Recurring concern

Unreliable integration of substance misuse services into patient care

First to latest report 9 Dec 2015 — 3 Mar 2026

Reports that mention this concern
15
Times this concern has been raised
15
Stated actions linked to this concern
31

What this concern includes

Includes failures within an explicitly identified substance misuse service pathway, including referral, liaison, cooperative working or coordination needed to provide integrated care.

What is not included
  • Excludes generic multidisciplinary or interagency working failures not explicitly tied to substance misuse services.
  • Excludes failures solely concerning the internal management, staffing or security of substance misuse services unless they directly prevent integrated patient care.
  • Excludes clinical assessment or treatment deficiencies that do not involve access to or coordination with substance misuse services.

Reports and published responses 15 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Derby and Derbyshire

    AI-generated summary

    Wendy BODDINGTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Wendy BODDINGTON was found deceased at home on 24 March 2025 after friends had been unable to contact her for several days. She had two fentanyl patches on her body instead of the single prescribed patch; toxicology found fentanyl at a fatal level, with prescribed codeine adding to the toxicity. The principal concern was that people receiving long-term, often high-dose opiate and opioid prescriptions for chronic pain may not receive adequate support to reduce, stop, or substitute these medications.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of specialist services for dependence on prescribed opiates and opioids

    Wider context from the report

    “The context for my concerns is the well-recognised situation of long-term prescription of opiate and opioid medications, often at high doses, for chronic pain. It is now recognised that such prescribing will usually cause other health problems, including dependence and tolerance, and over time becomes limited in controlling pain. Whilst current guidance is against such prescribing, there are many people who have been taking these medications for a long time for whom stopping or reducing the medications is very challenging. Use of those medications carries risk of accidental or deliberate overdose and death. Wendy’s inquest heard that her GP practice has initiated a targeted programme to identify patients who have been receiving long-term prescription of opiate and opioid medications and engage them in focussed review to agree planned reduction, stoppage, or substitution of those medications. This programme involves 2 senior GPs and 2 pharmacists and so is a significant commitment. The practice is incrementally concentrating on those patients with high-dose prescriptions. Relatedly the practice has introduced a number of measures to try and avoid patients being inappropriately prescribed these medications for chronic pain in the first place. In evidence the GP partner stated that he was unaware of other GP practices in the Derbyshire area undertaking similar programmes. The inquest also heard that there are no specialist services for patients who have developed dependence on opiates and opioids, and that substance misuse services will only work with people with non-prescribed drug issues. The inquest did hear anecdotal evidence that NHS England may be pursuing some relevant initiatives but the details and extent of this was unclear. My specific concern is that there appear to be a significant number of people who are being prescribed opiate and opioid medications for chronic pain, often at high doses and for long periods, but may not be receiving support to reduce, stop, or substitute those medications. It appears to me that the ICB is in a position to consider this problem and potential remedies on a regional basis, and feed into national strategies. ”

    Source location

    Wendy BODDINGTON · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Participate in a system-wide GIRFT chronic-pain review to identify pathway variation and service-delivery challenges.

    Verbatim wording from the response

    “Getting it Right First Time (GIRFT) chronic pain review”

    Source location

    Response from NHS Derby and Derbyshire Integrated Care Board
    Page 3 · response
    Published 9 March 2026

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement recommendations from the GIRFT chronic-pain review in line with national and organisational objectives.

    Verbatim wording from the response

    “In January 2026, the ICB participated in an NHS England GIRFT chronic pain virtual system review, working in collaboration with the Faculty of Pain Medicine and the British Pain Society. The review looked to identify variation and challenges across the whole chronic pain pathway to help address challenges in service delivery for pain management, in line with the strategic aims of the Department of Health and Social Care and NHS England. The aim is to develop a structured model to ensure patients receive personalised, holistic and evidence-based care at each stage, with seamless transitions between services– in turn, improving the patient experience. This is part of a programme of multiple ICS reviews, at the end of which a joint report will be published, highlighting priority areas for national improvement.”

    Source location

    Response from NHS Derby and Derbyshire Integrated Care Board
    Page 3 · response
    Published 9 March 2026

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and re-procure pain-management services.

    Verbatim wording from the response

    “Considering the concerns raised by the coroner in this report, the ICB is undertaking the following further actions:”

    Source location

    Response from NHS Derby and Derbyshire Integrated Care Board
    Page 4 · response
    Published 9 March 2026

    Open published response

  2. Essex

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    STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of liaison with external specialist substance misuse services

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”

    Source location

    STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report
    Page 5 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed dual-diagnosis capability within community teams through Care Coordinator training and team-based Dual Diagnosis Ambassadors.

