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recurance

Alexi Susiluoto

4 Apr 2025 · Coroner R Brittain · Inner North London

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. fragmented treatment of dual diagnoses

    “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”
  2. 2. homelessness exacerbates care fragmentation

    “the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless”

Linked reports

Repeats an earlier warningChristopher Lloyd26 Aug 2022 · 2 years 7 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“it is a matter of concern that he did not have ready access to a dual-diagnosis service locally”
Original on judiciary.uk ↗

This report

“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”
Full chain: Lack of local dual-diagnosis services

Responses

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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