“is as follows: I am concerned about the evidence I heard in this inquest that when an…”
Dated 24 Feb 2025, from the coroner for Swansea Neath and Port Talbot. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 21 Apr 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated24 Feb 2025
- Deadline21 Apr 2025
- Published on judiciary.uk26 Feb 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Swansea Bay University Health BoardNamed in the report as “SWANSEA BAY UNIVERSITY HEALTH BOARD” | Response publishedPublished on judiciary.uk in February 2025. |
The coroner’s concerns
is as follows: I am concerned about the evidence I heard in this inquest that when an individual is suffering from alcohol or drug addiction alongside a mental health diagnosis, which in this case was EUPD and depression, that the focus of SUBHB is normally to advise that individual to address their addiction before they can access mental health services. I heard that addiction services do not fall within the remit of SUBHB and are provided by third-sector agencies. I heard that individuals who have a mental health diagnosis may self -medicate to manage symptoms of a mental health deterioration and that increased use of alcohol/drugs can increase the risk of self-harm to such individuals which may prove fatal. I am concerned that there is no guidance to staff within SBUHB on how to manage individuals with addiction and a mental health diagnosis and how SUBHB staff should liaise with and work alongside third-sector agencies in respect of an individual suffering from addiction. I am also concerned that there appears to be a reluctance within SBUHB to offer mental health support alongside suggesting that an individual access addiction services. I am concerned that this may mean that individuals in mental health crisis and suffering from addiction may not be getting the mental health assessment and support that they require alongside seeking to overcome their addiction and as such there is continuing risk to life.
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, 2025-0105
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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