Recurring concern

Unreliable dual-diagnosis care pathways

First to latest report 27 Jun 2014 — 30 Apr 2026

Reports that mention this concern
22
Times this concern has been raised
32
Stated actions linked to this concern
78

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.

What is 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 and published responses 22 reports

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

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Emma Burbury · 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

    Emma Burbury collapsed after an altercation with her partner and died in hospital on 19 September 2018; the forensic pathologist considered it possible that injuries from the altercation caused or contributed to her death, but the evidence was insufficient to establish this as probable or certain. The report identified a missed opportunity to provide treatment after her July 2017 assessment and concerns about services for people with dual diagnoses, including care coordination, communication between organisations, engagement, and discharge arrangements.

    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 provide an adequate service to people presenting with a dual diagnosis

    Wider context from the report

    “It was accepted in evidence that it was “very regrettable” Emma was not taken on to caseload after her assessment in July 2017. There was clearly a missed opportunity to work with her while she was open to treatment. It was accepted that there was no guarantee this would have avoided the eventual outcome, but it was recognised a better service needed to be provided to those presenting with a dual diagnosis, like Emma. ”

    Source location

    Emma Burbury · 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

    Jointly fund a dedicated role providing oversight and scrutiny of dual-diagnosis strategy implementation and delivery.

    Verbatim wording from the response

    “In 2021 a dedicated role was jointly funded by both the NHS and local authority, to specifically provide additional oversight and scrutiny of the implementation and delivery of the dual diagnosis strategy. This work is ongoing and regular reporting serves robust governance”

    Source location

    2021-0382-Response-from-Kernow-CCG_Published
    Page 2 · response
    Published 18 November 2021

    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 ongoing governance of the dual-diagnosis strategy through formal oversight, risk management and reporting.

    Verbatim wording from the response

    “In 2021 a dedicated role was jointly funded by both the NHS and local authority, to specifically provide additional oversight and scrutiny of the implementation and delivery of the dual diagnosis strategy. This work is ongoing and regular reporting serves robust governance”

    Source location

    2021-0382-Response-from-Kernow-CCG_Published
    Page 2 · response
    Published 18 November 2021

    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

    Update and jointly implement the dual-diagnosis strategy with multiagency partners to improve integrated mental-health support.

    Verbatim wording from the response

    “As previously reported to your office, the Dual Diagnosis (DD) strategy for Cornwall and the Isles of Scilly was re-launched in 2018/19 after a period of review. This work was led by NHS Kernow CCG and Cornwall Council and culminated in a co-produced and jointly owned document supported by a range of multiagency partners and stakeholders including people with lived experience, carers and professionals from across statutory as well as the voluntary and third sectors. In 2021 the strategy was updated to incorporate emergent best practice guidance and executive level signatures from representative organisational leads, including CPFT and WAWY, demonstrate a clear commitment to continue to deliver the journey of change and improvement.”

    Source location

    2021-0382-Response-from-Kernow-CCG_Published
    Page 2 · response
    Published 18 November 2021

    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 implementing the Cornwall and Isles of Scilly Dual Diagnosis Strategy across Trust services.

    Verbatim wording from the response

    “The Trust has engaged with partner agencies in contributing to the implementation of the systemwide Cornwall and Isle of Scilly Dual Diagnosis Strategy (Adults) 2019 to 2022. The purpose of this strategy is to improve the delivery and experience of services for people with co-existing mental health, alcohol and drug problems; and recognises that these vulnerabilities do not exist in isolation, and that residents affected, will also have other associated complex needs, which require integrated, co-ordinated and consistently collaborative working.”

    Source location

    2021-0382-Response-from-Cornwall-Partnership_Published
    Page 1 · response
    Published 18 November 2021

    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

    Plan “what this means to me” workshops to help patient-facing staff embed Dual Diagnosis Strategy principles in practice.

    Verbatim wording from the response

    “Having recently ‘signed-up’ to this strategy, the Trust is fully committed to its delivery across all services and are active members of the Cornwall Council led multi-agency steering group. The Trust is currently planning “what this means to me” workshops to support patient facing staff groups embed the principles of the strategy into their clinical practice and this is regularly reviewed as part of the directorate’s Clinical Quality Assurance Group.”

    Source location

    2021-0382-Response-from-Cornwall-Partnership_Published
    Page 1 · response
    Published 18 November 2021

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Nicholas Jonathan SPOONER · 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

    Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.

