoreham in West Sussex, died at the Mill View Hospital in Hove on 16 February 2025 due to heroin toxicity.
Assistant coroner Gareth Jones issued a prevention of future deaths report and highlighted the conditions of Allen's leave not being met, searches being inadequate, delays in responses, and substandard CPR.
Jane Padmore, chief executive of Sussex Partnership Foundation Trust, says improvements have been made and "there are no further new actions that I consider the trust needs to take".
Jones said Allen had a history of drug and alcohol abuse as well as complex mental health issues
He was detained under the Mental Health Act and admitted to the Regency Ward in Mill View Hospital in October 2024.
The assistant coroner said Allen had been permitted escorted leave despite conditions not being met - these included producing a negative urine dip sample, his mental state being settled, and him taking all prescribed medication.
Allen, who had a history of absconding, ran away again while on leave and admitted taking heroin, cocaine, and alcohol.
Jones said when Allen returned to the ward, searches had not been inadequate and not escalated to be more thorough despite suspicious behaviour being noted by staff.
When staff found Allen unresponsive at about 05:05 GMT there had been delays in the response by the ward and medical staff, Jones said in his report.
These included a 10-minute delay in phoning for an ambulance, a 13-minute delay in phoning the on-call doctor, a delay in pulling the emergency alarm, and a delay in using a defibrillator.
"The emergency response to finding Kristian unresponsive, and subsequent actions taken were not effective and contributed to the circumstances of Kristian's death," the prevention of future deaths report said.
"There were multiple systemic failings in staff adhering to trust policy and procedures, inadequate training in response to a drug overdose, and widespread poor communication within the ward."
'Risk of future fatalities'
In the report Jones said staff being unaware of restrictions on patients' leave was a "frequent problem".
"This runs a risk of future fatalities if leave is being granted inappropriately," the report says.
The assistant coroner also raised concerns about staff not being being able to properly deal with cardiac arrests in acute mental health wards saying the response to Allen's had been "chaotic and disorganised".
Jones had also noted similar issues in an inquest nine months earlier, following a death in the same ward.
"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," he said.
Padmore said the trust had carried out a patient safety incident investigation following Allen's death and it subsequently implemented an improvement programme.
A trust spokesperson said: "Following Kristian's tragic death we carried out an internal investigation which identified the issues raised by the coroner and led to a range of improvements on the ward.
"This included enhanced training and ongoing monitoring of managing hospital leave for patients detained under the Mental Health Act.
"We have strengthened our processes for managing physical health emergencies, including new equipment and unannounced training assessments."
Allen's mother, Tracey Hayward-Holmes, said: "Addiction and mental health conditions don't just affect the person living with them, they ripple through the lives of everyone who loves them.
"Kristian's struggles were part of his illness - not the real him - and when he was well, he was such great company. Kristian is sorely missed, and I feel heartbroken to have lost him."
