Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0180, written 26 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Mar 2026 |
|---|---|
| Reference | 2026-0180 |
| Deceased | Alex Ganski |
| Coroner | Joseph Turner |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Mental Health related deaths |
| Organisation named | Sussex Community NHS Foundation Trust · Sussex Partnership NHS Foundation Trust · East Sussex Healthcare NHS Trust · University Hospitals Sussex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Mr Wes Streeting MP, Secretary of State for Health and Social Care 1 CORONER I am Joseph TURNER, Area Coroner for the coroner area of West Sussex, Brighton and Hove 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 INVESTIGATION and INQUEST Alex Ganski sadly died from injuries sustained when he jumped from a bridge on 20th July 2024. This was the fifth occasion in three years he had visited the same location with thoughts of self harm. His death was referred to the Coroner Service by Sussex Police and an investigation under s.1 Coroners and Justice Act 2009 was opened on 22nd July 2024. The inquest was held on 19th March 2026. The inquest concluded that Alex took his own life following traumatic events earlier in his life causing depression and long-term suicidal thoughts, leading to the use of illicit drugs. He had suddenly absconded from home that evening whilst under the influence of ketamine and diazepam, having relapsed following a period of addiction support. He was receiving specialist care for his mental health but there had not been fully shared information between the services supporting him, or a clear overall lead, creating a missed opportunity to more closely address the confluence of poor mental health, drug misuse, and resulting risk of self-harm. 4 CIRCUMSTANCES OF THE DEATH Alex was 19 but had undergone traumatic events in his teens which led to long term mental health struggles and suicidality. At the time he died he was under the care of the local Trust’s Mental Health Assessment and Treatment service, with a Registered Mental Health Nurse as his lead practitioner. Contact had been consistent. He had been misusing cannabis, ketamine and diazepam intermittently for some years, although had latterly ceased the latter two drugs whilst receiving support from the local Drug and Alcohol Wellbeing Network. He had been formally diagnosed with suicidal thoughts, anxiety and depression and his GP had prescribed medication although Alex had ceased taking this some weeks prior to death, with the GP’s knowledge. Although he had undergone assistance to reduce drug misuse, he had several relapses. Two weeks before he died this had resulted in the ambulance service attending to him, although he declined to be taken to hospital, contrary to paramedic advice. His drug support network was unaware of and not alerted to this incident. The week before he died he had overdosed on tablets bought on the internet. He appeared to have made a physical recovery but was granted mental health leave by his employer that week. He spent the week at home or on family day trips. His mood was low but there were no immediate concerns. However, he purchased several combined packs of ketamine and diazepam from a local dealer on the Friday and Saturday, despite family attempts to intervene. On the Saturday evening he had indicated willingness to consider a rehabilitation facility in his native Poland but he also made a further drug purchase. Suddenly at around 9.20 he burst out of the house and proceeded to a nearby bridge , from which he jumped sustaining fatal injuries. This was the fifth occasion in three years he had visited the same location with thoughts of self harm. 5 CORONER’S CONCERNS Regulation 28 – After Inquest Template Updated 15/07/2025 TG During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 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 d. 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. 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. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Template Updated 15/07/2025 TG In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 May 21, 2026. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (Mother) Sussex Partnership Foundation Trust Change, Grow, Live (West Sussex Drug and Alcohol Wellbeing Network) South East Coast Ambulance Service I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe 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 Dated: 26/03/2026 Joseph TURNER Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/07/2025 TG
1 response 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 Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU Mr Joseph Turner HM Coroner West Sussex, Brighton & Hove 09 June 2026 Dear Mr Turner, Thank you for the Regulation 28 report of 2 April 2026 sent to the Secretary of State for the Department of Health and Social Care about the death of Alex Ganski. I am replying as Parliamentary Under-Secretary of State for Women’s Health and Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Alex Ganski’s death, and I offer my sincere condolences to his 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 specific concerns that the report raises were • 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. • 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. • 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. It also notes 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. You also 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. Another concern was 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. We know that people with co-occurring substance use and mental health needs too often do not receive the integrated, person-centred care they require and deserve. I want to assure you that the Department of Health and Social Care (DHSC) is taking action on this important issue to improve the standards of care and integration of services for those with co-occurring substance use and mental health needs. In December 2025, DHSC and NHS England (NHSE) jointly published the Co-occurring Mental Health and Substance Use Delivery framework: https://www.gov.uk/government/publications/co-occurring-mental- health-and-substance-use-delivery-framework. The delivery framework builds on previous guidance, such as National Institute for Health and Care Excellence (NICE) guideline Coexisting severe mental illness and substance misuse (NG58), Public Health England (PHE) Better care for people with co-occurring mental health, and alcohol and drug use conditions and NHS England’s Community mental health framework for adults and older adults. The delivery framework includes recommended actions on how the health system can also work together to improve coordinated care. These recommended actions include an ask for services and clinicians to develop multidisciplinary teams to encourage collaborative case management and establishing joint working protocols between drug and alcohol services and mental health services. Furthermore, both the NICE and PHE guidance state the need for coordination of care, including appointing a named care coordinator