    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

    Denial of mental health support for people in crisis with co-occurring substance abuse

    Wider context from the report

    “Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support. ”

    Source location

    Nicholas Jonathan SPOONER · 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

    Recruit two Dual Diagnosis Workers for the East and West Brighton Assessment and Treatment Services.

    Verbatim wording from the response

    “Previously we also set out the principles which underpin SPFT's Co-occurring Substance Use and Mental Health 5-year strategy. Since then, we are pleased to be able to update you on the recruitment of two Dual Diagnosis Workers into SPFT's Assessment and Treatment Services (ATS) in Brighton. This has arisen as a result of additional funding being obtained, through the transforming community care plan, and has resulted in a Dual Diagnosis Worker for both East and West Brighton ATSs. Change Grow Live have made progress integrating the work of their Mental Health Liaison nurses with the newly appointed SPFT Dual Diagnosis nurses. Strategic meetings have taken place between Change Grow Live and SPFT managers and the nurses are working jointly to support some clients with dual diagnosis.”

    Source location

    Response from NHS Social Care
    Page 2 · response
    Published 2 November 2021

    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

    Integrate Mental Health Liaison and Dual Diagnosis nursing work through joint meetings and client support.

    Verbatim wording from the response

    “Previously we also set out the principles which underpin SPFT's Co-occurring Substance Use and Mental Health 5-year strategy. Since then, we are pleased to be able to update you on the recruitment of two Dual Diagnosis Workers into SPFT's Assessment and Treatment Services (ATS) in Brighton. This has arisen as a result of additional funding being obtained, through the transforming community care plan, and has resulted in a Dual Diagnosis Worker for both East and West Brighton ATSs. Change Grow Live have made progress integrating the work of their Mental Health Liaison nurses with the newly appointed SPFT Dual Diagnosis nurses. Strategic meetings have taken place between Change Grow Live and SPFT managers and the nurses are working jointly to support some clients with dual diagnosis.”

    Source location

    Response from NHS Social Care
    Page 2 · response
    Published 2 November 2021

    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

    Require new mental health and substance misuse commissioning to address co-existing needs and involve NHS Sussex and the City Council.

    Verbatim wording from the response

    “We committed to ensuring that all new commissioned services for both substance misuse and mental health conditions specifically considers co-existing needs, and our update is that NHS Sussex and the City Council continue to be committed to involving and working with each other in the development of commissioning plans to best meet the needs of people with co-existing needs, and this will be a requirement of all providers of services across mental health and substance misuse. All service developments will be informed by the government guidance on providing better care for people with co-occurring mental health and alcohol/drug use conditions, Better care for people with co-occurring mental health and alcohol and drug use conditions (publishing.service.gov.uk)”

    Source location

    Response from NHS Social Care
    Page 3 · response
    Published 2 November 2021

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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

    Operate the Staying Well Crisis Café as an out-of-hours community mental-health crisis support service.

    Verbatim wording from the response

    “Currently, the CCG commission a Staying Well (Crisis Café service) which commenced in January 21. The service provides an out of hours (05:30 – 22:30 Weekdays, 3:30 – 22:30 Weekends) community space, where anyone on the verge of, or experiencing, a mental health crisis (self-defined) can access non-clinical mental health support. The aim of the service is to prevent an escalation of mental health need and/or to avert further crisis, to provide an alternative provision to attending A&E or accessing other urgent care services and to provide a step down from clinical services.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 1 · response
    Published 2 November 2021

    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 substance-misuse outreach, harm-minimisation and dual-diagnosis support through recovery coordinators and specialist nurses.

    Verbatim wording from the response

    “Additionally, currently, CGL provide substance misuse services which are designed to improve service users’ mental health and well-being, where dual diagnosis has been identified. Specialist recovery co-ordinators support clients living in supported accommodation and benefit from the support of the CGL dual diagnosis nurses to improve access to specialist mental health services. These workers offer outreach support and harm minimisation interventions to those living in supported housing or who are homeless. In June 2021, SPFT, set out its Co-occurring Substance Use and Mental Health (COSUMH) Conditions 5 year strategy. That strategy recognises that more needs to be done and adopts the principles of ‘everyone’s business’, ‘no wrong door’, integrated care plans, clinical leadership and facilitating access to mutual aid.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 2 · response
    Published 2 November 2021

    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

    Implement the COSUMH five-year strategy for co-occurring substance-use and mental-health conditions.

