Kristian Allen

28 May 2026 

Mr Gareth Jones  
Assistant Coroner 
Coroner Service: West Sussex, Brighton and Hove 
Parkside Chart Way 
Horsham, RH12 1XH 

Dear Mr Jones 

Thank you for your letter dated 26 May 2025 enclosing your Regulation 28 report following 
the conclusion of the Inquest into the death of Kristian Allen.   

Firstly, I wish to extend my sincere condolences to Kristian's family and friends.  I know that 
Kristian's Inquest has just concluded and lasted for two weeks, which I recognise must have 
been  an  extremely  difficult  experience  for  his  Mother  and  Stepfather  who  I  understand 
attended throughout. Yet, I hope that the thoroughness of your Investigation, together with 
this response enable them to have answers, as well as assurances as to the improvement 
actions taken since Kristian's death in February last year.  

I understand that there are two areas which concern you, namely: authorisation of s17 leave 
and  responsiveness  to  cardiac  arrest.    I  also  understand  that  you  have  already  received 
documentary  and  heard  oral  evidence  detailing  the  range  of  actions  taken  by  the  Trust, 
including the actions taken in relation to both areas of concern.  Therefore, I recognise that 
you seek my further, specific assurance of those Trust actions and I am grateful to have the 
opportunity  to  write  to  you  with  this  response  and  thereby  provide  you  with  that  further 
assurance.   

Befrore  addressing  your  two  concerns,  it  should  be  noted  that  the  Trust  conducted  a 
comprehensive Patient Safety Incident Investigation (PSII) following Kristian's tragic death.  

Head office: Sussex Partnership NHS Foundation Trust, Portland House,  
44 Richmond Road, Worthing, West Sussex, BN11 1HS 

A teaching trust of Brighton 
and Sussex Medical School 

 
 
 
 
                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I am fully sighted on the findings of that PSII and was pleased to see that Kristian's Mother 
was collaboratively involved in it and that it candidly identified a full range of improvements.  
I  note  that  the  PSII  specifically  recognised  that  improved  consistency  in  practice  and 
application  of  standards  was  required  in  relation  to  both  your  areas  of  concern.  In 
accordance  with  the  PSIIs  recommendations,  the  Trust  implemented  a  coordinated 
training  and  governance 
programme  of  work  which  combines  Trust-wide  policy, 
improvements  with  targeted  ward-level  quality  improvement.    Notably,  the  PSII  openly 
identified that Mill View Hospital needed to improve upon embedding learning from previous 
incidents through a positive culture of learning.  I highlight this as I specifically note your 
reference,  and  therefore,  understandable  concern,  about  a  previous  death,  which  I 
understand was in May 2024, on the same ward.  I also highlight because I recognise that 
the  embedding  of  improvements  within  the  complexities  of  mental  healthcare  services  is 
multi-faceted in nature, takes time and committed, consistent re-enforcement.  This is why, 
following  Kristian's  death,  as  a  recommendation  in  the  PSII  we  introduced  the  ongoing 
executive led improvement plan that you heard about at the Inquest and I will further explain 
to you once I have specifically addressed your two concerns. 

Authorisation of s17 leave 
As you heard during the Inquest, the conditions of s.17 leave are documented in a patient's 
electronic clinical record on the specific s.17 leave form and I understand that that was done 
for Kristian.  However, I know that the nursing staff did not comply with the conditions despite 
them  being  clearly  on  Kristian's  electronic  record.    This  non-compliance  was  highlighted 
within the Trust's PSII report.  I confirm, as you heard in evidence, that the Trust has already 
taken action to address this.  Specifically, nursing staff's understanding of s.17 leave and 
the requirement to comply with conditions is tested though the use of competency tests.  I 
am informed that 
 (Clinical Director) gave evidence at the Inquest to explain that a 
staff  member's  competency  is  re-tested  until  they  can  satisfactorily  show  their  depth  of 
understanding.  Additionally, compliance is now consistently monitored via matrons, ward 
managers  and  governance  processes  to  ensure  high  quality  s.17  leave  understanding  is 
maintained.  Furthermore,  as  you  heard,  the  Trust  has  a  programme  of  audits  which 
specifically include checking legal compliance with s.17 leave conditions. The audits give 
rise  to  actions  which are  then  overseen.    Also,  at  ward-level  re-enforcement of expected 
standards  is  now  done  routinely  through  team  meetings,  safety  discussions  and  MDT 
processes.  Further, as you heard from 
, bespoke training is being provided to staff on 
s.17 leave and, notably, the outcome from Kristian's Inquest will be specifically included in 
that training session which is schedule for next week. The combination of all of the above 
provides me with confidence that s.17 leave compliance is now not only being adequately 
monitored  but  any  concerns  in  relation  to  inconsistent  practices  are  being  consistently 
recognised and addressed to ensure the expected standards are, and will continue to be, 
consistently applied. 

