Recurring concern

Unreliable care and protection arrangements for people with chronic alcohol dependence

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First reported 19 Jul 2018•Latest report 13 Oct 2025

Definition

What this concern includes

Includes failures in dedicated care, protection and coordination arrangements for people with chronic alcohol dependence, including guidance on applying relevant legal frameworks and coordination of treatment, follow-up and risk management between alcohol-dependence services.

Not included

Excludes generic mental-health, social-care or healthcare coordination failures where chronic alcohol dependence is not a material part of the asserted concern.
Excludes general alcohol-use, intoxication or withdrawal concerns unless the assertion concerns continuing care or protection for chronic alcohol dependence.
Excludes failures limited to one clinical episode, emergency treatment or hospital admission where no continuing alcohol-dependence care or protection arrangement is deficient.
Excludes generic policy, training or communication deficiencies unless they directly impair the dedicated care and protection arrangements for people with chronic alcohol dependence.

Reports: 3
Individual concerns: 3
Date range: 2018–2025
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

Hampshire Hospitals NHS Foundation Trust1

Midlands Partnership University NHS Foundation Trust1

Practice Plus Group1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

13 Oct2025
East Sussex
Concerns raised1
1. Failure to review, clarify and update Standard Operating Procedures before expiry
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Replace the expired alcohol-dependence SOP with ratified clinical guidance incorporating clearer monitoring, escalation, transfer, omitted-dose and documentation requirements.
  Stated by Practice Plus GroupStated completed
AI-generated summary

Jamie Stuart Funnell · 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

Jamie Stuart Funnell died at HMP Lewes on 16 December 2023 while withdrawing from alcohol and drugs. The inquest concluded that his death was due to the effects of drug and alcohol withdrawal, exacerbated by omissions by healthcare and prison staff. Concerns included failures in withdrawal assessment and monitoring, communication, CPR response, staff training, equipment maintenance, and updating relevant procedures.

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 review, clarify and update Standard Operating Procedures before expiry
Wider context from the report
“1.The Standard Operating Procedure for Assessment and Management of Alcohol Dependence expired in March 2024. I heard evidence that it will be replaced by an updated Policy on 9.10.25. I asked for a copy of the draft Policy to determine whether issuing a PPD could be avoided when hearing evidence about PFD matters but was advised by the PPG’s legal representative that this was not possible, without a reason why being offered. I consider that action should be taken to prevent a failure to update before their expiry all PPG’s Standard Operating Procedures including this one which the Clinical Reviewer found to be potentially unclear. His findings were published on 19.4.24, a month after the Standard Operating Procedure had expired, and yet it continues to remain out of date, almost 18 months later. PPG could have reasonably expected it would be subject to scrutiny in this inquest and update it accordingly and in a timely manner. Their failure to do so indicates a cavalier attitude to reviewing and updating important Policies and action should be taken to address this. ”
Source location
Jamie Stuart Funnell · 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
Replace the expired alcohol-dependence SOP with ratified clinical guidance incorporating clearer monitoring, escalation, transfer, omitted-dose and documentation requirements.

Verbatim wording from the response
“Standard Operating Procedure for Assessment and Management of Alcohol Dependence Please find the enclosed clinical guidance document for ‘Assessment and Management of Alcohol Dependence’. We can confirm that this was ratified at a Governance meeting on 9 October 2025.”

Source location
Response from Practice Plus Group
Page 2 · response
Published 14 October 2025
Open published response
8 Apr2024
Manchester North
Concerns raised1
1. Lack of overarching guidance on applying legal frameworks to manage and protect people with chronic alcohol dependence
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Existing Mental Capacity Act safeguards, including DoLS and practitioners’ case-law duties, are relied on to protect patients lacking capacity.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Carole Mather · 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

Carole Mather, aged 66, was found dead from hypothermia in an alleyway next to her home on 2 January 2023. She had attended hospital the previous day while intoxicated and complaining of shortness of breath, but discharged herself against medical advice. The principal concerns included the complexity of assessing mental capacity in people with chronic alcohol dependence and the lack of overarching guidance for health and social care practitioners on applying legal frameworks to manage and protect them.

