Alexander Channing

Coroner’s Support Officer 

5 February 2025 

Ref: Alexander Kieran Ari Channing - Prevention of Future Deaths Report  (ref: 22815272)  

Dear Ms Booth 

On behalf of Arts University Bournemouth, I acknowledge receipt of your letter dated 31 January 
2025 relating to the Prevention of Future Deaths Report following the inquest touching the death 
of Alexander Channing.  

I note the concern raised by HM Coroner: 

There is no training provided to the wellbeing services at the Arts University Bournemouth in 
relation to students diagnosed with Emotionally Unstable Personality Disorder. 

I confirm to HM Coroner that a full day training session on EUPD and personality disorders was 
delivered to 17 members of Student Services staff, including Wellbeing Practitioners and 
Counsellors, on Monday 6 January 2025.  

Training was provided by 
is a psychologist and has also trained in postgraduate Psychiatry at Cardiff University School of 
Medicine.  

, Senior Partner in Metal Health Training. 

Full details of the training provided are available at https://mentalhealthtraining.co.uk/the-
frontline-training-group/  

I trust this action fully addresses the concerns noted in the Prevention of Future Deaths Report. 

Yours sincerely 

Director of Student Experience and Employability

CONFIDENTIAL

Mr Richard T Middleton
Assistant Coroner Dorset
Civic Centre
Bourne Avenue
Bournemouth
BH2 6DY

Sent via e-mail 

Dear Mr Middleton,

Trust Headquarters
Wonford House
Dryden Road
Exeter
EX2 9AF

Tel: 01392 208683

Date:
  25 March 2025

Re. Mr Alexander Kieran Ari Channing – Regulation 28 report.

I write in my capacity as Interim Chief Nursing Officer & Allied Professions Lead for Devon
Partnership NHS Trust (DPT) in response to your regulation 28 report dated 31 January 2025.

If I can first pass on my condolences to Mr Channing’s family and friends.

In your report you highlighted areas of concern to The Vice Chancellor of Arts University
Bournemouth, The Chief Executive of Dorset Healthcare NHS Foundation Trust, along with us
Devon Partnership NHS Trust (DPT). In respect to the concerns pertinent to DPT I respond as
below:

There appears to be a failure amongst staff at the Exeter CMHT to appreciate that there
can be a direct transfer of a patient’s care to another CMHT Trust without the need for a
patient to have to first register with a GP surgery –

Patient transfers to out of area services remain a challenge for all NHS providers. We have an
agreed standard operating procedure that articulates the process to collaboratively transition a
person between community mental health services from Devon Partnership Trust to another
Trust. At times the referring team may still experience local challenges in relation to an out of
area transfer, as the policy relates to DPT’s processes only.  Details on referring a person to
another Trust where they do not yet have a GP can be found on page 6 point 6.6, this is the
specific detail,

1.

Person without a known Address and/or Registered GP on Transfer

1.1.  On occasion a person may not have a known address or registered GP in Devon or
part of Devon that is covered by the team the person is transitioning too.  This occurs where a
person has been placed out of area or temporarily moves (home address) or is in unstable
accommodation or is released from prison.  The lack of address/changed address or
registered GP, should not be the sole reasons for declining a transition or transferring to
another team/service whilst in the first 3 - 6 months of the initial transition.  If a service, even a
monitoring service is offered by a Trust service it is incumbent on the service being
transitioned to, to make reasonable adjustments (i.e. allocate to a practitioner/service

LEGAL\103850\00092\72630646.v1-3/6/25

72630646v1

 regardless of the eventual locality a person may be accommodated or where the GP will be
registered)

C16_Transitions_Ma
r24 (2).docx

Where this is the case, transfer will be planned and managed in a sensitive way taking into
account an individual’s needs. The existing service keyworker/care coordinator or person
identified in the Service Standard Operating Procedure [SOP], will be responsible for
management of the transfer and ensuring all communication is clear to the user, referrer and
receiving service to ensure that the person receives a seamless service.