    Verbatim wording from the response

    “Additionally, currently, CGL provide substance misuse services which are designed to improve service users’ mental health and well-being, where dual diagnosis has been identified. Specialist recovery co-ordinators support clients living in supported accommodation and benefit from the support of the CGL dual diagnosis nurses to improve access to specialist mental health services. These workers offer outreach support and harm minimisation interventions to those living in supported housing or who are homeless. In June 2021, SPFT, set out its Co-occurring Substance Use and Mental Health (COSUMH) Conditions 5 year strategy. That strategy recognises that more needs to be done and adopts the principles of ‘everyone’s business’, ‘no wrong door’, integrated care plans, clinical leadership and facilitating access to mutual aid.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 2 · response
    Published 2 November 2021

    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

    Commission a 24/7 crisis house for people in mental-health crisis, including those with substance-misuse support needs.

    Verbatim wording from the response

    “Also, the CCG is in the process of commissioning a new crisis house that will provide support to people in a mental health crisis who require 24/7 support and would otherwise be admitted to hospital. The tender for this service will be issued in October 2021 and the new service will start in the summer of 2022. The service will be for individuals with support needs for their mental health”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 1 · response
    Published 2 November 2021

    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

    Re-commission mental-health supported accommodation with greater care-model flexibility for people with substance-misuse needs.

    Verbatim wording from the response

    “BHCC and the CCG are also currently jointly re-commissioning mental health supported accommodation services with the intention of providing greater flexibility in the model of care. The timeline for this tender is the same as the crisis house and the same arrangements for people with substance misuse needs will apply.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 2 · response
    Published 2 November 2021

    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

    Require all newly commissioned substance-misuse and mental-health services to consider co-existing needs.

    Verbatim wording from the response

    “• ensure that all new commissioned services for both substance misuse and mental health conditions specifically considers co-existing needs.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 3 · response
    Published 2 November 2021

    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

    Deliver a community-based mental health offer including psychological therapies, physical healthcare, employment support, personalised care, medicines management and support for self-harm and coexisting substance use.

    Verbatim wording from the response

    “A new community-based offer will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use. This includes maintaining and developing new services for people who have the most complex needs and proactive work to address racial disparities. Local areas will be supported to redesign and reorganise community mental health teams to move towards a new place-based, multidisciplinary service across health and social care aligned with primary care networks.”

    Source location

    2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
    Page 3 · response
    Published 2 November 2021

    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

    Expand alternative provision for people experiencing mental health crisis, including sanctuaries, safe havens and crisis cafes.

    Verbatim wording from the response

    “We will also expand services for people experiencing a mental health crisis. As part of our COVID-19 response work, for those with severe needs or in crisis, all NHS mental health providers have established 24/7 urgent mental health helplines. In addition, under the NHS Long Term Plan, we will increase alternative forms of provision for those in crisis. Sanctuaries, safe havens and crisis cafes provide a more suitable alternative to A&E for many people experiencing mental health crisis, usually for people whose needs are escalating to crisis point, or who are experiencing a crisis but do not necessarily have medical needs that require A&E admission. These alternatives are commissioned through the NHS and local authorities, provided at relatively low cost and to high satisfaction, and usually delivered by voluntary sector partners.”

    Source location

    2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
    Page 3 · response
    Published 2 November 2021

    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 signposting and expand coverage of alternative mental health crisis services.

    Verbatim wording from the response

    “While these services now exist in a number of areas, we will work to improve signposting, and expand coverage to reach more people and make a greater impact.”

    Source location

    2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
    Page 3 · response
    Published 2 November 2021

    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

    Invest £13 million to sustain and enhance 24/7 crisis lines during 2021/22.

    Verbatim wording from the response

    “£58million of this extra £500million announced will be invested to bring forward the expansion of integrated primary and secondary care for adults with severe mental illness and £13million will be used for crisis support to sustain and enhance operation of 24/7 crisis lines in 2021/22.”

    Source location

    2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
    Page 4 · response
    Published 2 November 2021

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Sean Daniel FEGAN · 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

    Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.

    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 services for patients with dual diagnosis and significant drugs misuse problems

    Wider context from the report

    “3. Dual diagnosis – it was acknowledged that there was a ‘gap’ within the services in relation to dual diagnosis patients. There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems. ”

    Source location

    Sean Daniel FEGAN · 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

    Embed three substance-misuse workers within Local Mental Health Teams to support complex cases, collaboration, training and best-practice procedures.

    Verbatim wording from the response

    “As part of the Trust’s Transformation Project and as part of a pilot there will be three substance misuse workers embedded within the LMHTs, who will facilitate closer working with CGL, and recruitment is now underway to fill these posts . The substance misuse workers will also provide training and best practice procedures to staff, whilst also assisting with the more complex presentations.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 30 March 2021

    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

    Operate the established collaborative dual-diagnosis clinical reference group for case discussion and pathway identification.

    Verbatim wording from the response

    “The Trust’s strategy for promoting integrated care for people with comorbid mental health and substance misuse comprises of a number of components. This includes training on dual diagnosis which is enhanced by the appointment of the substance misuse staff. There is a bi-monthly collaborative clinical reference group for dual diagnosis now established, which includes a range of clinical staff from different services across Nottinghamshire, enabling case discussion and identification of pathways for mental health and substance misuse. There is also good engagement with public health in relation to the wider strategy in developing this area. The trust is currently exploring employment of peer support workers including number of posts and their deployment, supervision and training requirements, any specific roles to be undertaken by peer support workers and how to evaluate their impact.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 30 March 2021

    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

    There is no resistance or policy against treating people with co-occurring mental health and substance misuse conditions.

    Verbatim wording from the response

    “There is no resistance to, or policy within the Trust against treating dual diagnosis patients. The Trust is commissioned to work with CGL (Change, Grow, Live), who provide this service. We regret that the family and the inquest were left with the impression that the Trust is reluctant to engage with this patient group and stress that this is not the case; people with co morbid substance misuse are supported by our services.”

    Source location

    2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 30 March 2021

    Open published response

  4. Lincolnshire

    AI-generated summary

    Toby Peter Edward Nieland · 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

    Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

    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 adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis

    Wider context from the report

    “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to: a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases; b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases; c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 5 · 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

    Unavailability of specialist Dual Diagnosis workers for complex cases

    Wider context from the report

    “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to: a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases; b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases; c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 5 · 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

    Unavailability of a dedicated or commissioned drug and alcohol recovery service

    Wider context from the report

    “7. The circumstances of this case evidences a gap in the provision of care to a patient with a Dual Diagnosis in Lincolnshire by reason of there being no dedicated and/or commissioned drug and alcohol recovery team/service; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 4 · 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 interface between senior or experienced providers for complex cases

    Wider context from the report

    “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to: a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases; b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases; c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 5 · 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 to recognise and adequately manage complex Dual Diagnosis

    Wider context from the report

    “2. Unequivocal evidence established that the deceased suffered from an advanced progressive addiction overlaid with a vulnerable personality amounting to a complex Dual Diagnosis – the significance of which was not appreciated and therefore not managed adequately or appropriately; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 4 · 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

    Absence of a Dual Diagnosis protocol defining provider roles

    Wider context from the report

    “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to: a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases; b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases; c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 4 · 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

    Review staff structures and introduce specialist Dual Diagnosis roles, including dedicated mental-health nursing and recovery-worker capacity.

    Verbatim wording from the response

    “• We have reviewed our staff structures and introduced specialist Dual Diagnosis roles. We have taken steps to employ staff who can lead on complex cases, including a dedicated Mental Health Nurse and a Recovery Worker who is allocated Dual Diagnosis cases. Our Clinical Lead is a registered (NMC) Mental Health Nurse and Independent Prescriber with MSc level qualifications in substance misuse, neuropsychiatry and trauma. These roles work in partnership with mental health providers to enhance the care provided service users. They also train and support the wider substance misuse team at LPFT in early identification of those individuals with complex health issues.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    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 reciprocal training and cross-sector learning opportunities for partner staff on substance-misuse interventions.

    Verbatim wording from the response

    “• We have enhanced our reciprocal training to LPFT and regularly attend interface meetings for Dual Diagnosis patients and ensure we have input into community release plans. Additionally, we provide opportunities for staff from LPFT, the Police, Probation and Children's Services as well as housing providers. to spend time within our teams to further their experience of substance misuse interventions. We have commenced delivery of group work interventions within the Mental Health units in Lincoln (Discovery House and PHC) for those with a dual diagnosis.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    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

    Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.

    Verbatim wording from the response

    “Learning from the death of Mr Nieland, the Trust will strengthen the policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 26 October 2020

    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 training and competencies to cover dual-diagnosis presentations, risk assessment and information sharing.

    Verbatim wording from the response

    “The Trust is committed to a review of the training provided to staff to ensure they are appropriately equipped with the knowledge and ability to care for patients with dual diagnosis. The Learning and Development Lead is working with Divisional staff to develop the appropriate training package, over the next 6-12 months.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 7 · response
    Published 26 October 2020

    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

    Consider different or partnership-based approaches to commissioning services for people with dual diagnosis.

