During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.

(1) That no-one appeared to have looked at mental health except to note that he was alcohol dependant: This was an escalating presentation from someone who had no previous contact with the services_ his

(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team_ home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't: (3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.