Until a person’s eligibility for services is determined, there should be no gap in service
provision. The current services will continue until either the services the person is transitioning
to are in place, or the assessment shows that there are no eligible needs. It should be noted
that some services have long waiting lists.  A person that is needing to transition to one of
these services will have their referral reviewed with the local knowledge and prioritisation for
their waiting list status in the service being transitioned to, this service will support the
transition when agreed.

The services covered by the Policy recognise that smooth transition planning may require
collaborative involvement of a potential receiving service for a short period of time before the
person becomes eligible for that service, initially in a consultation and liaison capacity. This will
allow for adequate planning and hand over, without lengthy periods of uncertainty about what
the onward service might look like. In general, this would not be expected to exceed between
three to six months ahead, with the longer length for particularly complex cases. e.g. if a
person is not eligible for a service until they are aged 18 or 65 or move to within the catchment
area of a service, does not mean work on transition should not be undertaken prior to the cut-
off point.  It is not a case therefore of waiting for 3 months before a key worker is allocated,
then a further 3 month wait until the new key worker starts to work with the referred person.

The Trust aims to provide high quality, safe and effective services to all patients and
recognises the importance of enabling effective continuity of care, particularly at times of
transition when patients may be particularly vulnerable. It is important that any required
transition process is managed sensitively and collaboratively to support continued
engagement of the person and their support networks and safe and effective service delivery.

There was a lack of involvement of a responsible clinician in the process of discharge
planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset
Healthcare NHS Foundation Trust –

In terms of discharge planning from Liaison Psychiatry, in relation to the planned discharge
from the district hospital in Exeter, I can confirm that the following paragraph has been added
to the Liaison Psychiatry Services Exeter, Torquay and Barnstaple Specialist Services
Directorate Standard Operating Procedure. It gives detail on page 12 of the attached
document.

Page 2 of 4

 For people who have been placed under Section 2 or Section 3 within the DGH and the plan is
made for discharge to the community (not psychiatric hospital). The agreement is that the
Consultant who rescinds the section will consider if 48 hour follow up by Home Treatment
Team is required and make that referral prior to discharge. In those cases where this is not
required then the rationale will be clearly documented in the patient electronic records.

Individuals will be discharged from the service when the objectives and goals of the care and
treatment have been met. This may be following an assessment in the Emergency Department
or after a period of assessment. We will endeavour to signpost the person using our service to
appropriate support in the community as required and liaise with our partner agencies.

We do recognise and accept that an individual’s motivation to engage in treatment may vary
according to their mental state.  If an individual has made a choice not to engage in treatment,
then we will aim to signpost them to other appropriate services, unless there is evidence to
suggest that their capacity may be impaired, which would then require a capacity assessment
to be undertaken.

Upon discharge from Liaison Psychiatry a written assessment letter is provided for the patient,
to the General Practitioner and, if applicable, the care team that is taking on the care and
treatment of the individual.  A copy is offered to the individual who is also given a service user
satisfaction survey. The individual is also always asked whether they would like their carer or
relative to receive a copy.

Exeter Torbay and
North Devon Liaison Psychiatry Operational policy V2.0 Review ed November 2024.docx

Our aim is to ensure good working practices and relationships between the Liaison Psychiatry
team and across the Network functions within the Trust and with agencies/services outside the
Trust. DPT endeavours to ensure that any transfer of care of patients from the Liaison
Psychiatry Team to the appropriate Network function within or outside DPT is managed as
rapidly and effectively as possible.

There is no policy in place at Devon Partnership NHS Trust which encourages a
repeated proactive approach in seeking consent from a patient to share information at
relevant times.

Devon Partnership NHS Trust has a policy in relation to confidentiality. In the attached policy it
states that the person has a right to restrict disclosure to share information. DPT staff
members would routinely review a person consent to share information. These reviews of
confidentiality should take place when newly allocated to a new worker, identified new risks
occur, or periods of transitions between teams.