    Verbatim wording from the response

    “ii. The council and the CCG should consider different approaches to commissioning services that cater for those with dual diagnosis, this should form part of the commissioning cycle and include alternative models and joint commissioning opportunities Timeframe - October 2023”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 3 · response
    Published 26 October 2020

    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

    Identify commissioning gaps and deploy appropriately skilled dual-diagnosis workers across partner agencies.

    Verbatim wording from the response

    “Learning from the death of Mr Nieland, as stated above, the Trust is committed to the strengthening of its policies and protocols in accordance with the guidance issued by NICE and the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care Programme Approach which will have joint working with We Are With You’, utilising expertise of workers from both services in a collaborative manner. The Trust has already begun conversations with its Commissioning partners and We Are With You, to identify commissioning gaps and ways of ensuring workers with the right skills are deployed in both agencies.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 7 · response
    Published 26 October 2020

    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

    Evaluate dual diagnosis provision within substance misuse services and make recommendations on its adequacy and future commissioning.

    Verbatim wording from the response

    “ii. The substance misuse provision for dual diagnosis will be a central point of the next service evaluation; this inspection should determine if current provision is adequate and appropriate to meet the needs of those accessing the service and make recommendations to the provider and commissioner regarding provision and future commissioning potential. Timeframe - September 2021 to complete the review (Covid 19 restrictions may delay this action)”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 5 · response
    Published 26 October 2020

    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 internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.

    Verbatim wording from the response

    “We have summarised below the actions the Trust will take to learn from Mr Nieland’s death and enhance services for patients with a complex dual diagnosis presentation: To review internal policies and protocols as well as work together with “We Are With You” to embed care pathways between the two organisations to address gaps in services. (Leads: Clinical Director for Community Division and Quality Lead for the Community Division)”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 7 · response
    Published 26 October 2020

    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

    Continue engaging commissioners and system partners to secure appropriate funding for dual-diagnosis services and support.

    Verbatim wording from the response

    “vi. To continue to engage with Commissioners and all system partners including primary care, acute care services, and housing partners (not named in the letter but we recognise the importance of all partners in the system) to ensure the services required for patient with dual diagnosis are appropriately funded – clinical, management and leadership and administrative support. Lead: Director of Strategy, Planning and Partnerships - on-going”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 8 · response
    Published 26 October 2020

    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

    Attend Dual Diagnosis interface meetings and contribute to community release plans with mental-health and wider partner services.

    Verbatim wording from the response

    “• We have enhanced our reciprocal training to LPFT and regularly attend interface meetings for Dual Diagnosis patients and ensure we have input into community release plans. Additionally, we provide opportunities for staff from LPFT, the Police, Probation and Children's Services as well as housing providers. to spend time within our teams to further their experience of substance misuse interventions. We have commenced delivery of group work interventions within the Mental Health units in Lincoln (Discovery House and PHC) for those with a dual diagnosis.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    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 revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.

    Verbatim wording from the response

    “i. A joint working protocol is in place but has not been widely implemented across all services. The CCG, LPFT, We Are With You and Public Health should work together to review this protocol and implement a more robust”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    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

    Implement robust communication, information-sharing and aligned clinical pathways with We Are With You.

    Verbatim wording from the response

    “The Trust and ‘We Are With You’ (as Addaction is now called) will work together to ensure the implementation of robust communication systems; agree appropriate information sharing arrangements and ensure alignment of clinical pathways and protocols, with the aim to make collaborative working between the two organisations standard practice. The Trust confirms this is part of its work plan over the next six months, led by the Clinical Director for the Community Services Division working with the Quality lead for the Division.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 26 October 2020

    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

    Substance misuse training, advice and referral support are already available for mental health services to access.

    Verbatim wording from the response

    “appropriate referral into specialist treatment.' This provision is in place and available for Lincolnshire Partnership NHS Trust to access.”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 7 · response
    Published 26 October 2020

    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

    Current substance misuse provision is considered sufficient to manage dual-diagnosis needs, subject to review if joint working significantly increases.

    Verbatim wording from the response

    “The response to question 7 details the provision in place from We Are With You. The specification for the service is outcome focussed and expects the provider to meet all relevant guidance and provide the support and care appropriate for those using the service to make a full and sustainable recovery. This includes dual diagnosis. The current provision is sufficient to manage need however if joint working grows significantly this will be reviewed as part of the on-going management of the contract between Public Health and We Are With You.”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 6 · response
    Published 26 October 2020

    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

    The Trust was not commissioned to provide substance misuse services.

