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Hospital Lapses Led to Patient's Fatal Overdose
1 Jun
Summary
- Mental health patient died from heroin toxicity after leaving hospital.
- Inquest revealed multiple systemic failures in patient care and response.
- Hospital trust states improvements have been made following the incident.
A man detained under the Mental Health Act died from heroin toxicity after leaving hospital, an inquest has found. Kristian Allen, 36, died at Mill View Hospital in Hove on February 16, 2025. The assistant coroner identified multiple systemic failings contributing to his death.
Allen was allowed escorted leave from the Regency Ward despite not meeting conditions, such as providing a negative urine sample. He subsequently absconded, admitted to taking heroin, cocaine, and alcohol, and returned to the ward. Searches were inadequate despite suspicious behavior.
Emergency responses were significantly delayed, with a 10-minute wait to call an ambulance and a 13-minute wait to contact an on-call doctor. Substandard CPR and disorganized response to cardiac arrest were also cited. The assistant coroner expressed grave concern that similar fatalities could occur if actions are not taken.
The chief executive of Sussex Partnership Foundation Trust stated that improvements have been made following a patient safety investigation. These include enhanced training for managing hospital leave and strengthened processes for physical health emergencies, including new equipment and assessments.