GV03_Confidentiali
ty_Procedure_Feb19X (2).docx

Page 3 of 4

 The person has the right to request restricted disclosure of all or some of their confidential
personal information. If such a request is made there should be careful consideration of this
and all reasonable attempts to respect their wishes and address their concerns should be
made. Explanation of why the sharing is necessary in the particular circumstances should be
given and the risks in relation to any restriction.

Explicit consent must be received from the person and recorded on their electronic patient
records for any sharing of information which is not directly related to their care.  For example,
someone may wish to have information shared with some family members but not others.  It is
important to ensure the consent is clearly recorded and understood. The person may change
their mind about disclosure at any time before any disclosure is made and afterwards to
prevent any further disclosures.

If you feel that you need further detail, please do not hesitate to contact me again.

Yours Sincerely

Interim Chief Nursing Officer & Allied Professions Lead

Page 4 of 4

Corporate Office 
Sentinel House 
4-6 Nuffield Road 
Poole, Dorset 
BH17 0RB 
dorsethealthcare.nhs.uk 
01202 277003 

2 April 2025 

Dear Sir,  

Re: Regulation 28 Report to Prevent Future Deaths following the inquest touching on 
the death of Alexander Kieran Ari Channing  

I am writing following your letter dated 31st January 2025, following the inquest touching on 
the sad death of Alec.   

Firstly, I wanted to acknowledge the incredibly sad circumstances of this case. I was so sorry 
to hear about Alec’s death, which I can only imagine must be a tragedy which his family and 
friends continue to live with. My thoughts are with everyone who knew Alec and with the staff 
who worked alongside him.   

I acknowledge receipt of the Regulation 28 Report and the concerns you express as the 
Assistant Coroner overseeing the inquest, I note specifically the concern in relation to Dorset 
HealthCare NHS Foundation Trust ("Dorset Healthcare"):  

There was a lack of involvement of a responsible clinician in the process of discharge 
planning from the district hospital in Exeter to the care of Bournemouth CMHT at 
Dorset Healthcare NHS Foundation Trust.   

We would like to provide an assurance that Dorset HealthCare is fully committed to learning 
and taking any steps necessary to prevent future deaths and we understand the significance 
and importance of Regulation 28 Reports. 

Having carefully considered the concern described, we have again reviewed the 
circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the 
care of Devon Partnership Trust).  In terms of what took place, Dorset HealthCare was 
unfortunately not involved with discharge planning on this occasion, apart from being 
contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for 
Alec. The normal arrangement between NHS providers is for discharge arrangements to be 
led by the team seeking to transfer care.  Learning from the circumstances of Alec’s death, 
we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that 
there are effective and comprehensive discharge pathways between the two organisations.  

Whilst we are confident that Dorset HealthCare does have relevant policies and procedures 
in place and our usual practice is to engage with discharge plans when patients are being 
transferred from areas outside of Dorset, this has been a tragic reminder of the need to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ensure this responsibility is understood by all of our clinicians and managers.  We fully 
appreciate that we must take all steps possible across the NHS to facilitate the effective and 
well managed discharge of patients when they are transferring between services in different 
areas. 

Following the conclusion of the inquest, feedback was provided at a local level at multi-
disciplinary team meetings in the relevant area, this feedback included the concerns 
expressed by the Coroner and the experience of Alec's family.  

Learning and Review Groups have been introduced in the Trust, in line with the Patient 
Safety Incident Response Framework, introduced in the NHS in 2023. They form part of 
Dorset Healthcare's organisational patient safety framework and are intended to share and 
disseminate learning across the directorates. Learning will be shared within the Learning and 
Review Groups at the next meeting which is scheduled for April 2025. The specific learning 
will be around the discharge of patients to and from services outside the Dorset Area.   

I hope I have been able to provide reassurance that we have given proper consideration to 
your concerns and acted on the learning from this tragic case.   

Yours sincerely 

Chief Executive