Recurring concern

Unreliable dual-diagnosis care pathways

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First reported 27 Jun 2014•Latest report 30 Apr 2026

Definition

What this concern includes

Includes failures of the explicitly named dual-diagnosis service, pathway, policy or interface, including recognition and management of dual diagnosis, clinician training and access, referral and coordination, service availability, policy implementation, and adaptation to relevant complexity such as homelessness.

Not included

  • Excludes generic mental-health or substance-misuse service deficiencies where dual diagnosis is not the named shared concern.
  • Excludes generic training, communication, staffing or care-coordination failures unless they are directly tied to the dual-diagnosis pathway or service.
  • Excludes failures concerning a single condition without a material coexisting mental-health and substance-misuse component.
  • Excludes unrelated complex-needs pathways, including eating-disorder and emotional-needs pathways, unless the assertion explicitly concerns dual diagnosis.
  • Excludes neutral descriptions of dual-diagnosis policy or service arrangements that do not identify an unsafe deficiency.
Reports
22

Distinct published reports

Individual concerns
32

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
78

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8
Change, Grow, Live3
NHS England3
Nottinghamshire Healthcare NHS Foundation Trust3
Cornwall Council2
Cornwall Partnership NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Lancashire & South Cumbria NHS Foundation Trust2
NHS Cornwall and the Isles of Scilly Integrated Care Board2
NHS Greater Manchester Integrated Care Board2
NHS Surrey and Sussex Integrated Care Board2
Sussex Partnership NHS Foundation Trust2
All family members1
Blackpool Teaching Hospitals NHS Foundation Trust1
Bloomfield Medical Centre1

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.

  1. Nottinghamshire

    AI-generated summary

    Philip Anthony Denning · 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

    Philip Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.

    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

    Risk of future deaths from fragmented provision by a separate substance misuse organisation

    Wider context from the report

    “6. Even aside from the question of shared access to key records held by Nottinghamshire Healthcare and CRI, I am concerned that the current approach of having a separate organisation dealing only with substance misuse carries a risk of future deaths. Commissioners and providers will need to consider these matters carefully. ”

    Source location

    Philip Anthony Denning · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unclear remit of CRI in managing patients with co-occurring substance misuse and mental health problems

    Wider context from the report

    “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit. ”

    Source location

    Philip Anthony Denning · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 primary care understanding of access routes and service roles for patients with co-occurring substance misuse and mental health problems

    Wider context from the report

    “7. It is also clear that there is a significant lack of understanding in primary care about how to access help for patients like Philip. The respective roles of CRI, Nottinghamshire Healthcare and primary care talking therapies appear to be widely misunderstood. I have included reference to GPs and primary care largely with a view to raising awareness in this area. ”

    Source location

    Philip Anthony Denning · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 CRI to provide or arrange additional psychological support for patients with co-occurring substance misuse and mental health problems

    Wider context from the report

    “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit. ”

    Source location

    Philip Anthony Denning · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester City

    AI-generated summary

    ASHLEY CORIN DE WINTER PONSONBY · 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

    Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.

    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 staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients

    Wider context from the report

    “1. It is a matter of concern that any ward could be set up and operated involving the inherent risks of drug misuse by dual diagnosis patients without the staff having any training in recognising and dealing with the physical harm and risks arising from the use of illicit substances. The evidence from the independent psychiatrist was that this was an essential ingredient. Consequently, in rehabilitation wards or those with dual diagnosis patients where there is a risk of continuing drug misuse, the concern which arose was that without this, there was a risk of a future death arising. This has implications locally for the Trust, regionally and on a national basis. ”

    Source location

    ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report
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Data last updated 7 September 2026