Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of assistance for individuals with addictions and mental health difficulty
The earlier warning
Shane Hardy · 16 Jan 2017 · Katy Skerrett, Gloucestershire
“Individuals who suffer with addictions and mental health difficulties can fall between the services.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 25 Mar 2021 · Sean Fegan · Gordon Clow · Closely related · confidence 0.80 (moderate)
- 28 Jun 2021 · Nicholas Spooner · Veronica Hamilton-Deeley · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Shane Hardy · 16 Jan 2017
“Individuals who suffer with addictions and mental health difficulties can fall between the services.”
Later · 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”
What happened next
No web check of the stated actions has been published for this chain.