Lack of local dual-diagnosis services
Department of Health and Social Care received 3 coroners' reports about this hazard between 28 Jun 2021 and 4 Apr 2025.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“the CCG is in the process of commissioning a new crisis house that will provide support to people in a mental health crisis who require 24/7 support and would otherwise be admitted to hospital. The tender for this service will be issued in October 2021 and the new service will start in the summer of 2022.”
Stated timescale: summer of 2022
“We are clear that commissioners and providers of services have a joint responsibility to work collaboratively to meet the needs of people with co-occurring conditions.”
1 more stated action in the Promises tab.
- 1 year 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“it is a matter of concern that he did not have ready access to a dual-diagnosis service locally.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“the development of a Co- Occurring Conditions team who will deliver system-wide training in recognition of the complexities and contexts of those with co-occurring conditions”
Stated timescale: 1 August 2022
- 2 years 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“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”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2022Christopher Lloyd1 year 2 months after Nicholas Spooner · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of readily available local dual‑diagnosis services for individuals whose mental health crises are linked to substance misuse. They stress that such a service is needed to provide integrated assessment and treatment.
Nicholas Spooner · 28 Jun 2021
“Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support.”
Original on judiciary.uk ↗ Christopher Lloyd · 26 Aug 2022
“it is a matter of concern that he did not have ready access to a dual-diagnosis service locally.”
Original on judiciary.uk ↗ 2022 → 2025Alexi Susiluoto2 years 7 months after Christopher Lloyd · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of coordinated dual‑diagnosis services for people with co‑occurring substance misuse and mental health needs.
Christopher Lloyd · 26 Aug 2022
“it is a matter of concern that he did not have ready access to a dual-diagnosis service locally”
Original on judiciary.uk ↗ Alexi Susiluoto · 4 Apr 2025
“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”
Original on judiciary.uk ↗
Stated action · timescale: summer of 2022
“the CCG is in the process of commissioning a new crisis house that will provide support to people in a mental health crisis who require 24/7 support and would otherwise be admitted to hospital. The tender for this service will be issued in October 2021 and the new service will start in the summer of 2022.”
Stated action
“We are clear that commissioners and providers of services have a joint responsibility to work collaboratively to meet the needs of people with co-occurring conditions.”
Stated action · timescale: 01 November 2022
“the procurement process has completed, the contract has been awarded to Mental Health Matters and the service will start on 01 November 2022”
Stated action · timescale: 1 August 2022
“the development of a Co- Occurring Conditions team who will deliver system-wide training in recognition of the complexities and contexts of those with co-occurring conditions”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2022 | 0.77 | 0.32 | Identical · 0.90 | different |
| 2022 → 2025 | 0.82 | 0.15 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.