DAVID SEAN READ · Prevention of Future Deaths report

On 4 July 2016 I commenced an investigation into the death of DAVID SEAN READ, AGE 29 years. The investigation concluded at the end of the inquest on 23 January 2017. The medical cause of death is 1a) Mixed Drug and Alcohol Toxicity which includes Heroin Toxicity and the conclusion of the inquest was Drug and Alcohol Related

Mr Read lived at Herring House Trust, 51 St Nicholas Road, Great Yarmouth, Norfolk.

On 1 July 2016 Mr Read collapsed after injecting heroin. He was taken to James Paget University Hospital by paramedics where he died on 3 July 2016.

(1) Mr Read was referred to the Crisis and Resolution Home Treatment Team by his GP on 24 February 2016 as an urgent referral and was duly seen that evening when it was decided there should be input from the Community Mental Health Team.
(2) On 25 February 2016 Mr Read was referred by a Social Worker at Herring House, where he was residing, to the Community Mental Health Team and he was given an appointment for 21 March 2016, under 4 weeks from the date of the initial referral.
(3) This appointment was cancelled by Mr Read (no reason is recorded for the cancellation but Mr Read did start alcohol detoxification on this date) and his name was added to the waiting list for a fresh appointment to be arranged.
(4) The appointment was treated as a new referral and a new appointment date was sent out on the 18 May 2016 with a new appointment date of 14 July 2016. This is in excess of 16 weeks after the re-referral. Sadly Mr Read died in the meantime.