    Verbatim wording from the response

    “Significant changes to the Dual Diagnosis pathway will support a reduction in ‘refer-on’ practices and minimise the passing of individuals between teams.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 8 · response
    Published 20 January 2026

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Expand STORM training from Crisis Teams into Community Mental Health Teams.

    Verbatim wording from the response

    “Failure of Joint Working Externally (concern f) In parallel, we are expanding the rollout of STORM training, which has been successfully embedded within Crisis Teams, into our Community Mental Health Teams. This training supports high-quality, evidence-based assessment, safety planning, and risk documentation—all of which are critical components of safe community mental health practice. These capabilities are also essential for effective internal and external joint working, ensuring that when multiple agencies are involved in a person’s care, information is clear, risk is articulated consistently, and actions are well-coordinated. High-quality documentation and shared understanding of risk are safer handovers with partners such as primary care, crisis services, social care, ambulance services, and police, and they support more timely and informed decision-making across agencies.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 9 · response
    Published 20 January 2026

    Open published response

  3. South Wales Central

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    Lewis Rhys Thomas Petryszyn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lewis Rhys Thomas Petryszyn died in his shared cell at HMP Parc on 15 April 2022 after inhaling synthetic cannabinoids without intending to end his life. The principal concern was the absence of specified timeframes for intervention, ongoing support and case-load allocation for prisoners at risk of substance misuse, creating a risk of delayed support and intervention.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of specified prescribed timeframes for intervention, ongoing support and case load allocation for prisoners at risk of substance misuse

    Wider context from the report

    “(1) There was, and remains, an absence of specified prescribed timeframes in policies and procedures within which intervention, ongoing support, and/or case load allocation to/from Dyfodol must occur for prisoners likely to be at risk of substance misuse. (2) The absence of prescribed timeframes poses the real risk of delayed support and intervention to drug users ”

    Source location

    Lewis Rhys Thomas Petryszyn · Prevention of Future Deaths report
    Page 3 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed agreed intervention, support and caseload timeframes in the revised service specification for future procurement.

    Verbatim wording from the response

    “While the current service specification does not explicitly define timeframes for intervention, ongoing support, or case allocation, Dyfodol and CTM work to mutually agreed timeframes that are reviewed monthly. These timeframes will be formally embedded into the revised service specification as part of the future procurement process, once the existing contract expires.”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 1 · response
    Published 31 July 2025

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reduce the brief-intervention waiting period to the four-week target through recruitment and improved waiting-list management.

    Verbatim wording from the response

    “Brief interventions consist of up to ten one-to-one sessions per individual, alongside targeted group programmes. The target timeframe for initiating one-to-one brief interventions is four weeks. Following recent recruitment efforts and improved waiting list management, Dyfodol has successfully reduced the previous six-week waiting period. As of August 2025, the waiting list is compliant with the four-week target.”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 2 · response
    Published 31 July 2025

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Expand group provision with weekly rolling programmes for people waiting for one-to-one brief interventions.

    Verbatim wording from the response

    “To ensure continued support, Dyfodol has expanded its group provision, enabling those on the waiting list to access weekly rolling programmes such as the Drug Education Programme, SMART Recovery, and the Nudge Course (a four-week psychosocial programme focused on managing substance use and mental health).”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 2 · response
    Published 31 July 2025

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Submit a proposal to HMPPS to enhance the clinical substance misuse service at HMP & YOI Parc.

    Verbatim wording from the response

    “These proposals will be shared with relevant stakeholders prior to submission to HMPPS for consideration. Additionally, following consultation with G4S, Public Health Wales, Welsh Government, and other stakeholders, the Prison Healthcare Directorate has submitted a proposal to HMPPS to enhance the clinical substance misuse service at HMP & YOI Parc. This includes:”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 3 · response
    Published 31 July 2025

    Open published response

  4. Inner North London

    AI-generated summary

    Mr Alexi Susiluoto · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Alexi Susiluoto, who had a history of mental health disorders, substance misuse and epilepsy, was found deceased in a hotel room on 22 May 2024. His death was attributed to alcohol misuse disorder resulting in acute ethanol toxicity, with epilepsy and prescribed medication as contributing factors. The report raised concerns about fragmented care for people with dual diagnoses who are homeless, including confusion over which services and local authority were responsible for care and funding.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Fragmented provision of substance misuse and mental health treatment across different organisations

    Wider context from the report

    “1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues: a. That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient. I understand that this aspect is part of the current review; b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless. Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment. ”

    Source location

    Mr Alexi Susiluoto · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with the Department of Health and Social Care to improve access to mental health services and coordination across health services for people experiencing homelessness.

    Verbatim wording from the response

    “I am leading cross-government efforts to deliver the long-term solutions we need to get us back on track to ending all forms of homelessness. This includes chairing a dedicated Inter-Ministerial Group (IMG), bringing together Ministers from across Government to develop a long-term strategy. DHSC Ministers attend the IMG, and we are working closely with the DHSC to address the health needs of people experiencing homelessness and rough sleeping. This includes improving access to mental health services and improving join-up between all services across the health system to ensure people experiencing homelessness are supported with all their health needs. We expect to publish our Homelessness Strategy following the conclusion of Phase 2 of the Spending Review.”

    Source location

    Response from MHCLG
    Page 2 · response
    Published 17 April 2025

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a comprehensive action plan to improve provision for people with co-occurring substance-use and mental-health needs.

    Verbatim wording from the response

    “Your report mentions a review my department is taking into treatment for people with substance use and mental health conditions, and you raise concerns that the review is not considering the additional complexities and issues that occur when someone is also experiencing, or at risk of, homelessness. My department recognises the vital importance of high-quality integrated care for those with co-occurring conditions and who sleep rough, or who are at risk of sleeping rough. To clarify, we have not undertaken a formal review but, following recommendation from Dame Carol Black’s independent review of drugs, have been developing a comprehensive action plan to set out a path to improving service provision for those with co-occurring substance use and mental health needs.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 17 April 2025

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish UK clinical guidelines on alcohol treatment, including recommendations for co-occurring conditions, multidisciplinary assessment, care planning and care coordination.

    Verbatim wording from the response

    “- DHSC will soon publish the UK clinical guidelines on alcohol treatment to support and improve the quality of treatment for people with alcohol dependence. The guidelines include chapters on working with people with co-occurring alcohol dependence and mental health and/or physical health conditions. They also include recommendations on multi-disciplinary assessment, care planning and care co-ordination.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 17 April 2025

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue working with NHS England to improve integrated care for people with substance-use and mental-health needs.

    Verbatim wording from the response

    “Thank you for bringing these concerns to my attention. I want to assure you my department and NHSE recognise these issues and are continuing to work closely together to improve integrated care for those with substance use issues. I hope this response is helpful.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 17 April 2025

    Open published response

  5. North Wales (East and Central)

    AI-generated summary

    Emily Corfield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Emily Corfield, aged 41, was found deceased at home on 19 September 2021 after a history of alcohol misuse and two hospital admissions for coffee ground vomiting and alcohol withdrawal. The principal concern was the lack of evidence that the alcohol liaison team provided inpatient or outpatient support or that referrals to external organisations were made.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of systems and processes to ensure completion of alcohol liaison team referrals

    Wider context from the report

    “Emily had two inpatient admissions in the year of her death. Whilst the clinician had noted that she was for referral to the alcohol liaison team there was no evidence that Emily had in fact received any input from them either as an inpatient or as an outpatient nor any referrals to external organisations. It is concerning that there appears to have been no evidence that Emily was receiving support from the Alcohol Liaison Team whilst an inpatient on either occasion despite her long history of alcohol misuse and need for support. In the event that clinicians advise referral to alcohol liaison team, either as an inpatient or as an outpatient there ought to be systems and processes to ensure that this occurs. ”

    Source location

    Emily Corfield · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the service specification to include electronic contact, risk, signposting, referral and service-exit recording requirements.

    Verbatim wording from the response

    “In addition, concerning the monitoring of support, the new system, amongst other things, allows a “red flag” to be displayed for those patients who are considered to be a risk to themselves or others, has the option to add viewable risk management plans, records signposting that has taken place and has an internal referral system to refer patients directly to another service. Further, if a patient leaves the service, staff need to input the exit date, reason and other relevant information. Adferiad is updating its service specification to incorporate these requirements. The updated service specification will be implemented and rolled out to all staff by the end of September 2023.”

    Source location

    Response from Adferiad
    Page 3 · response
    Published 21 July 2023

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement and roll out the updated service specification to all staff by the end of September 2023.

