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Stuart Campbell

30 Oct 2017 · Coroner Alison Mutch · Manchester (South)
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The coroner's concerns

  1. 1. lack of escalation guidance for ADS workers

    “inquest was told that ADS were the lead contractor for the provision of services. The protocol between ADS and Pennine Care had an escalation policy | to be followed where an ADS worker felt the needs of an individual felt the | needs could not be met via ADS. An escalation had not taken place in this case. it was unclear what guidance was available to ADS workers. There was no | provision for clinical support for ADS”

  2. 2. shared care coordination failure

    “Care was shared care between ADS and the GP. The GP had not seen the deceased and it was unclear how shared care discussions could be facilitated and documented.”

Responses

2017-0390-Response-by-Addiction-Dependency-Solutions.pdf ↗

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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.

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