{"id":5633,"date":"2026-10-29T13:05:33","date_gmt":"2026-10-29T13:05:33","guid":{"rendered":"https:\/\/www.devon.gov.uk\/public-health\/?page_id=5633"},"modified":"2026-10-29T13:05:35","modified_gmt":"2026-10-29T13:05:35","slug":"prevention-of-drug-and-alcohol-related-harm-pdarh-2025-26","status":"publish","type":"page","link":"https:\/\/www.devon.gov.uk\/public-health\/about-public-health\/alliances-and-partnerships\/prevention-of-drug-and-alcohol-related-harm-pdarh-2025-26\/","title":{"rendered":"Prevention of Drug and Alcohol Related Harm (PDARH) 2025-26"},"content":{"rendered":"\n<h1 id=\"annual-report-may-2026\" class=\"wp-block-heading\">Annual Report, May 2026<\/h1>\n\n\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-d5be3348 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column doc-aside is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:25%\">\n<aside class=\"wp-block-group is-layout-constrained wp-block-group-is-layout-constrained\">\n<div class=\"wp-block-rank-math-toc-block\" id=\"rank-math-toc\"><h2>Contents<\/h2><nav><ul><li class=\"\"><a href=\"#1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\">1. Foreword<\/a><\/li><li class=\"\"><a href=\"#1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives-1\">2. Executive Summary<\/a><\/li><li class=\"\"><a href=\"#introduction\">3. Introduction<\/a><\/li><li class=\"\"><a href=\"#governance\">4. Governance<\/a><\/li><li class=\"\"><a href=\"#methodology\">5. Methodology<\/a><ul><li class=\"\"><a href=\"#panel-methodology\">Panel Methodology1<\/a><\/li><li class=\"\"><a href=\"#annual-report-methodology\">Annual report methodology<\/a><\/li><\/ul><\/li><li class=\"\"><a href=\"#the-drug-and-alcohol-harm-landscape\">6. The Drug and Alcohol Harm Landscape<\/a><\/li><li class=\"\"><a href=\"#reading-the-themes-context-and-related-system-challenges\">7. Reading the themes: Context and related system challenges<\/a><ul><li class=\"\"><a href=\"#structural-constraints\">Structural constraints<\/a><\/li><li class=\"\"><a href=\"#an-evolving-risk-environment\">An evolving risk environment<\/a><\/li><li class=\"\"><a href=\"#workforce-and-service-pressures\">Workforce and service pressures<\/a><\/li><li class=\"\"><a href=\"#stigma-disclosure-and-engagement\">Stigma, disclosure and engagement<\/a><\/li><\/ul><\/li><li class=\"\"><a href=\"#overview-of-reviews-undertaken\">8. Overview of Reviews Undertaken<\/a><\/li><li class=\"\"><a href=\"#findings\">9. Findings<\/a><ul><li class=\"\"><a href=\"#understanding-peoples-lives\">Understanding People\u2019s Lives<\/a><ul><li class=\"\"><a href=\"#theme-1-housing-and-placement-instability\">Theme 1: Housing and Placement Instability<\/a><\/li><li class=\"\"><a href=\"#theme-2-trauma-domestic-abuse-and-criminal-justice-contact\">Theme 2: Trauma, Domestic Abuse and Criminal Justice Contact<\/a><\/li><li class=\"\"><a href=\"#theme-3-social-isolation-bereavement-and-relational-loss\">Theme 3: Social Isolation, Bereavement and Relational Loss<\/a><\/li><li class=\"\"><a href=\"#theme-4-family-relationships-and-involvement\">Theme 4: Family Relationships and Involvement<\/a><\/li><\/ul><\/li><li class=\"\"><a href=\"#understanding-vulnerability-and-risk\">Understanding Vulnerability and Risk<\/a><ul><li class=\"\"><a href=\"#theme-5-intersecting-vulnerability-and-cumulative-need\">Theme 5: Intersecting Vulnerability and Cumulative Need<\/a><\/li><li class=\"\"><a href=\"#theme-6-safeguarding-vulnerability-and-multiple-exclusion-homelessness-meh\">Theme 6: Safeguarding, Vulnerability and Multiple Exclusion Homelessness (MEH)<\/a><\/li><li class=\"\"><a href=\"#theme-7-capacity-consent-and-ethical-practice\">Theme 7: Capacity, Consent and Ethical Practice<\/a><\/li><li class=\"\"><a href=\"#theme-8-cumulative-risk-and-missed-opportunities\">Theme 8: Cumulative Risk and Missed Opportunities<\/a><\/li><\/ul><\/li><li class=\"\"><a href=\"#understanding-system-response\">Understanding system response<\/a><ul><li class=\"\"><a href=\"#theme-9-supporting-engagement-access-and-autonomy\">Theme 9: Supporting Engagement, Access and Autonomy<\/a><\/li><li class=\"\"><a href=\"#theme-10-access-and-coordination-of-care\">Theme 10: Access and Coordination of Care<\/a><\/li><li class=\"\"><a href=\"#theme-11-professional-curiosity-and-hidden-harm\">Theme 11: Professional Curiosity and Hidden Harm<\/a><\/li><li class=\"\"><a href=\"#theme-12-coordination-communication-and-shared-ownership-of-risk\">Theme 12: Coordination, Communication and Shared Ownership of Risk<\/a><\/li><li class=\"\"><a href=\"#theme-13-workforce-capacity-and-pressures\">Theme 13: Workforce Capacity and Pressures<\/a><\/li><\/ul><\/li><\/ul><\/li><li class=\"\"><a href=\"#10-pdarh-in-practice-role-value-and-maximising-impact\">10. PDARH in practice: role, value and maximising impact<\/a><\/li><li class=\"\"><a href=\"#11-limitations-of-the-findings\">11. Limitations of the Findings<\/a><\/li><li class=\"\"><a href=\"#12-recommendations-for-ddasp\">12 Recommendations for DDASP<\/a><ul><li class=\"\"><a href=\"#ddasp-priority-area-1-recognise-intersecting-vulnerability\">DDASP Priority Area 1: Recognise Intersecting Vulnerability<\/a><\/li><li class=\"\"><a href=\"#ddasp-priority-area-2-strengthen-shared-ownership-of-risk\">DDASP Priority Area 2: Strengthen Shared Ownership of Risk<\/a><\/li><li class=\"\"><a href=\"#ddasp-priority-area-3-improve-engagement-and-access-to-care\">DDASP Priority Area 3: Improve Engagement and Access to Care<\/a><\/li><li class=\"\"><a href=\"#ddasp-priority-area-4-support-family-and-communities\">DDASP Priority Area 4: Support Family and Communities<\/a><\/li><li class=\"\"><a href=\"#ddasp-priority-area-5-build-workforce-capacity\">DDASP Priority Area 5: Build Workforce Capacity<\/a><\/li><\/ul><\/li><li class=\"\"><a href=\"#13-recommendations-for-pdarh-process\">13\u00a0 Recommendations for PDARH Process<\/a><\/li><li class=\"\"><a href=\"#14-conclusion\">14. Conclusion<\/a><\/li><li class=\"\"><a href=\"#15-acknowledgements\">15\u00a0\u00a0\u00a0 Acknowledgements<\/a><\/li><li class=\"\"><a href=\"#appendices\">Appendices<\/a><ul><li class=\"\"><a href=\"#appendix-a-governance\">Appendix A: Governance<\/a><\/li><li class=\"\"><a href=\"#appendix-b-methodology\">Appendix B: Methodology<\/a><\/li><li class=\"\"><a href=\"#appendix-c-overview-of-reviews-undertaken\">Appendix C: Overview of Reviews Undertaken<\/a><\/li><li class=\"\"><a href=\"#appendix-d-core-panel-membership\">Appendix D: Core Panel Membership<\/a><\/li><li class=\"\"><a href=\"#appendix-e-alcohol-related-deaths-thematic-review-recommendations\">Appendix E: Alcohol-Related Deaths Thematic Review Recommendations<\/a><\/li><li class=\"\"><a href=\"#appendix-f-strategic-indicators-detailed-context-data\">Appendix F: Strategic Indicators (Detailed Context Data)<\/a><\/li><li class=\"\"><a href=\"#auith\">Document Authors<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n\n\n<\/aside>\n\n\n\t<div class=\"dcc-documents-cpt-fixed dccdocs-sticky dccdocs-hidden\">\r\n    <div class=\"grid-container\">\r\n        <div class=\"grid-x grid-margin-x\">\r\n            <div class=\"cell medium-12\">\r\n                <a class=\"back-to-top hide-for-print\" href=\"#content\"><svg class=\"app-c-back-to-top__icon\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"13\" height=\"17\" viewBox=\"0 0 13 17\"><path fill=\"currentColor\" d=\"M6.5 0L0 6.5 1.4 8l4-4v12.7h2V4l4.3 4L13 6.4z\"><\/path><\/svg> Contents<\/a>\r\n            <\/div>\r\n        <\/div>\r\n    <\/div>\r\n\t<\/div>\r\n<\/div>\n\n\n\n<div class=\"wp-block-column doc-content is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:75%\">\n<article class=\"wp-block-group is-layout-flow wp-block-group-is-layout-flow\">\n<h3 id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\" class=\"wp-block-heading\">1. Foreword<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\"><br>As Director of Public Health for Devon County Council and Senior Responsible Officer for the Devon Drug and Alcohol Strategic Partnership (DDASP), I welcome this first annual report of the Devon Prevention of Drug and Alcohol Related Harm panel (PDARH) <\/p>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\">Drug- and alcohol-related deaths are among the most complex preventable harms experienced by our communities. Behind every death is a person and a set of circumstances that deserve to be understood with compassion and honesty. These deaths often disproportionately affect people already experiencing significant disadvantage, often cumulative across their lifetime, including adverse childhood experiences, homelessness, trauma, poverty, mental ill health, social isolation and other forms of exclusion.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\"><br>PDARH provides a structured, multi-agency approach to reviewing selected drug- and alcohol-related deaths across Devon, creating space for partners to reflect collectively on people\u2019s lives, the risks they experienced, the services that were involved, and opportunities where the system could have responded differently. This is particularly important at a time when drug-related deaths are increasing nationally and locally. This first annual report brings together learning from the PDARH during its first year, drawing together insights into the lives and experiences of those who have sadly died in Devon.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\"><br>This work to understand and learn from drug- and alcohol- related deaths sits within the wider context of the 10-year national drugs strategy, <a href=\"https:\/\/www.gov.uk\/government\/publications\/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives\/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives\" rel=\"noopener\">From Harm to Hope<\/a>, under which the DDASP operates. The strategy emphasises reducing harm, promoting recovery and improving community safety, and is supported by the <a href=\"https:\/\/assets.publishing.service.gov.uk\/media\/646b6bd4382a51000c9fc518\/National_Combating_Drugs_Outcomes_Framework_-_Supporting_metrics_and_technical_guidance_PDF__1_.pdf\" rel=\"noopener\">National Combating Drugs Outcomes Framework,<\/a> which tracks progress at both local and national levels.