    Verbatim wording from the response

    “In addition, concerning the monitoring of support, the new system, amongst other things, allows a “red flag” to be displayed for those patients who are considered to be a risk to themselves or others, has the option to add viewable risk management plans, records signposting that has taken place and has an internal referral system to refer patients directly to another service. Further, if a patient leaves the service, staff need to input the exit date, reason and other relevant information. Adferiad is updating its service specification to incorporate these requirements. The updated service specification will be implemented and rolled out to all staff by the end of September 2023.”

    Source location

    Response from Adferiad
    Page 3 · response
    Published 21 July 2023

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue communication clarifying the referral process to liaison services and share it with clinical teams across the Health Board.

    Verbatim wording from the response

    “During consideration of your concerns, it was identified that the liaison service did not receive a referral from the treating team located in our Integrated Health Community (East). In response to this, a communication has been produced that outlines the referral process to liaison services that will be shared with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. This communication has now been issued.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 21 July 2023

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the liaison psychiatry delivery framework with stakeholders and progress revisions through consultation and ratification.

    Verbatim wording from the response

    “Although in date and operational, the MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will be reviewed by a working group of stakeholders, to include liaison team managers and key clinicians, led by a senior manager to ensure the referral process is clear and unambiguous.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 21 July 2023

    Open published response

  6. Cumbria

    AI-generated summary

    Brenda SHIELDS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Brenda Shields died at home in Carlisle on 8 December 2022 after taking her life by ligature suspension while under the influence of a very high blood alcohol level. The principal concerns were that she was discharged without planned follow-up, her family was not involved as expected, relevant notifications and referrals were delayed or not made, and insufficient weight was given to her alcohol problems and recent history when assessing risk.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to make promised referrals to relevant specialist services

    Wider context from the report

    “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made. ”

    Source location

    Brenda SHIELDS · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and discuss Hadrian Unit discharge processes with staff to improve communication of onward referrals.

    Verbatim wording from the response

    “Actions/Recommendations:”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 4 · response
    Published 13 June 2023

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Record onward referrals and receiving-team acceptance on the electronic MDT proforma, with monthly compliance audits.

    Verbatim wording from the response

    “"Discharge processes to be reviewed by Hadrian Ward to ensure onward referrals are communicated with receiving teams”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 4 · response
    Published 13 June 2023

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The discharge included planned follow-up, with ongoing support from the Cumbria East Crisis Team and planned referrals to other services.

    Verbatim wording from the response

    “In addition to the above, this concern also suggests that Brenda was discharged from the Hadrian Unit and the Crisis Team without any planned follow up. Again, by way of clarification and in accordance with the written evidence provided, immediately following discharge from the Hadrian Unit, Brenda was supported in the community by the Cumbria East Crisis Team, and she continued to be supported by this service until the date of her sad death (on which date she was also discharged from the service). The role of crisis services is to provide people with safe, effective, compassionate, high-quality care whilst they remain in mental health crisis. Where appropriate and as in this case, the crisis service offers home treatment intervention to allow people to be discharged from hospital earlier whilst still experiencing an acute phase of illness.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 2 · response
    Published 13 June 2023

    Open published response

  7. North Northumberland and South Northumberland

    AI-generated summary

    Odessa Carey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to refer service users with substance misuse needs to substance misuse services

    Wider context from the report

    “2. Assessment of substance misuse The service user had a history of substance misuse in particular cannabis and its impact on mental health was recognised. Whilst I acknowledge issues regarding service user consent and compliance, I am concerned there was no referral to substance misuse services for advice or assessment and treatment whilst an inpatient or in the community. ”

    Source location

    Odessa Carey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Swansea and Neath Port Talbot

    AI-generated summary

    DEAN GARY GEORGE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    DEAN GARY GEORGE was found hanging in his cell at HMP Swansea on 16 March 2016 and the inquest concluded that his death was a suicide caused by hanging. Concerns included unequal access to opiate substitution therapy in Welsh prisons, inadequate risk assessment, insufficient information sharing between medical and prison staff, inadequate ACCT training, and an inequitable opiate detoxification system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of funding and implementation of the Integrated Drug Treatment System in Wales

    Wider context from the report

    “The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival. There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019. ”

    Source location

    DEAN GARY GEORGE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Welsh prisons need not implement England’s IDTS because existing Welsh guidance and comparative opioid-substitution services provide equivalent treatment options.

    Verbatim wording from the response

    “Although, in Wales, we do not have IDTS, we do offer comparative services, which are set out in the Welsh Government’s Substance misuse: Treatment of offenders (2009) guidance, and in the 2017 UK Guidelines on Clinical Management Drug Misuse and Dependence (the Orange Book).”

    Source location

    2020-0104-Response-from-Welsh-Government-Redacted.pdf
    Page 1 · response
    Published 5 June 2020

    Open published response

  9. Manchester North

    AI-generated summary

    Beverley Shaw · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of medical records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to respond to and action clinical information requests from the substance misuse service

    Wider context from the report

    “○ There is no record of a response from the GP practice to Turning Point following their letter dated the 15th May 2018. This had a number of requests for actions by the GP including the sharing of any blood results (LFT, FC and U&E), together with information confirming whether there was any blood disorders of drugs which may interact with methadone. There was no evidence that this information was shared or actioned. ”

    Source location

    Beverley Shaw · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Promote wider uptake of Focussed Care across Oldham practices to support substance-use-related care.

    Verbatim wording from the response

    “The events surrounding Ms Shaw’s death highlight the requirement for effective and up to date ‘Did Not Attend’ policies to be followed in Primary Care and to initiate discussion in practice meetings to ensure holistic information is shared and reviewed by the team in a manner which supports clinicians to make decisions based on the full facts and influencing factors. Such discussions can trigger communication back to secondary providers such as Turning Point to clarify and/or share information. The presence of Focussed Care within a number of Oldham practices has been seen to support such instances where substance use influences existing co-morbidities and as a CCG we are promoting wider uptake of this across the Oldham footprint.”

    Source location

    2019-0191-Response-by-Oldham-NHS-CCG
    Page 2 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a wide-ranging review of GP communication across all community substance misuse services.

    Verbatim wording from the response

    “Whilst we recognise that the clinician had written to the GP, we accept that there is more that we could do to improve this communication, not only in this tragic case but also more broadly across our substance misuse services. Therefore, we have undertaken a wide ranging review of GP communication across all our community substance misuse services, not just in Rochdale and Oldham. That review has been led by our Senior Management Team, including our senior clinical team, and our Risk and Assurance department.”

    Source location

    2019-0191-Response-by-Turning-Point
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve recording of GP communications in the electronic client records system.

    Verbatim wording from the response

    “This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.”

    Source location

    2019-0191-Response-by-Turning-Point
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and improve follow-up systems for requests to GPs for information.

    Verbatim wording from the response

    “We also reviewed our systems for following up requests to GPs for information and the way in which we transfer client data at the beginning and at the end of contracts.”

    Source location

    2019-0191-Response-by-Turning-Point
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A joint learning meeting with Turning Point would occur only if Oldham CCG supported it.

    Verbatim wording from the response

    “The practice would also, if supported through Oldham CCG have a meeting with Turning Point separately as a learning event to see what further changes we can both make to make sure miscommunications are avoided in the future”

    Source location

    2019-0191-Response-by-Hopwood-House-Medical-Practice
    Page 4 · response
    Published 23 August 2019

    Open published response

  10. Manchester South

    AI-generated summary

    Mr Crutchley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Crutchley was found dead at the home he shared with his parents, and the post-mortem examination concluded that he died from the combined toxic effects of cocaine and alprazolam. Concerns were raised that the Early Intervention Team lacked specialist drug and alcohol workers and that service users could face significant waits for talking therapies.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Dependence of service-user interaction with specialist drug and alcohol professionals on self-referral

    Wider context from the report

    “It is a matter of concern that the Early Intervention Team does not include specialist drug and alcohol workers amongst its number. Such professionals work for external providers and interaction with service users appear to be dependent on self-referral. ”

    Source location

    Mr Crutchley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop dual-diagnosis champion roles, provide additional training, and cascade substance-use skills through a train-the-trainer model.

    Verbatim wording from the response

    “The Tameside EIT are in the process of developing roles for dual diagnosis champions within the team who will be supported to undertake additional training in relation to substance and alcohol use and cascade these skills within the team through a ‘train the trainer’ model. This will support the team to provide a comprehensive offer in relation to assessment of alcohol/substance use, risk assessment including impact of use on illness and other risks including risk to self, other, neglect, vulnerabilities and exploitation, education, motivational work, harm minimisation and encouraging and supporting referral to and engagement with specialist drug and alcohol services.”

    Source location

    2019-0032-Response-by-Pennine-Care-NHS-Trust
    Page 3 · response
    Published 24 May 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026