Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0185, written 4 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Apr 2025 |
|---|---|
| Reference | 2025-0185 |
| Deceased | Alexi Susiluoto |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Parliamentary Under-Secretary of State for Public Health and Prevention via - Parliamentary Under-Secretary of State (Minister for Homelessness and Democracy) via Ministry of Housing, Communities and Local Government. 2 Marsham Street. London. SW1P 4DF. 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 4 INVESTIGATIONS and INQUESTS Mr Alexi Susiluoto died on 22/5/24. An investigation into his death was opened on 5/6/24. The inquest was part-head on 27/9/24 and concluded on 31/1/25. I reached the conclusion that Mr Susiluoto died from an alcohol-related death. CIRCUMSTANCES OF THE DEATH Mr Susiluoto was born in Finland on 16/9/92. He had lived in the UK for several years and had a significant medical history of mental health disorders, substance misuse and epilepsy (following a head injury). At the time of his death, Mr Susiluoto was homeless but being housed by Camden Council in various hotels across London, depending on availability. He continued to suffer from alcohol misuse and had periods of binge drinking. He was under the care of Turning Point for this issue and had previously been reviewed by multiple mental health trusts, depending on his location at the particular time of referral/review. Mr Susiluoto was found deceased in a hotel room on 22/5/24. The cause of his death was alcohol misuse disorder resulting in acute ethanol toxicity. Contributing factors were epilepsy and Olanzepine and Levetiracetam use (prescribed medication). 5 CORONER’S CONCERNS During the course of this 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN following the inquest into Mr Susiluoto’s death were as follows: 1 1. I heard evidence that the Office for Health Improvement and Disparities is currently undertaking a review of how patients with dual diagnoses (substance misuse and mental health disorders) are treated. I was concerned by two related issues: a. That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the same patient. I understand that this aspect is part of the current review; b. However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also homeless. Evidence presented at the inquest set out that this already complex situation is often compounded by homelessness, since individuals are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr Susiluoto’s case, this resulted in significant confusion as to who was providing his care and which local authority would fund potential substance misuse treatment. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 May 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, Mr Susiluoto’s family, East London NHS Foundation Trust, Turning Point and Central and North West London NHS Foundation Trust. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 4 April 2025 Assistant Coroner R Brittain 2
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Parliamentary Under-Secretary of State for Public Health and Prevention From 39 Victoria Street London SW1H 0EU Our ref: HM Assistant Coroner R Brittain 127 Poplar High Street, London, E14 0AE By email: Dear Mr Brittain, 30 May 2025 Thank you for the Regulation 28 report of 4th April 2025 sent to the Department of Health and Social Care about the death of Alexi Susiluoto. 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 Alexi Susiluoto’s death, and I offer my sincere condolences to their 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 concerns over the current provision of treatment and support for those with co-occurring mental health and substance use conditions, especially when these conditions are compounded by experiences of homelessness. In preparing this response, my officials have made enquiries with NHS England (NHSE) and the Care Quality Commission (CQC) to ensure we adequately address your concerns. Your report mentions a review my department is taking into treatment for people with substance use and mental health conditions, and you raise concerns that the review is not considering the additional complexities and issues that occur when someone is also experiencing, or at risk of, homelessness. My department recognises the vital importance of high-quality integrated care for those with co-occurring conditions and who sleep rough, or who are at risk of sleeping rough. To clarify, we have not undertaken a formal review but, following recommendation from Dame Carol Black’s independent review of drugs, have been developing a comprehensive action plan to set out a path to improving service provision for those with co-occurring substance use and mental health needs. NHSE and the Department of Health and Social Care (DHSC) have worked with subject matter experts, including people with lived experience, academics, clinicians, and service providers in creating this plan. The plan is aimed to be as inclusive as possible and is built on the principles of ‘Everyone’s job’ and ‘No wrong door’. The first principle, ‘Everyone’s job’, states that Commissioners and providers of mental health and alcohol and drug treatment services have a joint responsibility to meet the needs of people with co-occurring conditions by working together to treat those with mental health conditions as well as substance use conditions. This is regardless of their current situation, including whether they are rough sleeping or at risk of rough sleeping. The second principle, ‘No wrong door’, states that providers in alcohol and drug treatment, mental health and other services have an open- door policy for individuals with co-occurring conditions and make every contact count. Treatment for co-occurring conditions is available through every contact point and services should be working together seamlessly to meet needs. We are committed to promoting more cohesion between mental health services and substance use services, to ensure people no longer fall through the gaps of treatment. But we know that many people with co-occurring conditions, who may also experience homelessness, will still experience barriers in having their health needs met. As such, our action plan is just one part of a broader programme of work aiming to improve services: - In 2025/26 there will be a total targeted investment of £310m in drug and alcohol treatment and recovery systems across England, maintaining the level of funding available in 2024/25. DHSC is continuing to invest in improvements to local treatment services that have faced significant cutbacks in the past, to ensure those in need can access high quality help and support. This funding is administered through the Drug and Alcohol Treatment and Recovery Improvement Grant (DATRIG). - DHSC also works closely with the Ministry of Housing, Communities and Local Government (MHCLG) to deliver specific funding (£58.7m in 2025-26), in 83 local authorities, for drug and alcohol treatment services that support people who sleep rough or who are at risk of sleeping rough. This funding package includes harm minimisation support, rapid prescribing for opioid substitution treatment, and assertive outreach and inreach substance use support services to reach people whether they are living on the streets or within temporary accommodation. - DHSC directs local authorities to consider NICE guidance on Integrated health and social care for people experiencing homelessness when designing, commissioning and delivering drug and alcohol treatment services for people experiencing homelessness. - DHSC will soon publish the UK clinical guidelines on alcohol treatment to support and improve the quality of treatment for people with alcohol dependence. The guidelines include chapters on working with people with co-occurring alcohol dependence and mental health and/or physical health conditions. They also include recommendations on multi-disciplinary assessment, care planning and care co-ordination. - The CQC also recognise that individuals with co-occurring complex needs require joined-up care across multiple services and continue to monitor and engage with providers, particularly in relation to cross-organisational working and accountability and recognise the coroner’s concerns regarding access to this care. As part of their organisational strategy, published in 2021, CQC are committed to identifying and addressing gaps in service coordination, driving improvements, and holding providers accountable for delivering safe and effective care. CQC will use insights such as this Regulation 28 Report to inform their system monitoring and engagement with system leaders and will continue to ensure people using services they regulate receive safe, person-centred care. Thank you for bringing these concerns to my attention. I want to assure you my department and NHSE recognise these issues and are continuing to work closely together to improve integrated care for those with substance use issues. I hope this response is helpful. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR PUBLIC HEALTH AND PREVENTION
Ministry of Housing, Communities & Local Government Dr Richard Brittain Assistant Coroner for Inner North London Bow Coroner's Court Bow Road London E3 3AA Dear Dr Brittain, Deputy Prime Minister and Secretary of State for Housing, Communities & Local Government 2 Marsham Street London SW1P 4DF Our reference: 22 May 2025 RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - INQUEST INTO THE DEATH OF ALEXI SUSILUOTO Thank you for your letter and investigative report dated 4 April 2025 regarding the death of Alexi Susiluoto, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I was deeply saddened to learn of the tragic circumstances surrounding the death of Mr Susiluoto. I extend my heartfelt condolences to their family, friends, and all who knew and cared for them. The details outlined in your report are indeed troubling, and I am grateful to you for bringing these serious matters to my attention. Homelessness levels are far too high. This can have a devastating impact on those affected, including a range of health and social care issues, as tragically seen in Mr Susiluoto's case. Your report specifically raises concerns about the support in place for people experiencing homelessness with co-occurring substance misuse and mental health needs. We know that many people experiencing rough sleeping have substance misuse needs and can struggle to access the necessary support. In 2025/26, we are providing £58.?m to local authorities through the Rough Sleeping Drug and Alcohol Treatment Grant (RSDATG). This includes a £Sm funding contribution from the Office for Health Improvement and Disparities (OHIO) within the Department of Health and Social Care (DHSC). RSDATG funding will deliver substance misuse services for people sleeping rough or at risk in 83 local authorities and 4 pan-London projects. RSDATG funds evidence-based drug and alcohol treatment and wraparound support to improve access to treatment, including for those with co-occurring mental health needs, like Mr Susiluoto. A further purpose of the funding is to reduce the numbers of people sleeping rough or experiencing homelessness as a result of substance misuse and reduce the number of deaths from drug and alcohol poisoning. I understand the Parliamentary Under-Secretary of State for Public Health and Prevention in the DHSC will be responding separately on matters relevant to their department that your report raises,
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