PFD report

Thomas Christall · Prevention of Future Deaths report

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Issued 2 Aug 2017•Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of local in-patient detoxification facility availability
    Part of recurring concern: Insufficient inpatient detoxification capacity
  2. Failure to provide collaborative, integrated dual diagnosis treatment and assessment
    Part of recurring concern: Unreliable dual-diagnosis care pathways
  3. Delays in access to in-patient detoxification
    Part of recurring concern: Insufficient inpatient detoxification capacity
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

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

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  2. Action

    Review City Roads referrals through a multidisciplinary meeting, complete a pre-admission checklist, prepare patients for admission, and develop aftercare plans before detoxification.

    Stated by Brighton and Hove City CouncilStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  3. Action

    Provide out-of-city inpatient detoxification through City Roads, supported by service-user consultation, pathway planning and visits to establish the replacement service.

    Stated by Brighton and Hove City CouncilStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The Trust cannot provide local substance misuse services without being commissioned by Brighton and Hove City Council.

    Stated by Sussex Partnership NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of local in-patient detoxification facility availability

Wider context from the report

“(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK? ”

Is this part of a recurring concern?

Yes — Insufficient inpatient detoxification capacity.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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’ ”

Is this part of a recurring concern?

Yes — Unreliable dual-diagnosis care pathways.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in access to in-patient detoxification

Wider context from the report

“(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK? ”

Is this part of a recurring concern?

Yes — Insufficient inpatient detoxification capacity.

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

Review City Roads referrals through a multidisciplinary meeting, complete a pre-admission checklist, prepare patients for admission, and develop aftercare plans before detoxification.

Verbatim wording from the response

“In general patients are admitted to City Roads within ten days of having their assessment by the Pavilions doctor. All referrals to City Roads are reviewed at a multidisciplinary team meeting where a pre-admission checklist is completed. This includes service preparation work to ensure that an individual understands what will be required of them once they are in residence at the unit. This preparation work aims to ensure that people are referred at a point in their recovery journey where they are most likely to be successful. The aftercare support plan for once a person has successfully completed detoxification is also developed before the individual goes to City Road. This helps to ensure that the ongoing support a person will need to continue their recovery is in place.”

Source location

2017-0321-Response-by-Brighton-Hove-City-Council
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

Provide out-of-city inpatient detoxification through City Roads, supported by service-user consultation, pathway planning and visits to establish the replacement service.

Verbatim wording from the response

“In December 2015 Sussex Partnership NHS Foundation Trust gave notice that they would be terminating their substance misuse in-patient detoxification service from the 31st March 2016. The in-patient detoxification services at Mill View Hospital were no longer financially or clinically viable, following the withdrawal of a number of London Boroughs from their contract with Sussex Partnership NHS Foundation Trust. There was no alternative equivalent service in Brighton and Hove. The public health department elected to work with Cranston, the lead provider in the Pavilions Community Substance Misuse Services partnership, and to refer patients to their inpatient detoxification unit in London. Cranston have been providing this service from the City Roads location in London for a significant period of time, and patients come from many areas of the country.”

Source location

2017-0321-Response-by-Brighton-Hove-City-Council
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

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

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 cannot provide local substance misuse services without being commissioned by Brighton and Hove City Council.

Verbatim wording from the response

“The commissioning of local substance misuse services is undertaken by Brighton and Hove City Council. The local substance misuse services in Brighton and Hove were being provided by Sussex Partnership NHS Foundation Trust. In 2014 the service was put out to a tendering process by Brighton and Hove City Council. Sussex Partnership put in a full proposal and bid to keep the local substance misuse services as we recognise the value for patients and their families for services to be local to their homes, and the high number of service users who have mental health needs and substance misuse needs. Unfortunately, Sussex Partnership NHS Foundation Trust were not chosen by the commissioners of the service, Brighton and Hove City Council, to continue to provide this service. Sadly, it is not within our gift to provide these services if we are not commissioned to provide them by the commissioners.”

Source location

2017-0321-Response-by-Susssex-Partnership-NHS-Trust
Page 1 · response
Published 3 December 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

Brighton and Hove City Council is responsible for commissioning local substance misuse services.

Verbatim wording from the response

“The commissioning of local substance misuse services is undertaken by Brighton and Hove City Council. The local substance misuse services in Brighton and Hove were being provided by Sussex Partnership NHS Foundation Trust. In 2014 the service was put out to a tendering process by Brighton and Hove City Council. Sussex Partnership put in a full proposal and bid to keep the local substance misuse services as we recognise the value for patients and their families for services to be local to their homes, and the high number of service users who have mental health needs and substance misuse needs. Unfortunately, Sussex Partnership NHS Foundation Trust were not chosen by the commissioners of the service, Brighton and Hove City Council, to continue to provide this service. Sadly, it is not within our gift to provide these services if we are not commissioned to provide them by the commissioners.”

Source location

2017-0321-Response-by-Susssex-Partnership-NHS-Trust
Page 1 · response
Published 3 December 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

Out-of-city inpatient detoxification is not necessarily inadequate; limited local availability and separation from home may support successful detoxification.

