“The deceased had a long‑standing diagnosis of mixed anxiety and depression and alcohol…”

The coroner’s concerns

The deceased had a long‑standing diagnosis of mixed anxiety and depression and alcohol dependency. Evidence suggested she may have been suffering from a co‑occurring disorder (formerly “dual diagnosis”), warranting more active treatment, escalation, and a care coordinator. A recovery worker stated that Wigan addiction services receive numerous referrals involving service users with mental health needs requiring a care programme approach. Mental health provision was insufficient for such patients, and addiction services were perceived as an interim holding place for individuals with complex or nuanced needs. Neither the last assessing mental health clinician nor the author of the Rapid Review of Care identified: missed opportunities to appreciate her mental health deterioration the potential for a co‑occurring diagnosis the need for Home-Based Treatment Team referral. At least two family members had raised profound concerns about the deceased’s deteriorating mental state and paranoid behaviour to a Mental Health Team member. These concerns were not passed on to the assessing clinician. Communication was sub-optimal. Evidence suggested a lack of professional curiosity and confirmation bias regarding the cause of relapse—her alcohol misuse was not considered to be a symptom of mental health deterioration. Mental health staff stated that funding issues limit their ability to deploy escalated community care for patients who do not qualify for inpatient assessment or Home-Based Treatment Team referral. There is no mental health equivalent of “hospital at home” . Evidence confirmed a significant incidence of self‑harm or attempted self‑harm shortly after assessment and discharge from the Mental Health Team at Royal Albert Edward Infirmary, including self-discharges due to the challenging A&E environment. The evidence raises implications for: patient safety diagnostic accuracy risk assessment risk management safe discharge appropriate follow‑up.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0064

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0