Joseph William Cooper · Prevention of Future Deaths report

On 23 June 2025, I commenced an investigation into the death of Joseph William Cooper who died outside his home aged 28 years.

The medical cause of Mr Cooper’s death was determined at inquest to have been:

1)(a) Multiple traumatic injuries and profound acute alcohol and drug intoxication

II Depression and Alcohol Dependence Syndrome (Co-occurring conditions).
At the end of the inquest, I recorded the following Narrative Conclusion:

‘Mr Cooper died as a consequence of complications arising from injuries sustained in a fall from a height and profound intoxication in the context of unmet mental health needs’.

Mr Cooper died on 19 June 2025 outside his home having sustained multiple traumatic injuries in a fall which occurred after he had placed himself outside his third-floor window whilst profoundly intoxicated. Mr Cooper’s death was contributed to by the co-occurring conditions of depression and alcohol dependence syndrome.

1) The court heard evidence that at the time of his death, Mr Cooper had unmet mental health needs principally as a consequence of no specific service or treatment pathway existing locally which would provide wholistic and co-ordinated care for co-occurring mental health and substance misuse conditions (also known as ‘dual diagnosis’). I am concerned as to the lack of availability of commissioned services to provide care for patients with co-occurring mental health and substance misuse conditions both in this and other areas.

2) Mr Cooper was able to order large quantities of alcohol via online delivery services and have them delivered to his door quickly, including on occasions when he was already obviously intoxicated. I am concerned that large quantities of alcohol are so quickly and readily available from a range of retailers via online delivery services with only basic age-verification checks being undertaken.

3) The court heard evidence that professionals from the drug and alcohol service treating Mr Cooper had no access to his mental health records despite both mental health and drug and alcohol services being provided under the auspices of the same NHS Foundation Trust.

Whilst the court heard that Pennine Care NHS Foundation Trust is urgently seeking to grant viewer access to relevant patients’ mental health records to the drug and alcohol team, it is a matter of concern that no complete and unified digital NHS health records system currently exists within England and Wales.