On 25/02/2016 00:00 Dr Peter Dean commenced an investigation into the death of Justin John BROWN aged 43. The investigation concluded at the end of the inquest held by me on 22 March 2019. The conclusion of the inquest was that Justin Brown died from ketoacidosis due to diabetes and chronic alcohol abuse, with underlying conditions of chronic pancreatitis and bronchopneumonia. The jury returned a narrative conclusion finding that the condition causing the death had been developed through poorly controlled insulin administration by Mr Brown. His past medical history suggested a previous episode of ketoacidosis resulting in a hospital admission between 27 December 2015 and 4 January 2016. Upon discharge he had been warned that a relapse could be fatal upon consuming excessive amounts of alcohol combined with poor insulin control.

On 18 February 2016 at 22:19 welfare call was made to the police by Mr Brown’s sister who resided in London. Justin Brown resided in Suffolk. The information was passed from the Metropolitan police to Suffolk police who attended the address at 00:37 but got no response from the communal intercom and therefore left without making contact. The police returned to the address on 19 February at 12:18 and found Mr Brown deceased. Life was recognised as extinct by the ambulance service at 12:40. Mr Brown’s history included periods of support in rehabilitation and the incident referred to on 27 December when he had been admitted to James Paget University Hospital (JPUH) in a life-threatening condition. Upon discharge he was referred to Turning Point, the Drug and Alcohol Service, which was at that time the only drug service available in the Suffolk area for referrals from JPUH. There was no direct means of communication with the service. In evidence, the court heard that the process for referrals was by a telephone message to an answerphone. There was no acknowledgement or confirmation of service user contact. When supported Justin Brown was able to remain compliant for extended periods. Upon discharge he was keen to remain well.