Amy Chapman

REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT 
FUTURE DEATHS 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, for the Coroner Area West Sussex, Brighton and Hove in 
response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ 
following an investigation into the death of Amy Clare CHAPMAN, and an inquest 
that concluded on 24 April 2026. 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, Sussex Partnership NHS Foundation Trust provides this 
response within 56 days of the date of the Report to Prevent Future Deaths or 
any extension granted. 

2. 

DATE OF RESPONSE 

19 June 2026 

3. 

CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN identified in the report are as follows: 

My narrative conclusion above, which includes a neglect rider, shows what I 
consider to have been a very serious failure. I have, very helpfully, had a 
number of commitments to review matters and/or review them further (some 
reviewing having already taken place), but I consider that the threshold for 
making a PFD report is reached (which makes a report mandatory), and in any 
event, the matters revealed by this inquest are such that a formal report 
should be made. This is because PFD reports are published, and 
improvements can then properly be tracked if appropriate.  

The matters of concern are as follows: 

This may have been informed by there being insufficient focus in the 

Insufficient focus at the Brighton Haven on whether and how trips out 

1. 
should take place. I am concerned, bearing in mind evidence on record-
checking and keeping, that too much informality has crept in.  
2. 
policy, including in the policy as amended in October 2025.  
3.  Nurses not reading notes before taking significant decisions is a very 
serious concern, as is not then completing records of the decisions taken. 
4. 
5. 
when formal safety plans (and/or care plans) should be completed. An 
informal one on admission followed by a full one after 24 hours seems 
reasonable, but the process and expectations ought to be clarified.  
6. 

I am concerned about the variation in practice on the timing of notes.  
I am concerned about what seems to be a lack of certainty concerning 

The lack of family involvement in risk management and planning is a 

 
 
 There seems to be a lack of training for nurses moving from different 

I am concerned as to whether there is now a facility in the case notes 

breach of policy and would have been straightforward in this case.  
7. 
settings to the Haven.  
8. 
(now SystmOne) for there to be alerts around restrictions on trips out.  
9. 
no written checklist for nurses to use when authorising trips out.  
10.  There has been a commitment to look at this too, but whilst care plans 
are the subject of audits, there is no auditing of the observations document 
against case notes, checking that trips out were properly risk assessed and 
authorised. 

There has been a commitment to look again at this, but there is currently 

4. 

DETAILS OF ACTION TAKEN: How has the concern been addressed? 
[If no action is proposed, please explain why here. If you feel that the response 
should not have been sent to you, please state this]. 

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 Brighton Haven has taken the action, agreed at the Inquest, to introduce a 
new procedure for staff to follow when risk assessing patients prior to them 
taking time off the Haven.  
The new procedure has introduced an adaptation of the in-patient form, 
provided at Inquest, so that it is appropriate for use at the Haven.  The new 
Haven 'Record of Time Away and Return' form is now completed by Haven 
staff as part of a focused, proactive, therapeutic conversation about the 
patient's time away from the Haven.  
As the Haven is a voluntary, community service, patients are not detained at 
the Haven and do not require permission to leave. Yet, the Trust wholly 
recognises that, in the interests of patient safety, it is essential to be vigilant 
about a patient's plans and whereabouts when away from the Haven, and 
careful, structured, collaborative consideration is needed. Therefore, the new 
'Record of Time Away and Return' form is now used and records the clinical 
decision‑making and risk management of the patient prior to them leaving the 
Haven.  
The new 'Record of Time Away and Return' form is completed as part of a 
collaborative, therapeutic conversation with the patient and specifically covers 
the parameters of the patient's time off the Haven, focusing on their safety.  
The '5Cs' approach is utilised. This 5Cs approach mirrors the approach that is 
also in use, with good effect, at one of the Trust's inpatient hospitals, and is 
currently in the process of being further evaluated for Trust-wide introduction.  
The 5Cs approach involves assessing the safety and potential risks of the 
patient taking time away from Haven in a way that is supportive and containing 
for both the patient and staff, with focused consideration being given to the 
following: 

 
 
 Circumstances - Where are they going and what do they plan to do? When 
did they leave, and when are they planning to return? 
Clothing - What are they wearing? 
Current Mental State - How have they been over the last 24 hours? What 
impact has any PRN or regular medication had on this? Have there been any 
difficult conversations/acts of self-harm? Do they have capacity? 
Consideration of Risk - What are the current risks? Have they been out 
before, and how did it go? Do they have any thoughts of suicide/self-
harm/harm to others right now? What will they do if they feel unsafe while out? 
Contingency - Ensure we have a correct phone number for them and anyone 
accompanying them. How will they access support if they feel unsafe while 
out? If they do not return, where are they likely to go, and who can we contact 
to inform them/ask if they have been seen? Complete appropriate Missing 
Persons processes as per SPFT policy. 

Once a patient returns to the Haven the new 'Record of Time Away and Return' 
form is updated and, if Haven staff have any concerns arising from the patient's 
time off the Haven, e.g.: if the patient's presentation is altered or there are 
concerns regarding contraband items, these concerns are escalated to the 
Nurse-in-Charge and consideration is given to whether any further actions or 
plans to manage any associated risk are needed. 

The new Haven 'Record of Time Away and Return' form is now part of the 
Haven's clinical records audit programme, to ensure it is being correctly used 
and that staff can be further supported and trained in the new process, if 
needed. 

Specific, focused action has also been taken in relation to the individual practice 
concerns identified at Inquest to support and improve the Haven nurses' 
practice. 

Regarding the variation in practice on the timing of notes, the Trust has 
recognised that there was no specific standard in place at the Brighton Haven, 
so action has been taken to develop a specific standard to ensure accurate 
timings of interventions are consistently recorded. 

Action has also been taken to ensure there is certainty about when a formal 
care and safety plan should be completed. The Haven Operational Policy has 
been updated (to be ratified imminently) to include the following specificity: 

Whilst a formal care plan recorded on the Trust clinical information system 
care planning tab is not required until a person has remained in the Haven 
beyond 23 hours, it is recognised that care planning is an ongoing process 
which begins from the point of admission to the Haven.  
From admission onwards, there will be continuous consideration and 
discussion of the person’s care needs, risks, safety and required interventions 
and support. 

 
 This evolving clinical understanding will inform decision-making throughout the 
patient’s stay. 
Prior to the requirement to complete a formal care plan (for episodes 
exceeding 23 hours), this ongoing process of care planning must be clearly 
recorded as clinical entries within the person’s record. 
This ensures that care is actively planned and responsive from the outset, 
visible and auditable prior to any extended length of stay, aligned with the 
overarching principles of collaborative, dynamic risk formulation and crisis 
assessment within the Haven model. 

A number of actions have also been taken to improve family involvement, 
including, as part of a specific Brighton Haven Team training day, reaffirming 
the principles of the Triangle of Care and conducting carer involvement 
simulation sessions to improve practice.  Triangle of Care is a nationally 
recognised, collaborative framework that involves the patient, their carer, and 
professionals working together to support recovery, safety, and wellbeing.  
Adherence to the framework will be monitored.  

Action has also been taken to review and ensure the Haven induction process 
is robust and that Supervision of staff is consistently in place to address any 
support needs of new staff. 

Regarding the Coroner's suggestion that an alert be placed on the Electronic 
Patient Record system, around restrictions on trips out, the action taken, as 
described above, has been to include leave risks within the new 'Record of 
Time Away and Return' procedure and, additionally, notable leave risks are now 
also included on the Haven's handover document.  

5. 

DETAILS OF FURTHER ACTION PROPOSED 
Any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

All the above actions will be subject to ongoing monitoring, including focused 
auditing, to identify any further improvement actions that might be needed.  
Further improvement actions will then then be taken, as required. 

6. 

SIGNATURE 

Chief Executive Officer 
Sussex Partnership NHS Foundation Trust