Recurance · prevention of future deaths reports
Pre-inquest brief
Staff unaware of leave policy requirements
The earlier warning
Ryan Chapman · 31 Jan 2014 · Penelope Schofield, West Sussex
“During the course of the evidence it was shown that there a lack of understanding by staff of the Trust's Leave for Non detained patients Policy.”
judiciary.uk/prevention-of-future-death-reports/ryan-chapman
What was promised
Stated action 1 · response to Danuta Corbett (3 Apr 2014) · stated timescale: none stated
“We have since reinforced with staff that should these quite extraordinary circumstances arise again then a retrospective note must be completed.”
judiciary.uk/…/2014-0150-Response-by-Sussex-Partnership-NHS-Tru…
What recurred
- 3 Apr 2014 · Danuta Corbett · Veronica Hamilton-Deeley
- 26 May 2026 · Kristian Allen · Gareth Jones · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Ryan Chapman · 31 Jan 2014
“During the course of the evidence it was shown that there a lack of understanding by staff of the Trust's Leave for Non detained patients Policy.”
Later · Kristian Allen · 26 May 2026
“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 [the deceased] had to test negative for drug use before leave was allowed.”
What happened next
No web check of the stated actions has been published for this chain.