Regulation 28 – After Inquest Template Updated 15/07/2025 TG The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.