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\"><br>The learning in this report reinforces that drug- and alcohol-related deaths rarely arise from a single event. They are often shaped over time by cumulative and intersecting vulnerabilities, including housing tability, trauma, bereavement, social isolation, co-occurring mental health and substance use needs, and barriers to accessing timely support. Reducing harm therefore means more than improving individual services. It<br>requires us to strengthen the way we work together, recognise risk earlier, respond with persistence compassion and appropriate curiosity, and ensure that people receive coordinated support at the points when it is most needed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\"><br>There is also much in this report that reflects positive practice across Devon. The reviews identified examples of persistent engagement, flexible and trauma-informed responses, strong harm reduction practice, support for families, and effective multi agency working. These examples matter because they show what is possible when services remain connected, curious and committed to supporting people whose lives may be complex and whose needs may not fit neatly within single-service pathways.<br>This first annual report provides both a foundation and a challenge. It gives us a clearer understanding of recurring themes, highlights examples of good practice and identifies areas where system improvement is needed. The recommendations should now inform partnership priorities and operational practice, so that learning is translated into meaningful change.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\"><br>I would like to thank all partners who have contributed to the PDARH process during its first year. Your openness, reflection and commitment to shared learning are central to the success of this work. Most importantly, we seek to honour the individuals whose lives have been reviewed by using their experiences to strengthen prevention, improve practice and reduce future harm.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives\"><br>Steve Brown<br><strong>Director of Public Health, Devon County Council<\/strong><\/p>\n\n\n\n<h3 id=\"1-foreword-as-director-of-public-health-for-devon-county-council-and-senior-responsible-officer-for-the-devon-drug-and-alcohol-strategic-partnership-ddasp-i-welcome-this-first-annual-report-of-the-devon-prevention-of-drug-and-alcohol-related-harm-panel-pdarh-drug-and-alcohol-related-deaths-are-among-the-most-complex-preventable-harms-experienced-by-our-communities-behind-every-death-is-a-person-and-a-set-of-circumstances-that-deserve-to-be-understood-with-compassion-and-honesty-these-deaths-often-disproportionately-affect-people-already-experiencing-significant-disadvantage-often-cumulative-across-their-lifetime-including-adverse-childhood-experiences-homelessness-trauma-poverty-mental-ill-health-social-isolation-and-other-forms-of-exclusion-pdarh-provides-a-structured-multi-agency-approach-to-reviewing-selected-drug-and-alcohol-related-deaths-across-devon-creating-space-for-partners-to-reflect-collectively-on-peoples-lives-the-risks-they-experienced-the-services-that-were-involved-and-opportunities-where-the-system-could-have-responded-differently-this-is-particularly-important-at-a-time-when-drug-related-deaths-are-increasing-nationally-and-locally-this-first-annual-report-brings-together-learning-from-the-pdarh-during-its-first-year-drawing-together-insights-into-the-lives-and-experiences-of-those-who-have-sadly-died-in-devon-this-work-to-understand-and-learn-from-drug-and-alcohol-related-deaths-sits-within-the-wider-context-of-the-10-year-national-drugs-strategy-from-harm-to-hope-under-which-the-ddasp-operates-the-strategy-emphasises-reducing-harm-promoting-recovery-and-improving-community-safety-and-is-supported-by-the-national-combating-drugs-outcomes-framework-which-tracks-progress-at-both-local-and-national-levels-the-learning-in-this-report-reinforces-that-drug-and-alcohol-related-deaths-rarely-arise-from-a-single-event-they-are-often-shaped-over-time-by-cumulative-and-intersecting-vulnerabilities-including-housing-instability-trauma-bereavement-social-isolation-co-occurring-mental-health-and-substance-use-needs-and-barriers-to-accessing-timely-support-reducing-harm-therefore-means-more-than-improving-individual-services-it-requires-us-to-strengthen-the-way-we-work-together-recognise-risk-earlier-respond-with-persistence-compassion-and-appropriate-curiosity-and-ensure-that-