Emily Rose Collishaw · Prevention of Future Deaths report

On 21 September 2023 an investigation was commenced into the death of Emily Rose Collishaw, aged 35. The investigation concluded at the end of the inquest on 18 June 2024. The medical cause of death was recorded at inquest as Sudden Unexplained Death in Alcohol Misuse. The narrative conclusion read:

Alcohol Related Death: Neither intoxication nor ketoacidosis were the direct cause of death. she was recovering from a recent high alcohol intake and probably died from an associated arrhythmia.

As recorded on the Record of Inquest:

Emily was found dead with rigor mortis in her flat on Wednesday 6th September 2023 in non suspicious circumstances. She was suffering from alcohol dependency, drinking several bottles of wine daily. She had begun treatment for substance misuse with Pier Road Project in December 2022, having regular contact with a key worker. In June 2023 Bexley Home Treatment Team managed her mental health care, following admission to hospital with injuries from a fall, whilst intoxicated. Her family felt that she was not competent to self discharge, a view not supported by a psychiatrist. Clinical staff visited and she was often intoxicated until discharge from their care on 4th July to Pier Road Project. She was referred for inpatient rehabilitation suitability assessment, but a placement was not available until November 2023.

1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.

2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients.