Mr Alexi Susiluoto · Prevention of Future Deaths report

Mr Alexi Susiluoto died on 22/5/24. An investigation into his death was opened on 5/6/24. The inquest was part-heard on 27/9/24 and concluded on 31/1/25.

I reached the conclusion that Mr Susiluoto died from an alcohol-related death.

Mr Susiluoto was born in Finland on 16/9/92. He had lived in the UK for several years and had a significant medical history of mental health disorders, substance misuse and epilepsy (following a head injury). At the time of his death, Mr Susiluoto was homeless but being housed by Camden Council in various hotels across London, depending on availability.

He continued to suffer from alcohol misuse and had periods of binge drinking. He was under the care of Turning Point for this issue and had previously been reviewed by multiple mental health trusts, depending on his location at the particular time of referral/review.

Mr Susiluoto was found deceased in a hotel room on 22/5/24. The cause of his death was alcohol misuse disorder resulting in acute ethanol toxicity. Contributing factors were epilepsy and Olanzepine and Leviteracetam use (prescribed medication).

1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues:
a. That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient. I understand that this aspect is part of the current review;
b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless. Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment.