Source · Prevention of Future Deaths

Joseph Cooper

Ref: 2026-0237 Date: 30 Apr 2026 Coroner: Chris Morris Area: Greater Manchester South Responses identified: 2 / 1 View PDF

There is an absence of commissioned services for co-occurring mental health and substance misuse conditions, and large quantities of alcohol are easily available online. Concerns also arise from the lack of a unified digital NHS health records system.

Date 30 Apr 2026
56-day deadline 25 Jun 2026
Responses identified 2 of 1

Coroner's concerns

AI summary
There is an absence of commissioned services for co-occurring mental health and substance misuse conditions, and large quantities of alcohol are easily available online. Concerns also arise from the lack of a unified digital NHS health records system.
View full coroner's concerns
1)  The court heard evidence that at the time of his death, Mr Cooper had  unmet mental health needs principally as a consequence of no specific  service or treatment pathway existing locally which would provide  wholistic and co-ordinated care for co-occurring mental health and  substance misuse conditions (also known as ‘dual diagnosis’). I am  concerned as to the lack of availability of commissioned services to  provide care for patients with co-occurring mental health and substance misuse conditions both in this and other areas. 

2)  Mr Cooper was able to order large quantities of alcohol via online delivery services and have them delivered to his door quickly, including on  occasions when he was already obviously intoxicated. I am concerned  that large quantities of alcohol are so quickly and readily available from a  range of retailers via online delivery services with only basic age-verification checks being undertaken.  

3)  The court heard evidence that professionals from the drug and alcohol  service treating Mr Cooper had no access to his mental health records  despite both mental health and drug and alcohol services being provided under the auspices of the same NHS Foundation Trust.  Whilst the court heard that Pennine Care NHS Foundation Trust is urgently seeking to grant viewer access to relevant patients’ mental health records  to the drug and alcohol team, it is a matter of concern that no complete  and unified digital NHS health records system currently exists within  England and Wales.

Responses

2 respondents
Department of Health and Social Care Central Government
PDF
Received

No AI summary available.

NHS Greater Manchester
PDF
Received

No AI summary available.

Report sections

Investigation and inquest
On 23 June 2025, I commenced an investigation into the death of Joseph William Cooper who died outside his home aged 28 years.  The medical cause of Mr Cooper’s death was determined at inquest to have  been: 

1)(a) Multiple traumatic injuries and profound acute alcohol and drug intoxication   II Depression and Alcohol Dependence Syndrome (Co-occurring conditions). 

At the end of the inquest, I recorded the following Narrative Conclusion:  ‘Mr Cooper died as a consequence of complications arising from injuries  sustained in a fall from a height and profound intoxication in the context of unmet mental health needs’.
Circumstances of the death
Mr Cooper died on 19 June 2025 outside his home having sustained multiple  traumatic injuries in a fall which occurred after he had placed himself outside his third-floor window whilst profoundly intoxicated. Mr Cooper’s death was  contributed to by the co-occurring conditions of depression and alcohol  dependence syndrome.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is  a significant risk of future deaths and I believe each of you have the power to take such action
Copies sent to
I can confirm I have sent the report to2.  Pennine Care NHS Foundation Trust3.  The Disclosure and Barring Service4.  North West Ambulance Service NHS Foundation Trust 5.  Greater Manchester Integrated Care Board6.  Stockport Metropolitan Borough Council

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Report details

Reference
2026-0237
Date of report
30 April 2026
Coroner
Chris Morris
Coroner area
Greater Manchester South

Responses identified

Responses identified 2 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Jun 2026.

Sent to

Department of Health and Social Health

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