    Verbatim wording from the response

    “The Trust recognises there is currently a commissioning gap in the provision of care to patients identified as having a dual diagnosis. Currently mental health services and substance misuse services are commissioned separately in Lincolnshire with the services provided by two organisations. The Trust is a provider of specialist mental health services and is not commissioned to provide substance misuse services. The local Clinical Commissioning Groups (CCG) and the Local Authority’s Public Health department commission ‘We Are With You’ (formerly ‘Addaction’) to provide substance misuse services.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 6 · response
    Published 26 October 2020

    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

    Clinical Commissioning Groups and the Local Authority’s Public Health department commissioned substance misuse services from the external provider.

    Verbatim wording from the response

    “The Trust recognises there is currently a commissioning gap in the provision of care to patients identified as having a dual diagnosis. Currently mental health services and substance misuse services are commissioned separately in Lincolnshire with the services provided by two organisations. The Trust is a provider of specialist mental health services and is not commissioned to provide substance misuse services. The local Clinical Commissioning Groups (CCG) and the Local Authority’s Public Health department commission ‘We Are With You’ (formerly ‘Addaction’) to provide substance misuse services.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 6 · response
    Published 26 October 2020

    Open published response

  5. East Sussex

    AI-generated summary

    Reece Tristan Lapina-Amarelle · 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

    Reece Tristan Lapina-Amarelle, aged 20, died by suicide after being discharged from hospital with the expectation that he would immediately attempt to take his life. The report identifies concerns about insufficient resources and treatment for people with serious mental illness and substance misuse, inadequate information-sharing between services, limitations of voluntary support, and the Mental Health Act's failure to provide an appropriate plan of action focused on safety.

    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 resources for people with serious mental illness and alcohol or drug misuse histories

    Wider context from the report

    “(1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories. ”

    Source location

    Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report
    Page 1 · 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 a treatment system for people with serious mental illness and alcohol or drug misuse histories

    Wider context from the report

    “(1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories. ”

    Source location

    Reece Tristan Lapina-Amarelle · 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

    Develop and implement integrated community mental health models providing psychological, physical-health, employment, personalised-care, medicines-management and substance-use support.

    Verbatim wording from the response

    “In recognition of the above, we are taking specific steps to improve access to, and quality of, support for people with co-existing SMI and substance misuse. The NHS Long Term Plan, published earlier this year, details how new and integrated models of primary and community health services will transform the delivery of mental health care for adults and older adults with SMI, including people with a ‘personality disorder’ and those with co-existing substance misuse. As the NHS Mental Health Implementation Plan 2019/20 – 2023/24 sets out, this new community-based offer, backed by significant investment over the next five years, will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.”

    Source location

    2019-0274-Response-by-NHS-England
    Page 2 · response
    Published 18 October 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

    Continue supporting the “no wrong door” approach for people presenting with co-occurring mental health and substance misuse conditions.

    Verbatim wording from the response

    “The Government continues to support the ‘no wrong door’ approach when people present to services with co-occurring conditions. Commissioning guidance encourages services to respond collaboratively, effectively and flexibly, offering”

    Source location

    2019-0274-Response-by-Department-of-Health-and-Social-Care
    Page 2 · response
    Published 18 October 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

    Local authorities hold statutory responsibility for commissioning public health services, including drug and alcohol services.

    Verbatim wording from the response

    “The Health and Social Care Act 2012 transferred statutory responsibility for the commissioning of public health services, including drug and alcohol services, to local authorities. NHS England and NHS Improvement do recognise it as a very important issue, with significant implications for the mental health of individuals, particularly for those affected by coexisting severe mental illnesses (SMI) and substance misuse, like Mr Lapina-Amarelle. We also recognise the importance of ensuring closer working between mental health services and substance misuse services to ensure people’s needs are met in an integrated, holistic and timely manner. As such, the ongoing move towards Integrated Care Systems (ICSs) across England is intended to help address some of these issues and to provide joined up health and care to whole populations across the NHS, social care and public health.”

    Source location

    2019-0274-Response-by-NHS-England
    Page 2 · response
    Published 18 October 2019

    Open published response

  6. Manchester South

    AI-generated summary

    David Alan Price · 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

    David Alan Price had a long history of alcohol use to cope with mental health difficulties and was found at home on 12 November 2018. The inquest heard that he would have benefited from an integrated mental health counselling and detoxification service, which was not available in Stockport.

    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 integrated mental health counselling and alcohol detoxification services

    Wider context from the report

    “The inquest heard evidence that David Alan Price had a long standing problem with alcohol which he used to self-medicate his anxiety in particular. He made a number of attempts to give up alcohol. These were ultimately unsuccessful. The inquest heard that one of the challenges was to provide support which would enable him to treat his mental health difficulties e.g. anxiety alongside detoxification and supporting him in staying alcohol free. The inquest heard that he would have benefited from an integrated mental health counselling/detoxification service. This would have enabled joint treatment. Such a programme is not available in Stockport. ”

    Source location

    David Alan Price · 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 services are considered sufficient to meet the needs of people with co-occurring mental health and alcohol problems.

    Verbatim wording from the response

    “We recognise that with these services in place Mr Price should have been able to benefit from them, but did not. The CCG and Local Authority have reviewed and are recommending the following actions:”

    Source location

    2019-0145-Response-by-Stockport-NHS-CCG
    Page 2 · response
    Published 29 July 2019

    Open published response

  7. Cornwall and Isles of Scilly

    AI-generated summary

    PAUL MATTHEW GILLAM · 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

    Paul Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery plan.

    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 operate the Cornwall dual diagnosis policy effectively

    Wider context from the report

    “(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT. ”

    Source location

    PAUL MATTHEW GILLAM · Prevention of Future Deaths report
    Page 3 · 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

    Complete the review of the Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults.

    Verbatim wording from the response

    “In order to support this multi-agency joint working there is a Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults covering the period 2016 - 2019. This is a multi-agency co-produced strategy that has been developed by members of Safer Cornwall and providers of services. The purpose of this strategy is to assist with the delivery and experience of integrated and inclusive service delivery for people with co-existing mental health and substance misuse problems, and their associated complex needs. However, as acknowledged in the strategy, there are challenges to creating a culture of shared responsibility which can leave people struggling to gain access to evidence based interventions as well as targeted support for substance misuse.”

    Source location

    2019-0045-Response-by-Kernow-CCG
    Page 2 · response
    Published 24 May 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

    Develop and implement a robust multi-agency implementation plan for the dual diagnosis strategy.

    Verbatim wording from the response

    “A multi-agency steering group has been set up to review the strategy and develop an implementation plan. The steering group consists of key organisations (including CFT and Addaction) and is being supported by the commissioning organisations. The steering group will report progress into the Mental Health Crisis Care Concordat who will report to Safer Cornwall. The Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis and sets out how organisations will work together. These arrangements will ensure the review of the strategy and its implementation, as well as appropriate oversight of progress and effectiveness.”

    Source location

    2019-0045-Response-by-Kernow-CCG
    Page 2 · response
    Published 24 May 2019

    Open published response

  8. Cornwall and Isles of Scilly

    AI-generated summary

    Marcus HANCE · 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

    Marcus Hance died on 13 October 2017 from the synergistic effect of a reckless overdose of illicit and therapeutic drugs, in the context of a history of drug abuse. Concerns included the separation of support for substance misuse from support for associated mental health issues, the approach that substance misuse should be addressed before mental health treatment, and his discharge from the Community Mental Health Team after two missed appointments.

    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

    Requirement for substance misuse treatment before mental health treatment

    Wider context from the report

    “(2) The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed. ”

    Source location

    Marcus HANCE · 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

    Work in partnership with NHS Kernow on ongoing reviews of the Dual Diagnosis strategy, service interdependencies, and service specifications.

    Verbatim wording from the response

    “Thank you for providing me with the response provided by NHS Kernow Clinical Commissioning Group, commissioners of mental health services, confirming the on-going review in relation to the Dual Diagnosis strategy; the review of the interdependencies between Outlook Southwest and the Trust and the review of a number of service specifications between NHS Kernow and the Trust.”

    Source location

    2018-0173-Response-by-Cornwall-NHS-Trust
    Page 1 · response
    Published 8 July 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

    Review interdependencies between mental health and substance misuse services, refreshing referral, transition, risk management and information-sharing protocols.

    Verbatim wording from the response

    “NHS Kernow are reviewing interdependencies between Outlook SW and Cornwall Partnership NHS Foundation Trust. This work includes a joint refresh of existing protocols in support of smooth referral pathways and transitions between services and different service lines, a review of risk management processes and information sharing arrangements. The intention is to conclude this work by December 2018.”

    Source location

    2018-0173-Kernow-NHS-Trust
    Page 2 · response
    Published 8 July 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

    Cornwall Council leads commissioning of drug and alcohol services, assigning responsibility for that provision to another body.

    Verbatim wording from the response

    “NHS Kernow are partners in the implementation of the existing Dual Diagnosis Strategy, along with DAAT commissioners and Cornwall Partnership NHS Foundation Trust. The strategy requires that at an operational and clinical level, services work together to ensure safe and seamless care for individual’s most affected. The Crisis Care Concordat multi-agency group, Chaired by the GP Clinical Lead for Mental Health, includes representation from the Drug and Alcohol Action Team (DAAT), and is reviewing its local action plans with a view to setting out revised actions associated with Dual Diagnosis. Cornwall Council are lead commissioners of drug and alcohol services, and there is a joint commitment to establish meaningful, equitable and sustainable service change and promote joint working across agencies.”

    Source location

    2018-0173-Kernow-NHS-Trust
    Page 2 · response
    Published 8 July 2018

    Open published response

  9. Brighton and Hove

    AI-generated summary

    Thomas Christall · 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

    Thomas Christall’s inquest concluded that he took his own life. Concerns included the lack of a local inpatient detoxification facility, long waiting times, and insufficiently collaborative treatment for people with dual diagnosis, with delays and refusals increasing distress and despair.

    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 provide collaborative, integrated dual diagnosis treatment and assessment

    Wider context from the report

    “(2) A much more collaborative approach to dual diagnosis patient's treatment is needed. The dual diagnosis is at the heart of this problem. It is not appropriate to try to separate each component and only agree to treat/assess one component when the other is dealt with. The dual diagnosis is the person. When in crisis they are doubly at risk. That period of risk should be reduced as quickly as possible. The delays and refusals serve to exacerbate the patient's distress and increase their despair. As Thomas Wall said in a text message to his supportive ex-wife ‘I want to get better but I can’t do that on my own whereas I can take my life on my own’ ”

    Source location

    Thomas Christall · 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

    Disseminated Public Health England guidance to relevant clinical and community service leads to inform teams’ dual-diagnosis service delivery.

    Verbatim wording from the response

    “████████ Head of Legal Services, briefed me fully on the inquest of Mr Wall and I was heartened that you praised the substantial input to Mr Wall’s care from the Trust’s Assessment and Treatment Service, the Mental Health Rapid Response Service, the General Practitioner and Pavilions and acknowledged the difficulties faced by these services as mental health and substance misuse services are not managed by one local provider such as the Trust. Following the inquest, ████████ ensured that the informative Public Health England guidance shared at the inquest by ████████ was provided to the Clinical and Service Director for Brighton and Hove, ████████, and the General Manager for Community Services for Brighton and Hove, ████████ to ensure their teams are aware of the recent guidance to aid them in delivering services.”

    Source location

    2017-0321-Response-by-Susssex-Partnership-NHS-Trust
    Page 2 · response
    Published 3 December 2017

    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

    Implement an integrated dual-diagnosis service model with co-located workers, shared records, agreed pathways and regular complex-case meetings.

    Verbatim wording from the response

    “Progress has been made in a number of areas including the implementation of a Dual Diagnosis integrated model through the re-procurement of substance misuse services. 3.5 whole-time equivalent DD workers are now co-located with mental health services to increase joint working, engagement with support, and ensure smooth transition. Clinicians within substance misuse services can now access Sussex Partnership electronic patient records and vice versa. There are now agreed pathways between the services with regular meetings where complex cases are discussed to ensure that people receive appropriate support and care and do not fall between the gaps.”

    Source location

    2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
    Page 1 · response
    Published 3 December 2017

    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

    Establish dual-diagnosis referral and care protocols, related training, and access to primary-care mental-health support.

    Verbatim wording from the response

    “Agreed referral and care pathway protocols are now in place for those with dual needs including increased awareness and training and increased access to primary care mental health support for those with dual needs which are no longer an automatic exclusion. The new service specification for primary mental health services supports a more proactive approach.”

    Source location

    2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
    Page 2 · response
    Published 3 December 2017

    Open published response

  10. Preston and West Lancashire

    AI-generated summary

    Stephen McDermott · 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

    Stephen McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.

    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 assess coexisting mental health issues in people presenting with substance misuse

    Wider context from the report

    “5) Mr McDermott’s problems were repeatedly treated as substance misuse issues without any consideration or assessment of whether mental health issues might be the underlying cause of the substance misuse issues. Individuals assessing Mr McDermott repeatedly had their views clouded by substance misuse issues, which prevented Mr McDermott from being referred into mental health services for assessment. Although the Trust’s ‘Team Incident Review’ [‘TIR’] identified that a “more flexible approach” was required in relation to overlapping substance misuse and mental health issues, there was no evidence at the inquest that trust policies or procedures have changed in this respect, nor any evidence of staff being trained to approach such cases differently; ”

    Source location

    Stephen McDermott · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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