On 27th October 2017 commenced an investigation into the death of Marcus HANCE: The investigation concluded at the end of the inquest on 315t 2018. The conclusion of the inquest was as follows Marcus HANCE died on 13th October 2017 at The Queens Head Inn, North Street, St Austell from the synergistic effect of a reckless overdose of illicit and therapeutic drugs, within the context of a history of drug abuse: My conclusion as to the death is that it was Related.

Marcus Hance was found dead at his home address from a reckless overdose of illicit and therapeutic drugs, including amphetamine and heroin. Marcus had a complex medical history which included a diagnosis of borderline personality disorder and a history of drug abuse. This was characterised as a dual diagnosis, namely a personality disorder and dependency: Guy May Drug drug

The evidence the Cornwall Partnership NHS Foundation Trust (CPT) concerned the role of the Mental Health Services: This included Community Mental Health Team (CMHT) assessments which revealed a history of mental health difficulties and a diagnosis of Borderline Personality Disorder. The CPT conclusion on a number of repeat referrals was that the dependency should be addressed before any mental health treatment could proceed. On the occasion that the deceased was referred to CMHT, Marcus was discharged following two instances ofnon-attendance at CMHT appointments. Addaction provided care and treatment from 2013 to 2017 in an attempt to deal with the dependency_ The only real engagement was from March 2017 but was problematic and progress was not sustained_ The work by Addaction did not involve any measures to address the mental health issues, but was focused upon addressing the drug abuse. Marcus continued to abuse drugs up until his death

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action, namely (1) To review the commissioning of services to support individuals who have drug and alcohol dependency and associated complex mental health issues. (2) To review whether and alcohol agencies should have the support of relevant mental health professionals to address issues of dual diagnosis, and for appropriate referring pathways and assessments within these agencies to ensure the appropriate support is provided to increase the prospects of rehabilitation. (3) A review generally of the current pathway and provision for persons from long drug drug drug drug drug drug being with dual diagnosis. (4) To review whether a joint approach can be facilitated by mental health services and by and alcohol dependency services in cases of dual diagnosis. (5) To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken, or alternatively to involve the police if there are concerns for the individual' $ welfare: