“(brief summary of matters of concern) Section 4 contains the jury’s findings as revealed…”

The coroner’s concerns

(brief summary of matters of concern) 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. 7.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0241

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0