The deceased had medical history that included mixed anxiety and depression with associated alcohol dependence syndrome. Her condition had been actively managed my local addiction, primary and secondary mental health services and her general practitioner. Her relapse profile included recourse to chronic alcohol misuse as coping strategy to episodic emotiona dysregulation resulting from socia stressors her physical health concerns and personal circumstances Such relapses had previously involved inadvertent harm by way of overdose of her prescribed medications_ with transient self-harming ideation. She had twice previously undergone inpatient detoxification and rehabilitation had also required active phases of support from her local Home-Based Treatment Team_ On the 26th of July 2025, following heightened anxiety and depression because of recent social stressors the deceased had relapsed into alcohol misuse_ In the morning of the 28th of July 2025 the deceased was admitted to Royal Albert Edward Infirmary, Wigan following an inadvertent overdose of her Zolpidem medication She did not wish to engage in a full mental health assessment but agreed to referral to the community mental health team and then self-discharged_ Later in the she was to re-present at the hospital, with symptoms of further deterioration in her mental health self-induced alcoholic aged drug her self-and day, and intoxication following concerns for her welfare during a prolonged attendance at her residence bY paramedics_ She was referred to the Mental Health Liaison Team by reason of her suicidal ideation and following 30-minute assessment by a mental health practitioner , was assessed to have full capacity. During her assessment; the deceased disclosed that she had recently been involved in incident with family member in circumstances that created safeguarding referral. However, the full nature of her mental health deterioration and emotional dysregulation, her irrational recent behaviour was not appreciated to be a significant mental health deterioration, it being evaluated t0 be more attributable to her recourse to alcohol misuse and so she was discharged from hospital with conservative community-based care plan. It was considered that she did not meet the threshold for deployment of escalated home-based treatment. Whether this clinical decision had bearing upon the outcome cannot be established. As part of the response to the safeguarding alert; on the 31st of July 2025 the deceased was arrested and questioned by Greater Manchester Police. She was assessed as being fit for interview and was released after accepting caution. On the 3rd of August 2025, following concern for her welfare, relatives and emergency services attended her residence at Belvedere Road_ Ashton-in-Makerfield where the deceased was discovered in a collapsed and unresponsive condition in the lounge, being verified as dead and beyond attempted resuscitation by attending paramedics: The deceased's postmortem samples revealed the presence ofl pat concentrations of medium toxicological significance, and alcohol and at levels of low toxicological significance. CCTV footage at her residence confirmed that she had been at her home from the Ist of August 2025 her phone last being used on the Znd of August 2025 The evidence could not establish with precision the amount, order, time or circumstances of her self-administration of the substances found within her samples and whilst not of themselves individually fatally toxic, in combination together, were sufficient t0 have brought about respiratory depression thereafter loss of consciousness in which she suffered hypoxic driven multi-organ failure, death occurring on the 2nd of August 2025 From within her residence police discovered an undated handwritten note of intent, but the evidence revealed several contra-indicators to active suicidality in addition to anecdotal evidence of her recent descent into dysfunctional, irrational and unpredictable behaviour bordering on paranoia therefore the issue of whether her actions were deliberate and intentional were established to be equivocal: CORONER"S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern: In my opinion there is risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The deceased had a well established diagnosis of mixed anxiety and depressive disorder and profound alcohol dependency syndrome in evidence, it was established that there was no recent documented mental health diagnosis and that it was possible that the deceased ought to have been considered suffering from 'co-occurring disorder' (formerly dual diagnosis and so eligible for a more active treatment and care escalation pathway, including a care co-ordinator. An experienced recovery worker gave evidence to the effect that addiction services Wigan receive significant number of referrals of senvice users who are suffering from and ongoing mental health issues that may require care programme approach because are suffering from possible co-occurring disorders and that the mental health element of treatment and care is insufficient to meet the needs of the patient the perception being that a referral to addictions services is being used as an interim means to deal with cohort of service users with nuanced or even as in this case complex needs. Neither the treating mental health clinician who last assessed the deceased before her death nor the author of Rapid Review of Care Report identified the missed opportunities to appreciate the full extent of the deceased'$ mental Ith deteriora nor the potential differential cO-occurring' diagnosis nor meaningful consideration of a referral t0 the Home Based Treatment Team The evidence established that at least two family members had brought to the attention of member of the Menta Health Team their profound concerns their recent lived experiences with the deceased that underpinned these concerns their views that the deceased was paranoid, at greater risk to herself but none of these concerns were brought to the specific attention of the assessing clinician the communication between the Mental Health Team and family members being sub-optimal: evidence established potential lack of professional curiosity and confirmation bias as to the aetiology of the deceased's relapse profile her recourse to alcohol misuse not being evaluated to be consequence of mental health deterioration. Both her last treating mental health practitioner and the author of the Rapid Review stated that there are funding issues that affect their ability to deploy escalated interim home based/community care for patients who do not qualify for voluntary/involuntary in patient assessment; or Home Based Treatment Team referral there was stated to be no mental health equivalence of 'hospital at home afforded to patients with physical health condition. The evidence established confirmation of significant incidence of patients suffering from self-harm or attempted self-harm in the immediate or short term following purported assessment and discharge after interface with the Mental Health Team based at the Royal Albert Edward Infirmary including self-discharges because of the challenging environment with the Accident & Emergency Department: The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up_