Verbatim wording from the response

“In December 2015 Sussex Partnership NHS Foundation Trust gave notice that they would be terminating their substance misuse in-patient detoxification service from the 31st March 2016. The in-patient detoxification services at Mill View Hospital were no longer financially or clinically viable, following the withdrawal of a number of London Boroughs from their contract with Sussex Partnership NHS Foundation Trust. There was no alternative equivalent service in Brighton and Hove. The public health department elected to work with Cranston, the lead provider in the Pavilions Community Substance Misuse Services partnership, and to refer patients to their inpatient detoxification unit in London. Cranston have been providing this service from the City Roads location in London for a significant period of time, and patients come from many areas of the country.”

Source location

2017-0321-Response-by-Brighton-Hove-City-Council
Page 1 · response
Published 3 December 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

Brighton & Hove City Council’s Public Health department is responsible for commissioning adult and substance misuse inpatient detoxification beds.

Verbatim wording from the response

“As a CCG we are very keen to reflect on the services we commission with a view to making improvements and avoiding future patient harm. Brighton & Hove City Council’s Public Health department is the responsible commissioner for the adult and substance misuse in-patient detoxification beds. ████████ Interim Director of Public Health has therefore provided a reply although he and his team were not named in the report.”

Source location

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

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Offer an alternative inpatient detoxification provider when City Roads is unsuitable for the client.

    Stated by Brighton and Hove City CouncilStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  2. 2

    Monitor dual-service contact levels and regularly review service-user feedback reports.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  3. 3

    Undertake drug-related-death audits to identify whether people continue to fall through service gaps.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 3 December 2017.
  4. 4

    Feed the concerns back to the next Dual Diagnosis Steering Group meeting and discuss them directly with the provider.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.
  5. 5

    Review current guidance for people with co-occurring mental-health and substance-use conditions and the latest service-user report at the next Steering Group meeting.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.
  6. 6

    Increase supported accommodation for people with high support needs, including dual-diagnosis and medium-support housing provision.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.

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 an alternative inpatient detoxification provider when City Roads is unsuitable for the client.

Verbatim wording from the response

“If following the assessment it is felt that City Road is not suitable for the client an alternative provider is offered. Since the closure of the inpatient beds in Brighton and Hove, East Sussex refer their clients to a unit in Tunbridge Wells and West Sussex use a range of providers including Cranston.”

Source location

2017-0321-Response-by-Brighton-Hove-City-Council
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

Monitor dual-service contact levels and regularly review service-user feedback reports.

Verbatim wording from the response

“There has been an increase in the number of people in contact with both secondary Mental Health and Substance Misuse services measured using the Public Health England fingertips tool. Service user feedback is regularly reviewed with the most recent Service User report being produced in May 2017. Drug Related Death audits are being undertaken – examination of cases to review if people still falling through gaps in services. The next meeting of the Dual Diagnosis Steering Group will review the latest Public Health England guidance for better care of people with co-occurring mental health and alcohol and drug use conditions and the local Service User report.”

Source location

2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
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

Undertake drug-related-death audits to identify whether people continue to fall through service gaps.

Verbatim wording from the response

“There has been an increase in the number of people in contact with both secondary Mental Health and Substance Misuse services measured using the Public Health England fingertips tool. Service user feedback is regularly reviewed with the most recent Service User report being produced in May 2017. Drug Related Death audits are being undertaken – examination of cases to review if people still falling through gaps in services. The next meeting of the Dual Diagnosis Steering Group will review the latest Public Health England guidance for better care of people with co-occurring mental health and alcohol and drug use conditions and the local Service User report.”

Source location

2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
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

Feed the concerns back to the next Dual Diagnosis Steering Group meeting and discuss them directly with the provider.

Verbatim wording from the response

“Despite the above I am aware the service needs ongoing review and development. Our mental health commissioning team are aware of this case and I will ensure that your [and the CCGs] concerns are fed back and discussed at the next Dual Diagnosis Steering Group meeting and will also ensure the CCG has direct discussions with the provider.”

Source location

2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
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

Review current guidance for people with co-occurring mental-health and substance-use conditions and the latest service-user report at the next Steering Group meeting.

Verbatim wording from the response

“There has been an increase in the number of people in contact with both secondary Mental Health and Substance Misuse services measured using the Public Health England fingertips tool. Service user feedback is regularly reviewed with the most recent Service User report being produced in May 2017. Drug Related Death audits are being undertaken – examination of cases to review if people still falling through gaps in services. The next meeting of the Dual Diagnosis Steering Group will review the latest Public Health England guidance for better care of people with co-occurring mental health and alcohol and drug use conditions and the local Service User report.”

Source location

2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
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

Increase supported accommodation for people with high support needs, including dual-diagnosis and medium-support housing provision.

Verbatim wording from the response

“Provision of accommodation with support has been increased for those with high support needs, including those with DD and the inclusion of DD in medium support housing. The Fulfilling Lives project run by Brighton Housing Trust is focussed on patients with multiple and complex needs.”

Source location

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

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026