Kristian Edward Allen · Prevention of Future Deaths report

An investigation into the death of Kristian Edward Allen was commenced on the 18th of February 2025. Because he was detained under s3 of the Mental Health Act 1983 at the Millview Hospital in Hove it was compulsory for this Inquest to be heard in front of a jury. The jury heard evidence between the 12th of May 2026 and the 21st of May. They reached a conclusion on the 22nd of May 2026. I determined towards the conclusion of the evidence that this is an Article 2 Inquest.

Kristian Edward Allen had a history of drug and alcohol abuse, and complex mental health issues. He was detained under Section 3 of the Mental Health Act and admitted to Millview Hospital in October 2024. The following factors contributed to the circumstances of Kristian’s death on 16th February 2025.

Kristian had a Section 17 leave of absence plan created by the responsible clinician on 13th February, this plan covered the next 7 days. This included the conditions to be met by Kristian to be permitted leave. These were producing a negative Urine Dip Sample, his mental state being settled, and him taking all prescribed medication. The staff nurse apprised Kristian’s escorted leave on 15th February despite none of these conditions being met, a history of absconding and a positive cocaine test being recorded. During this leave, Kristian absconded and admitted to taking heroin, cocaine and alcohol.

Upon his return to the ward, searches of Kristian were inadequate and not escalated to a more thorough search despite Kristian having absconded and suspicious behaviour being noted by staff. Hospital policy allows for enhanced searches where the risk assessment deems it appropriate. Measures to ensure that no illegal drugs entered the ward were inadequate.

Quality of observations were insufficient. Intake of heroin, alcohol and cocaine warranted an increased level of observations from intermittent to eyesight, but only intermittent observations were carried out as part of the care plan determined by the on call doctor and consultant which was then conveyed to ward staff. In addition to this, intermittent observations were not in line with best practise, therefore there were potentially missed opportunities to identify respiratory failure and/or signs of a Regulation 28 – After Inquest Document Template Updated 30/07/2021 overdose. E.g. there was no concern by ward staff to affect an appropriate sleeping position. Paramedics noted that sleeping on your back having taken drugs and alcohol is a risk.

Kristian was overheard mentioning to a peer he wanted police and an ambulance at 00:04am on 16th February. There is no evidence that this was investigated by the ward staff. The fact that police and ambulance were not called at this time, is not deemed to be a contributory factor to Kristian’s death.

Upon finding Kristian unresponsive at 5:05am, there were delays in the response by the ward and medical staff. These were: a 10 minute delay in phoning an ambulance (called at 5:15am), 13 minute delay in phoning the on call dr (called at 5:18am), a delay in pulling the emergency alarm, a delay in using the defibrillator, attempting to place an I Gel and administering Naloxone.

There was a lack of clear organisation and communication when coordinating the response to finding Kristian unresponsive which contributed to all the delays. There were communication issues noted repeatedly in relation to Kristian’s substance intake, which would have impacted decision making by hospital staff.

The paramedics observed substandard CPR administered by Millview staff. With the positioning, depth and timings being incorrect. In the Patient Safety Incident Investigation report, it was noted that 95% of staff were up to date on CPR training provided by the trust. Narrative Conclusion Narrative At 6am on 16th February 2025, Kristian Edward Allen was declared deceased due to heroin toxicity at Millview Hospital. Controls on granting Kristian leave failed to be implemented, searches were inadequate given the level of risk through his substance history and known drug use within the ward. The level of observations were insufficient given Kristian’s admitted drug and alcohol intake. The emergency response to finding Kristian unresponsive and the subsequent actions taken were not effective and contributed to the circumstances of Kristian death. 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.

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.