Kristian Allen
26 May 2026 · Coroner Gareth Jones · West Sussex, Brighton and Hove
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inappropriate leave authorisation
“staff are unaware of leave conditions and this is not being properly monitored”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“Leave was considered first on 1.11.2013 when Mrs. [name redacted] was on 15 minute observations.”
This report
“staff are unaware of leave conditions and this is not being properly monitored.”