for every person with co-occurring needs. However, as indicated in your report on the circumstances surrounding Mr. Ganski’s death, compliance with guidance on co-occurring conditions has been limited to date, and the delivery framework aims to improve that. The framework commits DHSC and NHSE to deliver several national actions to improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services. These actions include the commitment to publish guidance on the statutory duty to co- operate issued under the Health and Care Act 2012. This guidance, which is currently in development, will define how local authorities and NHS bodies should work together to achieve positive health outcomes for people with co-occurring needs. The duty to co- operate guidance will be supported by an accompanying quality standard checklist for joint care planning. DHSC will develop the checklist tor support implementation of the duty to co-operate guidance when agreeing care plans. This will enable more consistency between mental health services and drug and alcohol services. The Staying Safe from Suicide guidance applies to all mental health practitioners in the NHS, private or charity sectors and the eLearning is available free to all. The guidance, alongside e learning for practitioners, ensures that frontline staff are working to the latest evidence in identifying and managing suicide risk. It is now a requirement within the NHS Medium Term Planning Framework that mental health practitioners across all providers undertake training and deliver care in line with this guidance. The Personalised Care Framework also looks to improve continuity, clarity and safety by ensuring people experiencing serious mental illness have a named professional coordinating their care, a care plan that reflects their needs now, quicker re-access to support when things deteriorate, and more consistent standards of good care wherever they live. The Personalised Care Framework has been shared in draft with NHS organisations ahead of its expected publication. Regarding your concerns raised in relation to sharing information and data between services and clinicians, the delivery framework also states that all service providers need to work together with all relevant local services to agree data sharing arrangements that reflect the needs of people with a co-occurring mental health and substance use need. This is also in line with the NICE guidance recommendations on information sharing, 1.4.6 and 1.4.7. Work is ongoing alongside NHSE and sector partners to overcome barriers to data sharing between services. Through our wider children and young people’s mental health reforms, we are working to strengthen clear clinical leadership and oversight, multiagency working, and information sharing, so that no child falls through gaps between services. That is why children and young people’s mental health is a core pillar of our 10 Year Health Plan. Our goal is a preventative, person centred approach to mental health, a system where support begins early, in schools and communities; where no young person falls through the cracks; and where children and families are listened to, engaged with, and supported in ways that reflect their reality. Transforming the system will take time, but we are already making progress by tackling longstanding structural challenges, expanding early support, building the workforce, modernising legislation, investing in innovation, and aligning national ambition with strong local leadership. Alongside this we are reducing the longest waits for specialist services, embedding mental health support for young people within new Young Futures Hubs, and accelerating the rollout of Mental Health Support Teams across England to reach full national coverage by 2029. These teams are designed to support earlier identification of risk, rapid information-sharing between services and clearer pathways into longer-term support where required. We also recognise the importance of continuity of care during the transition to adult services. As such, we expect to develop bespoke guidance in the revised Mental Health Act Code of Practice on the care and treatment of patients who are under 18. This will account for the specific needs and vulnerabilities of this cohort and will cover the critical issue of transition to adult services. Finally, the new developmental service specification for children and young people’s intensive mental health services will no longer require the provider to routinely transfer or discharge a young person at their 18th birthday. This decision will be based upon the view of the clinical team, and if they believe that the young person is receiving appropriate therapeutic care which would be disrupted by a transition to other services; then until that period of care is completed and the appropriate arrangements are in place they can remain in children and young people’s services. The developmental service specification is currently being tested using existing resources, with the aim of learning from this phase before full publication and onward implementation, subject to funding. You may also be interested in the following publication of guidance to support transitions for CYP across multiple services NHS England » Supporting young people to transition into adolescent and adult services In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission to ensure we adequately address your concerns. Upon reviewing your report, our NHSE colleagues felt it was more appropriate to reply directly to you as you highlight the concerns that the absence of any national guidance/advice to frontline emergency crews. You may want to address your report to NHSE, so that they can also address your concerns. I have asked to see a copy of their reply. CQC have shared the following information regarding Mr Ganski’s death: Plexus allows practitioners to securely access relevant patient information as part of the shared health and care record. This includes name; date of birth; gender, address, contact details, NHS number to help identify you correctly; name and address of your GP, details of medications etc, community and mental care plans as we all adult social care data. Plexus currently allows sharing of patient data between organisations that were in the Sussex Health and Care partnership, which is now known as NHS Surrey and Sussex ICB: • GP practices • University Hospitals Sussex NHS Foundation Trust • East Sussex Healthcare NHS Trust • Queen Victoria Hospital • Sussex Community NHS Foundation Trust • Sussex Partnership NHS Foundation Trust • East Sussex County Council • West Sussex County Council • Brighton & Hove Council • Sussex Care homes & Domiciliary Care There are similar initiatives in other parts of the country, but not in all areas. CQC inspected mental health crisis services and health-based places of safety at Sussex Partnership NHS Foundation Trust in June 2025. The report is yet to be published and we are unable to provide a timeline for when that will happen. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR WOMEN’S HEALTH AND MENTAL HEALTH
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