 
 
 
 Response to cardiac arrest 
I  appreciate  your  concern  in  relation  to  staff  not  being  properly  able  to  deal  with  cardiac 
arrests.  You will have heard how this was recognised within the Trust's PSII and the need 
to  strengthen  preparedness  and  response  to  medical  emergencies,  including  opioid 
overdose, resulted in recommended action.  The identified action was the need to increase 
staff  confidence  in  administering  Immediate  Life  Support  (ILS).    I  am  informed  that  the 
Inquest heard of the impact upon staff of conducting ILS and how their confidence can be 
impacted by the rarity of having to conduct ILS.  I confirm, as you heard, that as a direct 
action from the PSII into Kristian's death the Trust introduced regular simulation training ie: 
unannounced emergency simulations to which staff then have to respond.  It is recognised 
that simulation training enables staff to develop their confidence beyond the basic level of 
skills and confidence achieved via the already existing mandatory ILS training.   Additionally, 
as you heard, the Trust has now introduced new Automated External Defibrillators (AEDs) 
to support staff.  These new AEDs give real-time information to the staff conducting CPR to 
inform them as to whether their rate and depth of CPR application is appropriate, thereby 
supporting staff to deliver high-quality CPR in line with guidelines.  These new AEDs are 
also used in training to enable the resus team to see if those they are training are conducting 
CPR as optimally as possible.  As you also heard in evidence the Trust's Resus policy has 
been updated to formalise the inclusion of simulation as standard in both clinical and non-
clinical areas to enhance and embed medical emergency and cardiac arrest training, thereby 
ensuring staff remain competent and confident with emergency processes and procedures. 
The  policy  stipulates  that  simulations  will  be  completed  monthly  throughout  SPFT  in 
inpatient hospitals. As 
 informed you, the most recent simulation on Kristian's ward 
took place on 20th May, involving 8 staff and simulated a scenario of an opioid overdose 
leading to cardiac arrest. I am informed that feedback from the ILS team was that the ward-
team's response was well led.  

Oversight of improvements  
As  I  referenced  above,  the  Trust's  PSII  openly  recognised  that  embedding  of  a  learning 
culture, specifically around areas of quality, was required at Mill View Hospital.  Further, the 
PSII candidly recognised that the improvements identified following Kristian's death would 
require ongoing monitoring and executive oversight to support the necessary embedding of 
learning.  I confirm that the Trust's Chief Nursing Officer has executive oversight of the PSII's 
actions.  The  Trust  has  had  a  recent  change  in  its  Chief  Nursing  Officer,  with  the  new, 
permanent Chief Nursing Officer starting eight weeks ago. She has taken over as executive 
lead and will have ongoing oversight of the improvement plan, including a monthly oversight 
meeting  at  Mill  View  Hospital. I  can  also  confirm  that  the  improvement  plan  for  Kristian's 
ward is aligned with the Royal College of Psychiatrists’ Culture of Care programme. This 
Culture  of  Care  programme  provides  a  framework  for  improving  the  quality,  safety  and 

 
 
  
 
 therapeutic  environment  of  inpatient  care  through  cultural  and  behavioural  change, 
supported by: 

•  structured review of ward practice with staff and patients 
•  use of patient and staff feedback to identify priorities 
• 

testing and embedding changes using quality improvement methods 

Through this programme, Kristian's ward has implemented changes to: 

increase access to therapeutic activity and structured daily routines 
improve the physical and sensory environment 

• 
• 
•  strengthen patient involvement and community meetings 
• 
improve communication and consistency of care delivery  

Additionally,  Mill  View  Hospital,  as  a  whole,  have  been  subject  to  external  review  by 
recognised specialist consultants in organisational performance and service improvement. 
Their work has focused on strengthening ward-level processes and operational consistency, 
including  clarifying  roles  and  responsibilities,  improving  documentation  standards,  and 
ensuring that actions agreed in MDTs and reviews are clearly recorded, owned and followed 
through. This has supported the development of a structured ward-level improvement plan, 
enabling learning, including from PSIIs, to be translated into consistent day-to-day practice 
and more reliable delivery of care processes.  

In conjunction with the above, to ensure learning is embedded and sustained, at a divisional 
level,  Brighton  and  Hove,  has  strengthened  its  governance and oversight,  to ensure  that 
learning from  incidents  is  systematically  reviewed,  shared  and translated  into  changes  in 
practice, it now has: 

•  a  new  fortnightly  Quality  Matters  meeting,  providing  structured  review  of  safety, 

• 

• 

quality and improvement actions 
fortnightly  Patient  Safety  Learning  Bulletins,  setting  clear  expectations  for  clinical 
practice across services 
routine discussion of learning within team meetings, supervision, MDTs and safety 
huddles 

•  Newly appointed Head of Nursing and Quality for Acute & Urgent Care services in 

Brighton and Hove  

•  Newly established substantive consultant psychiatrist on Kristian's ward 

In summary, given the comprehensive range of actions already taken by the Trust there are 
no further new actions that I consider the Trust needs to take.  That said, as I recognised 
above, all improvement requires sustained, committed focus.  So, whilst I can already say 
that the actions described above are now embedded within policy, training, governance and 
ward-level  quality  improvement  processes,  which  are  subject  to  ongoing  monitoring  to 
ensure improvements continue, I would like to assure you that the oversight and focus on 

 
 
 
 
 
 these improvements will remain sharply in the Trust's focus to ensure sustained quality care 
is provided to our patients. 

Thank  you  for  raising  your  important  concerns.    I  hope  that  the  content  of  this  response 
provides you and Kristian's family with assurance that meaningful action has already been 
taken, however, if I can be of any further assistance to you, please do not hesitate to contact 
me. 

Yours sincerely  

Chief Executive