Lack of assistance for individuals with addictions and mental health difficulty
Change Grow Live received 3 coroners' reports about this hazard between 16 Jan 2017 and 28 Jun 2021.
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 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Individuals who suffer with addictions and mental health difficulties can fall between the services.”
Original on judiciary.uk ↗ No published response from Change Grow Live was found for this report.
- 4 years 2 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“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 ↗ Change Grow Live responded.Response (PDF) ↗
- 3 months laterIdentical hazardConfidence 0.90 · higha different coroner
“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 ↗ Repeated from the earlier report:mentalhealth
Change Grow Live responded, stating 1 specific action.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
- All reports to Change Grow Live
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.
2017 → 2021Sean Fegan4 years 2 months after Shane Hardy · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that people with co‑occurring substance misuse and mental health needs are not adequately served by existing services. The earlier report describes a referral loop that leaves the person without help, while the later report notes a gap and resistance to treat dual diagnosis patients.
Shane Hardy · 16 Jan 2017
“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.”
Original on judiciary.uk ↗ Sean Fegan · 25 Mar 2021
“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 ↗ 2017 → 2021Nicholas Spooner4 years 5 months after Shane Hardy · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a gap in services for people with co‑occurring mental health and substance use issues, where standard services fail to address the combined needs.
Shane Hardy · 16 Jan 2017
“Individuals who suffer with addictions and mental health difficulties can fall between the services.”
Original on judiciary.uk ↗ 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”
Original on judiciary.uk ↗
No published response from Change Grow Live was found for this report.
No specific action could be extracted with a verified quote.
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.”
- 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 Change Grow Live 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 |
|---|---|---|---|---|
| 2017 → 2021 | 0.65 | 0.13 | Closely related · 0.80 | different |
| 2017 → 2021 | 0.69 | 0.11 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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.