“(brief summary of matters of concern) My narrative conclusion above, which includes a…”

The coroner’s concerns

(brief summary of matters of concern) My narrative conclusion above, which includes a neglect rider, shows what I consider to have been a very serious failure. I have, very helpfully, had a number of commitments to review matters and/or review them further (some reviewing having already taken place) but I consider that the threshold for making a PFD report is reached (which makes a report mandatory) and in any event, the matters revealed by this inquest are such that a formal Regulation 28 – After Inquest Template Updated 15/07/2025 TG report should be made. This is because PFD reports are published and improvements can then properly be tracked if appropriate. The matters of concern are as follows: 6 1. Insufficient focus at the Brighton Haven on whether and how trips out should take place. I am concerned, bearing in mind evidence on record-checking and keeping, that too much informality has crept in. 2. This may have been informed by there being insufficient focus in the policy, including in the policy as amended in October 2025. 3. Nurses not reading notes before taking significant decisions is a very serious concern, as is not then completing records of the decisions taken. 4. I am concerned about the variation in practice on the timing of notes. 5. I am concerned about what seems to be a lack of certainty concerning when formal safety plans (and/or care plans) should be completed. An informal one on admission followed by a full one after 24 hours seems reasonable, but the process and expectations ought to be clarified. 6. The lack of family involvement in risk management and planning is a breach of policy, and would have been straightforward in this case. 7. There seems to be a lack of training for nurses moving from different settings to the Haven. 8. I am concerned as to whether there is now a facility in the case notes (now SystmOne) for there to be alerts around restrictions on trips out. 9. There has been a commitment to look again at this, but there is currently no written checklist for nurses to use when authorising trips out. 10. There has been a commitment to look at this too, but whilst care plans are the subject of audits, there is no auditing of the observations document against case notes, checking that trips out were properly risk assessed and authorised.

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, 2026-0247

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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