Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Nicholas Spooner · 28 Jun 2021 · Veronica Hamilton-Deeley, Brighton and Hove
“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.”
judiciary.uk/…/nicholas-spooner-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Nicholas Spooner (28 Jun 2021) · stated 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.”
judiciary.uk/…/2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Pu…
Stated action 2 · response to Nicholas Spooner (28 Jun 2021) · stated timescale: none stated
“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.”
judiciary.uk/…/2021-0360-Response-from-Dept.-of-Health-and-Soci…
Stated action 3 · response to Nicholas Spooner (28 Jun 2021) · stated 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”
1 further stated action is listed on the full chain page.
What recurred
- 26 Aug 2022 · Christopher Lloyd · Chris Morris · Identical hazard · confidence 0.90 (high)
- 4 Apr 2025 · Alexi Susiluoto · R Brittain · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · Christopher Lloyd · 26 Aug 2022
“it is a matter of concern that he did not have ready access to a dual-diagnosis service locally.”
What happened next
No web check of the stated actions has been published for this chain.