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 overarching guidance on applying legal frameworks to manage and protect people with chronic alcohol dependence
Wider context from the report
“It was against this background that the Court heard of the lack of overarching guidance for health and social care practitioners which specifically addresses the application of legal frameworks available to manage and protect those with a chronic dependence on alcohol. Such guidance would be of benefit to health and social care practitioners and by extension to the individuals affected. ”
Source location
Carole Mather · Prevention of Future Deaths report
Page 1 · 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
Existing Mental Capacity Act safeguards, including DoLS and practitioners’ case-law duties, are relied on to protect patients lacking capacity.

Verbatim wording from the response
“If a patient was found to not have the mental capacity to discharge themselves, and they are or will be deprived of their liberty, then the hospital may need to consider whether to use the Deprivation of Liberty Safeguards (DoLS), under the Mental Capacity Act 2005. The DoLS can authorise the deprivation of liberty of a person being accommodated in a hospital or care home for the purpose of providing care or treatment. Any such restrictions placed on a person in these circumstances must be in their best interests and necessary and proportionate. Decision makers should therefore make full consideration as to whether less restrictive options, such as appropriate support packages, can be implemented in place of DoLS authorisation.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 29 April 2024
Open published response
19 Jul2018
Southampton and New Forest
Concerns raised1
1. Lack of a coordinated plan to treat alcohol dependence
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.
  Stated by Hampshire Hospitals NHS Foundation TrustStated completed
2. Action
  Provide alcohol-service inpatient access through weekly and arranged ad hoc Inclusion inreach.
  Stated by Hampshire Hospitals NHS Foundation TrustStated completed
3. Action
  Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.
  Stated by Hampshire Hospitals NHS Foundation TrustStated completed
1. Action
  Participate in a monthly multi-provider High Intensity User Group to identify further support for frequent attenders.
  Stated by Hampshire Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.
  Stated by Hampshire Hospitals NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Nigel Malloy · 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

Nigel Malloy fell from a second-floor window on 29 October 2017 while intoxicated with alcohol, suffered severe head injuries, and died in hospital two days later. He was alcohol dependent and had depressive symptoms, with previous similar falls and multiple hospital admissions, but concerns were raised that there was no information sharing or coordinated treatment plan between the relevant alcohol-support services.

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 a coordinated plan to treat alcohol dependence
Wider context from the report
“The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence. ”
Source location
Nigel Malloy · 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
Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.

Verbatim wording from the response
“• A 24 hour referral service and dedicated pathway with Inclusion”

Source location
2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018
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
Provide alcohol-service inpatient access through weekly and arranged ad hoc Inclusion inreach.

Verbatim wording from the response
“• At the time of Mr Malloy’s admissions to the Trust, Inclusion were running a weekly inreach service on a Sunday.”

Source location
2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018
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
Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.

Verbatim wording from the response
“• Regular telephone liaison between Inclusion and the Trust when one of their users is an inpatient or in relation to referrals”

Source location
2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018
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
Participate in a monthly multi-provider High Intensity User Group to identify further support for frequent attenders.

Verbatim wording from the response
“• Monthly High Intensity User Group involving multiple providers to discuss whether there is any further support which can be provided to high intensity users such as Mr Malloy”

Source location
2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018
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
Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.

Verbatim wording from the response
“As per our response to point 2 above, the Trust made the initial referral to Inclusion on 21.09.17 and subsequently liaised with them to arrange Mr Malloy’s first attendance and ensure that Mr Malloy had attended as planned.”

Source location
2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 2 · response
Published 23 September 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to review, clarify and update Standard Operating Procedures before expiry

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Lack of overarching guidance on applying legal frameworks to manage and protect people with chronic alcohol dependence

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of a coordinated plan to treat alcohol dependence

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Respondent positions 1

Actions described in response 4

Respondent positions 1