On 12 October 2015 commenced an investigation into the death of Philip Anthony Denning, aged 25_ The investigation concluded at the end of the inquest on 4 February 2016. The conclusion of the inquest was accident. The cause of death was diamorphine intoxication. His date of death was 23 July 2015.

This is a summary of the evidence we heard at the inquest: It is not intended as a full history: Philip had a history of substance misuse since his teenage years. This included using heroin in his later life_ He also had a history of depression and had been prescribed anti-depressants by his GP for a number of years heard evidence of multiple overdoses in the past: The evidence showed that; from at least May 2014, Philip's GP felt that he needed help not just with substance misuse, but also mental health issues. Philip himself wanted this help, as did his parents_ He was receiving help from CRI; between October 2014 and January 2015,and then again from March 2015 onwards heard evidence from the medical lead of New Directions (CRI); himself a consultant addiction psychiatrist: He set out clearly the role and aims of CRI. He told us that; whilst that service employs addiction psychiatrists, they would not be able to provide psychology input or talking therapies to patients city We

It is fair to say that the evidence highlighted an element of frustration for Philip's GPs, in the sense that they clearly believed that Philip needed psychology input; but it was far clear how best to access this for him: was told that this is a common frustration in current GP practice, when dealing with patients with both substance misuse and mental health problems_ After attending the ED at QMC on 2 December 2014 following an overdose_ he was seen by a consultant psychiatrist, employed by Nottinghamshire Healthcare NHS Foundation Trust: He offered Philip a further appointment (29 January 2015). Philip did not attend that appointment: Philip's family were adamant that he was not given that appointment date, and would have attended if he had been given it, as he was himself trying to access help. Philip was discharged by Nottinghamshire Healthcare on that date , following his non-attendance_ The evidence suggested that neither Philip nor his GP was made aware of this discharge. He had in fact taken further overdoses in the days before 29 January 2015. Nottinghamshire Healthcare has already undertaken to remind staff of correct policy when patients do not attend initial follow-up appointments regarding notification to patients and their GPs. Philip was referred to Dual Diagnosis, but after considerable delay, their advice was that he was not suitable for that service, and he should continue to be treated by the CRI: In April 2015, CRI asked Philip's GP to follow up a psychology referral for him: When the GP contacted CRI by telephone in June 2015 to try to clarify matters, to discuss Philip's need for psychology input; and to explain that Dual Diagnosis were not able to accept him as a patient, she was told by an employee of CRI that would arrange for an addiction psychiatrist to see Philip. Sadly, Philip died less than a month after that The evidence suggested that Philip had a period of abstinence, or at least lower intake, in the months before his death. After receiving a benefits payout;, he appears to have bought and used heroin, resulting in his death. did not record a conclusion of suicide. would be required, for such a conclusion, to be satisfied beyond reasonable doubt that Philip intended to take his own life. It is not certain that, if further psychology input had been offered, Philip's death would have been avoided_ The difficulty and lack of clarity in managing patients with both substance misuse and mental health issues was clearly seen during this inquest however, and am concerned that there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you: