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recurance

Shane Hardy

16 Jan 2017 · Coroner Katy Skerrett · Gloucestershire

A similar concern from this report was raised again 2 times later. See the linked reports.

The coroner's concerns

  1. 1. lack of assistance for individuals with addictions and mental health difficulties

    “Individuals who suffer with addictions and mental health difficulties can fall between the services. Mental health services consider it not to be a mental health issue, and refer to alcohol treatment services. If the individual then refuses to engage with the latter, the jt individual is left receiving no assistance”
  2. 2. lack of information sharing between agencies

    “When multiple agencies are involved in providing support services to an individual, there can be a lack of information sharing between those agencies. No agency is identified as the lead agency for communication purposes.”

Linked reports

Raised again laterSean Fegan25 Mar 2021 · 4 years 2 months later
Closely relatedConfidence 0.80 · moderate

This report

“Individuals who suffer with addictions and mental health difficulties can fall between the services. Mental health services consider it not to be a mental health issue, and refer to alcohol treatment services.”

Later report

“Dual diagnosis - it was acknowledged that there was a 'gap' within the services in relation to dual diagnosis patients. There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems.”
Original on judiciary.uk ↗
Full chain: Lack of assistance for individuals with addictions and mental health difficulty
Raised again laterNicholas Spooner28 Jun 2021 · 4 years 5 months later
Identical hazardConfidence 0.90 · high

This report

“Individuals who suffer with addictions and mental health difficulties can fall between the services.”

Later report

“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”
Original on judiciary.uk ↗
Full chain: Lack of assistance for individuals with addictions and mental health difficulty

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error