"We will not be the last family in this tragic situation", mum warns
Tracey Allen is urging for proof changes are being made after her son died after "systemic failings" at a Sussex mental health hospital previously warned over care
Tracey Allen describes her son Kristian as a "big character" with a "big heart".
He was the oldest of four and, as a child, would perform Nativity plays with his sisters, dressing up and using toys for props.
As he grew, he found a love for what his mum calls "high energy hobbies" - climbing the ranks of scouts and taking part in abseiling, canoeing, air rifle shooting and archery along the way.
At 19, he was first admitted to hospital over his mental health.
And at 36, a coroner found that "multiple systemic failings" contributed to his death.
"Multiple missed opportunities" to prevent my son's death
"I actually thought he was going to a place of safety and that he would be looked after with professional support - and he was failed." Tracey, whose from Littlehampton, told Greatest Hits Radio.
Kristian, who had schizophrenia and ADHD, was in the care of Millview Hospital when he died in Feburary 2025.
The care provider was among five in Sussex given a warning notice by watchdogs just months later, over failing to ensure that care was "consistently safe, appropriate, met their needs", ensured privacy and "protected them from avoidable harm."
Last month, Kristian's inquest found he had been allowed leave from the ward despite not meeting the conditions for him to do so.
Despite his history of drug use, a coroner ruled searches of Kristian on his return - and measures to ensure no illegal substances entered the ward - were "inadequate".
Observations had been "insufficient", and when he was found unresponsive, a "lack of clear organisation and communication" delayed urgent care.
Tracey told Greatest Hits Radio she believes that if Kristian hadn't been unduly given leave, he would still be alive.
"There were multiple missed opportunities to prevent his death and it didn't happen." she shared.
Kristian's official cause of death was heroin toxicity.
Case led to "a range of improvements" on the ward, says Trust
A spokesperson for Sussex Partnership NHS Foundation Trust said:
"We offer our sincere condolences to the family and friends of Kristian Allen.
"Following Kristian's tragic death we carried out an internal investigation which identified the issues raised by the Coroner and led to a range of improvements on the ward.
"This included enhanced training and ongoing monitoring of managing hospital leave for patients detained under the Mental Health Act.
"We have strengthened our processes for managing physical health emergencies, including new equipment and unannounced training assessments.
"We take any reports of drug misuse on wards extremely seriously - raising safeguarding concerns, involving the police and carrying out searches where necessary."
"We will not be the last family in this tragic situation"
But Tracey is urging for proof the changes are taking place.
"It's all very well and good to say that you are putting these things into place.
"But what I want to know is who is ensuring that these are adhered to? Who's auditing it? Where's the due diligence?
"Who's ensuring that in weeks or months down the line that these new protocols are still in place and that this new learning is embedded into the ward?
"I believe that unless the systemic failures at Millview Hospital are addressed and resolved, I sadly feel that we will not be the last family in this tragic situation."