“The court heard evidence that at the time of his death, Mr Cooper had unmet mental health…”

The coroner’s concerns

1) The court heard evidence that at the time of his death, Mr Cooper had unmet mental health needs principally as a consequence of no specific service or treatment pathway existing locally which would provide wholistic and co-ordinated care for co-occurring mental health and substance misuse conditions (also known as ‘dual diagnosis’). I am concerned as to the lack of availability of commissioned services to provide care for patients with co-occurring mental health and substance misuse conditions both in this and other areas. 2) Mr Cooper was able to order large quantities of alcohol via online delivery services and have them delivered to his door quickly, including on occasions when he was already obviously intoxicated. I am concerned that large quantities of alcohol are so quickly and readily available from a range of retailers via online delivery services with only basic ageverification checks being undertaken. 3) The court heard evidence that professionals from the drug and alcohol service treating Mr Cooper had no access to his mental health records despite both mental health and drug and alcohol services being provided under the auspices of the same NHS Foundation Trust. Whilst the court heard that Pennine Care NHS Foundation Trust is urgently seeking to grant viewer access to relevant patients’ mental health records to the drug and alcohol team, it is a matter of concern that no complete and unified digital NHS health records system currently exists within England and Wales. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. Mr Cooper’s family 2. Pennine Care NHS Foundation Trust 3. The Disclosure and Barring Service 4. North West Ambulance Service NHS Foundation Trust 5. Greater Manchester Integrated Care Board 6. Stockport Metropolitan Borough Council I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE HM Area Coroner Manchester South

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, 2026-0237

Added to Minute Book

8 Oct 2026

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