Concerns raised 5 Unclear documentation of shared care discussions View source Unclear guidance available to ADS workers View source Unclear facilitation of shared care discussions View source Failure to escalate individuals’ unmet needs View source Lack of clinical support for ADS workers View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Stuart Michael Campbell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stuart Michael Campbell was found suspended by a ligature on 5 March 2017 after reporting escalating drug and alcohol use and emotional distress. The inquest identified concerns about the absence of escalation from the drug and alcohol service to Pennine Care, unclear guidance and lack of clinical support for workers, and uncertainty about how shared care with the GP could be facilitated and documented.
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. The report was sent to ADS (Addiction Dependency Solutions); that does not assign responsibility.
PFD Monitor interpretation Unclear documentation of shared care discussions
Wider context from the report “2. Care was shared care between ADS and the GP. The GP had not seen the deceased and it was unclear how shared care discussions could be facilitated and documented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADS (Addiction Dependency Solutions); that does not assign responsibility.
PFD Monitor interpretation Unclear guidance available to ADS workers
Wider context from the report “1. The inquest was told that ADS were the lead contractor for the provision of services. The protocol between ADS and Pennine Care had an escalation policy to be followed where an ADS worker felt the needs of an individual felt the needs could not be met via ADS. An escalation had not taken place in this case. It was unclear what guidance was available to ADS workers. There was no provision for clinical support for ADS workers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADS (Addiction Dependency Solutions); that does not assign responsibility.
PFD Monitor interpretation Unclear facilitation of shared care discussions
Wider context from the report “2. Care was shared care between ADS and the GP. The GP had not seen the deceased and it was unclear how shared care discussions could be facilitated and documented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADS (Addiction Dependency Solutions); that does not assign responsibility.
PFD Monitor interpretation Failure to escalate individuals’ unmet needs
Wider context from the report “1. The inquest was told that ADS were the lead contractor for the provision of services. The protocol between ADS and Pennine Care had an escalation policy to be followed where an ADS worker felt the needs of an individual felt the needs could not be met via ADS. An escalation had not taken place in this case. It was unclear what guidance was available to ADS workers. There was no provision for clinical support for ADS workers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADS (Addiction Dependency Solutions); that does not assign responsibility.
PFD Monitor interpretation Lack of clinical support for ADS workers
Wider context from the report “1. The inquest was told that ADS were the lead contractor for the provision of services. The protocol between ADS and Pennine Care had an escalation policy to be followed where an ADS worker felt the needs of an individual felt the needs could not be met via ADS. An escalation had not taken place in this case. It was unclear what guidance was available to ADS workers. There was no provision for clinical support for ADS workers.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations