Emily Collishaw

Parliamentary Under Secretary of State for Public Health   
and Prevention at Department for Health and Social Care  

39 Victoria Street  

London    
SW1H 0EU  

Our ref: 
HM Coroner Andrew Harris   
South London Coroner’s Service,  
2nd Floor, Davis House,  
Robert Street, Croydon CR0 1QQ  

By email: 

2 October 2024  

Dear Mr Harris,  

Thank you for the Regulation 28 report of 27th June 2024 sent to the Minister for Public Health, 
Department of Health and Social Care about the death of Emily Collishaw. I am replying as 
the Minister with responsibility for Public Health and Prevention.  

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of  Emily 
Collishaw’s  death  and  I  offer  my  sincere  condolences  to  her  family  and  loved  ones.  The 
circumstances  your  report  describes  are  concerning  and  I  am  grateful  to  you  for  bringing 
these matters to my attention.   

The report raises the following concerns:  

1.  Emily’s mother reported that it took some time for the organizations working with her 
daughter to agree their roles and that the degree of support was insufficient to maintain 
her physical health or promote abstinence over such a long period of six months before 
she died. The family felt that the referral for residential care should have been made 
earlier, especially as her housing situation was a risk to her health. It was accepted 
that Emily did not engage consistently but did reduce intake on a number of occasions, 
only to relapse.  

2.  The  inquest  heard  from  professionals  that  the  period  of  waiting  for  a  residential 
rehabilitation  placement  was  about  three  months  but  could  be  as  long  as  seven 
months. Evidence was heard from the manager of the Pier Project that the delay in 
accessing  residential  care  had  been  progressively  getting  longer  over  the  last  10 
years, which posed risks such as sudden death to patients.   

In  preparing  this  response,  my  officials  have  made  enquiries  with  the  Care  Quality 
Commission to ensure we adequately address your concerns.  

  
  
 
 
 
 
  
  
  
  
  
  
  
  
  
 My  department  recognises  the  need  to  improve  specialist  drug  and  alcohol  treatment 
services. Additional funding has been available since 2022/23 for local authorities to improve 
the quality and capacity of drug and alcohol treatment, including inpatient detoxification and 
residential  rehabilitation  services,  and  an  additional  £266.7  million  was  made  available  to 
them this year.   

I  am  aware  of  variability  across  the  country  in  access  to  inpatient  detoxification  and/or 
residential  rehabilitation.  To  address  this  (as  part  of  the  increased  funding  provided  since 
2022/2023), combinations of ring-fenced funding, targets, additional guidance and targeted 
support  have  been  used  to  improve  capacity  and  quality  of  inpatient  detoxification  and 
residential rehabilitation. We also plan to publish further guidance for local areas on improving 
access to residential rehabilitation later this year.  

In London in 2021, following the steady closure of the city’s inpatient detoxification units due 
to  increasing  costs  and  an  unsustainable  spot  purchase  funding  model,  the  PanLondon 
Inpatient Detoxification Programme was established to address the issue and an 11-bed unit 
in St Thomas’ hospital was opened. The unit provides a high level of care for a small cohort 
of people with complex needs. Work is currently underway, led by the London Regional Team 
of the Office for Health Improvement and Disparities (OHID) to further develop sustainable 
inpatient detoxification provision in London.  

At a local level we would expect alcohol and drug treatment services to do what they can to 
minimise  delays  in  accessing  inpatient  detoxification  and  residential  rehabilitation,  provide 
individual support to anyone waiting for it, and to regularly review their needs. The UK Clinical 
guidelines on alcohol treatment (to be published later this year) will include recommendations 
to promote this good practice.  

Guidance has been issued on the importance of integrated and co-ordinated care for people 
with co-occurring mental health and alcohol or drug conditions including NICE Guidance 58 
and Better Care for people with co-occurring mental health and alcohol/ drug use conditions. 
OHID’s Commissioning Quality Standard  provides guidance for service commissioners on 
improving services for people with co-occurring mental health and alcohol or drug conditions. 
Local services should work together so that people can access the help they need for both 
their mental health and their alcohol or drug use.  

We do, though, recognise that improvement is still needed across England, and OHID and 
NHSE will continue to work closely together to improve integrated and co-ordinated care for 
people with comorbidities, including co-occurring mental health conditions and alcohol and 
drug use conditions.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,

Me

Subject: FW: Death of Emily Rose Collishaw - Coroner's Reg. 28 report ref

OFFICIAL

Sent: Monday, August 12, 2024 8:51 AM
To
Subject: RE: Death of Emily Rose Collishaw - Coroner's Reg. 28 report (Ref: |

Dear Diane,

Many thanks for sharing a copy of this coroner’s report into the death of Ms Emily Rose Collishaw. After reviewing
the report, MHCLG officials do not consider that there is a specific policy angle here for us to respond to, solam
writing to confirm that there will not be a response from this Department. | have informed the Department for
Health and Social Care who will be the lead Department responding to this report.

Thank you again, and please let me know if you have any questions.

Best wishes,

|
a

Ministry of Housing, Correspondence Unit
Ministry of Housing, Communities & Local Government

Communities & gov.uk/mhclg | @mhelg
Local Government

Mr Andrew Harris 
Assistant Coroner  
South London Coroner’s Service 
2nd Floor 
Davis House 
Robert Street 
Croydon 
CR0 1QQ 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

26/09/2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Emily Rose Collishaw 
who died on Wednesday 6 September 2023.   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  27 
June 2024 concerning the death of Emily Rose Collishaw on 6 September 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Emily’s  family  and  loved  ones. NHS  England  are 
keen to assure the family and the Coroner that the concerns raised about Emily’s care 
have been listened to and reflected upon.   

Your Report raised the concern that the organisations working with Emily took time to 
agree their different roles, that the level of support provided was insufficient and that 
the referral for residential care should have been made earlier.  You also raised that 
the delay in accessing residential care has progressively been getting longer over the 
past 10 years, which poses risks such as sudden death to patients. 

NHS England has been engaging with South East London Integrated Care Board (SEL 
ICB), who we note you have also sent your Report to.  We are advised by SEL ICB 
that Mental Health colleagues have reviewed Emily’s care and consider that there is 
evidence  of  coordination  between  the  Home  Treatment  Team  and  the  Pier  Road 
Project  (PRP)  interface,  to  include  joint  visits  and  information  sharing,  as  well  as 
consultation with the family. I would refer you to SEL ICB’s full response to your Report 
for further information.  

The PRP is commissioned locally by the Local Authority, London Borough of Bexley, 
as is usual for drug and alcohol rehabilitation services for which responsibility sits with 
local government, overseen by the Department of Health and Social Care (DHSC). I 
note  that  you  have  also  addressed  your  Report  to  the  DHSC,  as  well  as  the 
Department  of  Levelling  Up,  Housing  and  Communities,  and  it  would  be  more 
appropriate  for  the  government  to  comment  on  your  concerns  about  wait  times  for 
residential rehabilitation placements.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
  
 
 Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Emily, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.     

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director