Recurring concern

Unreliable access to appropriate addiction support

First to latest report 26 Dec 2014 — 30 Apr 2021

Reports that mention this concern
7
Times this concern has been raised
7
Stated actions linked to this concern
3

What this concern includes

Includes failures of arrangements specifically intended to enable people with addiction to access, receive or continue appropriate addiction support, including non-deterral by disciplinary policy, referral, coordination with addiction services and confirmation of support during care transitions.

What is not included
  • Excludes generic mental-health, social-care or discharge-support deficiencies unless they specifically concern access to addiction support.
  • Excludes prescribing or medication-quantity concerns where addiction support or referral is not the identified unsafe condition.
  • Excludes generic communication, policy or inter-agency coordination failures without a direct addiction-support connection.
  • Excludes failures concerning addiction prevention, treatment quality or recovery outcomes where access or arrangement of appropriate support is not deficient.

Reports and published responses 7 reports

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

  1. Manchester South

    AI-generated summary

    Jade Rayner · 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

    Jade Nicole Rayner was a vulnerable adult with complex mental and physical health needs, including seizures, alcohol use and fluctuating capacity. She was found unresponsive at home on 30 March 2020 and had a fatal level of prescribed antidepressants and alcohol in her system. Concerns included the absence of an effective multi-agency strategy, failures in recording and investigating a reported sexual offence, and alcohol misuse support that could not meet the needs of a complex case involving underlying trauma.

    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 alcohol misuse support programmes able to meet complex trauma-related needs

    Wider context from the report

    “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code. 2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol. 3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. ”

    Source location

    Jade Rayner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Alcohol misuse support for complex trauma-related cases was considered best addressed by the Greater Manchester Health and Social Care Partnership.

    Verbatim wording from the response

    “3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.”

    Source location

    2021-0128-Response-from-Greater-Manchester-Police-Redacted
    Page 3 · response
    Published 4 May 2021

    Open published response

  2. Inner West London

    AI-generated summary

    Daniel Brian Mervis · 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

    Daniel Brian Mervis died aged 23 after a mixed drug overdose on 25 October 2019. He had a history of drug misuse and addiction, relapsed in the final two months of his life, and was found deceased in the flat of a known drug dealer. Concerns included the lack of an overarching drug policy across Oxford University colleges, a potential conflict between disciplinary measures and support for students with drug addiction, and the need for drug misuse policies to be more widely advertised.

    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 align disciplinary policy with support for students suffering from drug addiction

    Wider context from the report

    “2. That there is an apparent conflict between St John’s stated policy to deal with utmost severity with those students who misuse or supply drugs, and the apparent support those students who suffer with drug addiction are offered. This conflict may discourage such students to seek help for their addiction out of fear of the consequences, either legal or disciplinary. A policy of the College which is well publicised and stresses the confidential nature of support offered may mitigate this risk. ”

    Source location

    Daniel Brian Mervis · 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

    Rewrite the student handbook section to clarify confidential addiction support and protection from potential legal or disciplinary consequences.

    Verbatim wording from the response

    “2. St John’s will adopt the template policy outlined in response one. In addition to this it will be rewriting the appropriate section of the student handbook to make sure that there is greater clarity about the confidential support that students are able to receive without worrying about any potential legal or disciplinary consequences.”

    Source location

    2021-0027-Response-from-St-Johns-College-Oxford-Redacted
    Page 2 · response
    Published 9 February 2021

    Open published response

  3. Suffolk

    AI-generated summary

    Justin John BROWN · 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

    Justin John Brown was found deceased at his address on 19 February 2016 after police attended following a welfare call. The inquest concluded that he died from ketoacidosis due to diabetes and chronic alcohol abuse, with underlying chronic pancreatitis and bronchopneumonia. A principal concern was that he had been discharged from hospital without confirmed addiction support, and that referral monitoring and communication with the drug service were inadequate.

    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 confirm addiction support at hospital discharge

    Wider context from the report

    “Justin Brown had been discharged from hospital without confirmed support for his addiction between 4 January and his death on 19 February 2016. In light of his history of cooperation with the service the hospital would have been assisted by an agreed protocol and closer working with the commissioned drug service to enable monitoring of referrals sent and outcomes for the service users. ”

    Source location

    Justin John BROWN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Karen Moran · 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

    Karen Moran was found at home on 7 April 2018 and died after unsuccessful resuscitation attempts at Tameside General Hospital. Toxicology showed raised levels of prescribed dihydrocodeine and gabapentin, and the inquest heard that her recognised addiction to prescribed medication was not addressed through referral while repeat prescriptions continued to provide access to significant amounts of medication.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to refer patients with recognised addiction to prescribed medication for addiction support

    Wider context from the report

    “She had a long term addiction to prescribed medication that had been recognised. Medication continued to be prescribed on repeat prescriptions with no referral to address the addiction. The prescribing pattern meant she had access to significant amounts of prescribed medication. ”

    Source location

    Karen Moran · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner South London

    AI-generated summary

    Jamie Pashley · 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 Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.

    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

    Limited availability of hospital alcohol liaison nurse support

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

    Source location

    Jamie Pashley · 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

    Consider a business case to increase the Alcohol Liaison team and improve patient access to liaison staff.

    Verbatim wording from the response

    “The Trust acknowledges that there is demand for an increased team so that patients can access staff that they worked with whilst an in-patient. Approach approaches have been made to local CCGs and charities without success to date, and so the Trust is considering a business case to increase the Alcohol Liaison team. The benefits to”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 2 · response
    Published 4 August 2017

    Open published response

  6. Inner West London

    AI-generated summary

    Jaroslaw Rogala (otherwise known as Jarek) · 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

    Jaroslaw Rogala, also known as Jarek, was found deceased by hanging in his bedroom on 3 September 2016 after experiencing suicidal ideation while intoxicated with alcohol. The report raised concern that patients with addiction at risk of suicide may have no inpatient facility available for care and supervision during a crisis.

    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 inpatient facilities for admitting patients with addiction for care and supervision during crisis

    Wider context from the report

    “That those patients with addiction are risk of suicide as there are no in-patient facilities to admit them for care and supervision when in crisis in circumstances as described in this case. ”

    Source location

    Jaroslaw Rogala (otherwise known as Jarek) · 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

    Offer higher-risk consenting patients transfer to the Lotus Psychiatric Decision Unit for up to 48 hours of support, monitoring and extended assessment.

    Verbatim wording from the response

    “In fact, with the support of our Commissioners, local services for patients in mental health crisis have improved since the time of Mr Rogala’s contact with our services, and this may provide you with further reassurance. Since November 2016, clinicians working in the Trust’s Emergency and Urgent Mental Health Services (including Liaison Psychiatry and Home Treatment teams) have been able to offer higher risk consenting patients the option of transfer to the Lotus Psychiatric Decision Unit (PDU). The Lotus suite enables patients to be supported and monitored for up to 48 hours in a dedicated safe space at Springfield University Hospital and permits an extended assessment to be undertaken. The outcome of this could indicate a formal admission to an acute psychiatric ward, or some other form of support.”

    Source location

    2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-NHS-Trust
    Page 2 · response
    Published 12 February 2017

    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 disputes that addiction-related crisis patients are discriminated against or lack access to a safe place under existing service criteria.

    Verbatim wording from the response

    “From our consideration of the case and the criteria of existing services we therefore do not believe that patients with an addiction are discriminated against when a co-existing mental health crisis, such as suicidal ideation, is identified. Where significant risk is indicated, the use of the Mental Health Act may also be considered to ensure a patient is conveyed to a place of safety for an assessment even when they are not agreeable. However, the use of the Mental Health Act was not an option in the case of Mr Rogala as his risk was not determined to be high at the time of assessment; he had a primary dependence on alcohol which is an exclusion under the Mental Health Act; and he had capacity to make decisions himself.”

    Source location

    2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-NHS-Trust
    Page 2 · response
    Published 12 February 2017

    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 local crisis services provide appropriate assessment, support and potential inpatient admission for patients with addiction and suicidal thoughts.

    Verbatim wording from the response

    “The possibility of a gap in service provision has been considered in the event of the circumstances of the case being different, for example: if Mr Rogala had been assessed as suicidal in the context of alcohol dependence or be requesting admission to hospital. If this had been the case, psychiatric liaison services would have explored a range of options with the aim of the risk of him acting on his thoughts being alleviated. This may have led to a referral to the home treatment service which is able to provide intensive support for people who are suicidal, regardless of the presence of alcohol or any other form of addiction.”

    Source location

    2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-NHS-Trust
    Page 2 · response
    Published 12 February 2017

    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 are responsible for commissioning the full range of local mental health and substance misuse services.

    Verbatim wording from the response

    “Our deepest sympathies are extended to the family and friends of Mr Rogala. The conclusion that we have reached indicates there is no current gap in services that would have prevented him accessing a safe place, and the criteria for accessing crisis support from mental health services do not discriminate against those patients who are in crisis due to the presence of an addiction, other than the statutory exclusions written into the Mental Health Act. In discussion with CCG commissioners who are the responsible body for commissioning a full range of services, including mental health and substance misuse services, the Trust also believes the framework of services within Wandsworth and Merton to be in line with arrangements in other parts of London, and consistent with the overall national picture.”

    Source location

    2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-NHS-Trust
    Page 3 · response
    Published 12 February 2017

    Open published response

  7. Manchester North

    AI-generated summary

    Anthony Maurice Huggan · 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

    Anthony Maurice Huggan, who had a longstanding drug problem, was admitted to hospital after an accidental opiate overdose but self-discharged against medical advice on 3 June 2014. He was found deceased at home the following day after taking excessive amounts of prescribed and illicit substances; post-mortem examination and toxicology identified combined drugs toxicity involving Pregabalin, Morphine and Methadone. Concerns included the lack of an out-of-hours community drugs service and the timeliness of follow-up or welfare checks after a life-threatening overdose and self-discharge.

    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 suitable out-of-hours service for people with drug addiction problems

    Wider context from the report

    “1. The lack of a suitable out of hours service, resulting in an undue burden being placed upon the emergency services and the NHS (none of whom are best placed to deal with and support those with drug addiction problems). ”

    Source location

    Anthony Maurice Huggan · 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.

Back to top

Data last updated 7 September 2026