people-receive-coordinated-support-at-the-points-when-it-is-most-needed-there-is-also-much-in-this-report-that-reflects-positive-practice-across-devon-the-reviews-identified-examples-of-persistent-engagement-flexible-and-trauma-informed-responses-strong-harm-reduction-practice-support-for-families-and-effective-multi-agency-working-these-examples-matter-because-they-show-what-is-possible-when-services-remain-connected-curious-and-committed-to-supporting-people-whose-lives-may-be-complex-and-whose-needs-may-not-fit-neatly-within-single-service-pathways-this-first-annual-report-provides-both-a-foundation-and-a-challenge-it-gives-us-a-clearer-understanding-of-recurring-themes-highlights-examples-of-good-practice-and-identifies-areas-where-system-improvement-is-needed-the-recommendations-should-now-inform-partnership-priorities-and-operational-practice-so-that-learning-is-translated-into-meaningful-change-i-would-like-to-thank-all-partners-who-have-contributed-to-the-pdarh-process-during-its-first-year-your-openness-reflection-and-commitment-to-shared-learning-are-central-to-the-success-of-this-work-most-importantly-we-seek-to-honour-the-individuals-whose-lives-1\" class=\"wp-block-heading\">2. Executive Summary<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">This first annual report brings together learning from the 2025 \u2013 2026 reporting period of the Devon Prevention of Drug and Alcohol Related Harm (PDARH) review process . PDARH provides a structured, multi-agency approach to reviewing selected drug- and alcohol-related deaths to identify opportunities for prevention, improve system responses and strengthen partnership learning. It complements, rather than<br>replaces, statutory review processes by both exploring experiences through a drug and alcohol lens and providing an earlier opportunity to identify recurring themes, emerging risks and areas of improvement.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>During the reporting period, PDARH reviewed 12 individuals: seven through individual case reviews and five through a thematic review of alcohol-related deaths. Cases were selected to maximise opportunities for learning and prevention rather than to provide a representative sample of all drug- and alcohol-related deaths in Devon.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>Across the reviews, a consistent picture emerged. Deaths rarely arose from a single issue, a single decision or a single missed opportunity. Instead, they reflected the interaction of multiple vulnerabilities over time, including substance use, mental ill health, trauma, homelessness, poverty, social isolation, bereavement, criminal justice involvement and poor physical health. These vulnerabilities often combined to create levels of need greater than the sum of their individual parts.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>Risk was typically cumulative and predictable rather than sudden or unexpected. Reviews identified recurring opportunities for intervention, including hospital admissions, non-fatal overdoses, housing instability, bereavement, relationship breakdown and periods of disengagement from support. However, systems were often organised around individual issues, service thresholds or episodes of crisis rather than cumulative vulnerability, limiting opportunities for earlier prevention.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>The reviews highlighted particular challenges in four areas:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Recognising and responding to intersecting vulnerabilities that cut across traditional service boundaries.<\/li>\n\n\n\n<li>Supporting people whose vulnerability was apparent but whose circumstances did not always align with statutory safeguarding criteria.<\/li>\n\n\n\n<li>Maintaining engagement with individuals experiencing trauma, substance dependence, homelessness and other forms of severe and multiple disadvantage.<\/li>\n\n\n\n<li>Coordinating responses across agencies where risk was shared but ownership was often unclear.<\/li>\n<\/ul>\n<\/article>\n\n\n\n<p class=\"wp-block-paragraph\">Alongside these challenges, the reviews identified many examples of effective practice. Positive outcomes were most evident where services maintained persistent and compassionate engagement, adapted support to individual circumstances, applied trauma-informed approaches, shared information effectively and worked together to develop a holistic understanding of risk. Strong harm-reduction practice, proactive housing support, continuity of care during periods of transition and collaborative multi-agency working were all associated with better outcomes.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>The first year of PDARH has also demonstrated the value of the review process itself. By bringing together agencies from across the system, PDARH has created a space for reflection, challenge and shared learning. