WithYou

Private and voluntary organisations · Registered charity

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First report 29 Nov 2016•Latest report 26 Aug 2020

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports: 3
Published responses: 33%
Concerns addressed: 7
Stated actions: 7

Concerns and recipient responses

Statements from WithYou linked to the concerns in each report. Select any concern, action or position to view the source wording.

26 Aug2020
Lincolnshire
Concerns raised14
1. Lack of assertive outreach and organised welfare checks after community discharge
2. Failure to seek immediate family views on accommodation and treatment and care pathways
3. Failure to communicate immediate family concerns to relevant care agencies
1. Lack of adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis
2. Lack of an adequate Care Programme Approach
3. Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures
4. Unavailability of specialist Dual Diagnosis workers for complex cases
5. Unavailability of a dedicated or commissioned drug and alcohol recovery service
6. Lack of interface between senior or experienced providers for complex cases
7. Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
8. Failure to recognise and adequately manage complex Dual Diagnosis
9. Failure to appoint a care coordinator to monitor care under an appropriate care plan
10. Lack of coordination between mental health and addiction services
11. Absence of a Dual Diagnosis protocol defining provider roles
Actions described in response 6
1. Action
  Attend Dual Diagnosis interface meetings and contribute to community release plans with mental-health and wider partner services.
2. Action
  Provide reciprocal training and cross-sector learning opportunities for partner staff on substance-misuse interventions.
3. Action
  Use a prompt system at every NSP visit to assess presentation, health, housing, harm reduction, substance use and treatment referrals.
1. Action
  Review Dual Diagnosis pathways across the treatment system jointly with partner organisations and commissioners.
2. Action
  Review staff structures and introduce specialist Dual Diagnosis roles, including dedicated mental-health nursing and recovery-worker capacity.
3. Action
  Implement an enhanced NSP questionnaire to identify complex health issues and mental-health concerns, informing risk assessment and decisions.
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. The report was sent to WithYou; that does not assign responsibility.
PFD Monitor interpretation
Lack of assertive outreach and organised welfare checks after community discharge
Wider context from the report
“6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care; ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek immediate family views on accommodation and treatment and care pathways
Wider context from the report
“1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care; ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate immediate family concerns to relevant care agencies
Wider context from the report
“1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care; ”
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 WithYou; that does not assign responsibility.
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; ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Lack of an adequate Care Programme Approach
Wider context from the report
“4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan; ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures
Wider context from the report
“5. Inadequate evaluation of the deceased's previous history; his purported non-concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to a missed opportunities to appreciate a series of acceptable relapse signatures; ”
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 WithYou; that does not assign responsibility.
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; ”
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 WithYou; that does not assign responsibility.
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; ”
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 WithYou; that does not assign responsibility.
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; ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
Wider context from the report
“8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis; ”
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 WithYou; that does not assign responsibility.
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; ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Failure to appoint a care coordinator to monitor care under an appropriate care plan
Wider context from the report
“4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan; ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Lack of coordination between mental health and addiction services
Wider context from the report
“3. In any event, even on the basis upon which community care was deemed appropriate, there was an absence of any co-ordination between mental health service provision and addiction services; ”
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 WithYou; that does not assign responsibility.
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; ”
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
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
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
Use a prompt system at every NSP visit to assess presentation, health, housing, harm reduction, substance use and treatment referrals.

Verbatim wording from the response
“• Our staff now use a ‘prompt system’ at each visit. These include discussions around the persons initial presentation, mental and physical health, housing needs, harm reduction, more in depth substance use and clarifying and discussing referrals into structured treatment should it be required and consented to.”

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 Dual Diagnosis pathways across the treatment system jointly with partner organisations and commissioners.

Verbatim wording from the response
“I can confirm that we have participated in ‘Planned Dual Diagnosis Work” meetings with LPFT and our respective commissioners. And we have jointly agreed to review Dual Diagnosis pathways across the treatment system.”

Source location
2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
Page 1 · 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 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
Implement an enhanced NSP questionnaire to identify complex health issues and mental-health concerns, informing risk assessment and decisions.

Verbatim wording from the response
“• We have introduced better identification of those with complex health issues. We have implemented an enhanced standard questionnaire for our NSP service users. It incorporates questions to ascertain concerns individuals may have on their own mental health and current engagement with mental health (or any other relevant) services. The aim is to enable the key-worker to make better informed decisions of any immediate concerns / risks surrounding an individual’s mental health, based on presentation and information disclosed.”

Source location
2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
Page 2 · response
Published 26 October 2020
Open published response
12 Dec2018
Cornwall and Isles of Scilly
Concerns raised4
1. Failure of Addaction to communicate and provide feedback to GPs
2. Failure to consider consent for disclosure to GPs at Recovery Plan reviews
3. Lack of consideration of underlying mental health issues in patients with alcohol or drug problems
1. Failure of mental health services to accept responsibility for providing professional care
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Benjamin Colin Williamson · 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

Benjamin Colin Williamson had a long history of alcohol-related issues and was receiving treatment, with regular GP contact. He died on 4 April 2018, and the inquest recorded a conclusion of suicide, with asphyxia by hanging and alcohol intoxication. Concerns included fragmented mental health services for people with both mental health and alcohol problems, and inadequate liaison and feedback between Addaction and the GP.

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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Failure of Addaction to communicate and provide feedback to GPs
Wider context from the report
“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider consent for disclosure to GPs at Recovery Plan reviews
Wider context from the report
“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Lack of consideration of underlying mental health issues in patients with alcohol or drug problems
Wider context from the report
“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Failure of mental health services to accept responsibility for providing professional care
Wider context from the report
“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”
Open source report
29 Nov2016
Cornwall and Isles of Scilly
Concerns raised2
1. Reduced access to face-to-face alcohol reduction workers and Alcoholics Anonymous support on the Mainland
2. Lack of accessible face-to-face alcohol support on the Isles of Scilly
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Robert Lloyd · 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

Robert Lloyd drowned after becoming motionless and floating face down while swimming at Porthcressa Beach on 30 July 2016. Post-mortem toxicology found a blood alcohol level likely to have affected his cognition. Evidence at the inquest raised concerns about limited face-to-face alcohol-support services on the Isles of Scilly, particularly after the termination of the helicopter service, and the resulting difficulty engaging with service users.

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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Reduced access to face-to-face alcohol reduction workers and Alcoholics Anonymous support on the Mainland
Wider context from the report
“At the inquest evidence was read from the GP and Addaction as to Mr Lloyd’s abuse of alcohol and the difficulty in providing supportive treatment for alcohol abusers on the Isles of Scilly. It was acknowledged that due to the island's location and with limited air and boat services after the termination of the helicopter service some years ago, the support was limited. This has meant that the service users on the Islands have had limited face to face support and had to rely of video link support due to the inability of alcohol support professionals to travel to the Islands in bad weather. This had led to a difficulty in engaging with this group of users. Mr Lloyd’s mother, at inquest explained how the reduction in service (on the termination of the helicopter service) had affected her son and made it more difficult for him to control his drinking habit especially on a small island with a strong alcohol drinking culture. In the past he had access to face to face alcohol reduction workers and he was able to attend (for a small travel fee) the Alcoholics Anonymous group on the Main Land. ”
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 WithYou; that does not assign responsibility.
PFD Monitor interpretation
Lack of accessible face-to-face alcohol support on the Isles of Scilly
Wider context from the report
“At the inquest evidence was read from the GP and Addaction as to Mr Lloyd’s abuse of alcohol and the difficulty in providing supportive treatment for alcohol abusers on the Isles of Scilly. It was acknowledged that due to the island's location and with limited air and boat services after the termination of the helicopter service some years ago, the support was limited. This has meant that the service users on the Islands have had limited face to face support and had to rely of video link support due to the inability of alcohol support professionals to travel to the Islands in bad weather. This had led to a difficulty in engaging with this group of users. Mr Lloyd’s mother, at inquest explained how the reduction in service (on the termination of the helicopter service) had affected her son and made it more difficult for him to control his drinking habit especially on a small island with a strong alcohol drinking culture. In the past he had access to face to face alcohol reduction workers and he was able to attend (for a small travel fee) the Alcoholics Anonymous group on the Main Land. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised14

Lack of assertive outreach and organised welfare checks after community discharge

Failure to seek immediate family views on accommodation and treatment and care pathways

Failure to communicate immediate family concerns to relevant care agencies

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

Lack of an adequate Care Programme Approach

Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures

Unavailability of specialist Dual Diagnosis workers for complex cases

Unavailability of a dedicated or commissioned drug and alcohol recovery service

Lack of interface between senior or experienced providers for complex cases

Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis

Failure to recognise and adequately manage complex Dual Diagnosis

Failure to appoint a care coordinator to monitor care under an appropriate care plan

Lack of coordination between mental health and addiction services

Absence of a Dual Diagnosis protocol defining provider roles

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised4

Failure of Addaction to communicate and provide feedback to GPs

Failure to consider consent for disclosure to GPs at Recovery Plan reviews

Lack of consideration of underlying mental health issues in patients with alcohol or drug problems

Failure of mental health services to accept responsibility for providing professional care

Concerns raised2

Reduced access to face-to-face alcohol reduction workers and Alcoholics Anonymous support on the Mainland

Lack of accessible face-to-face alcohol support on the Isles of Scilly

Actions described in response 6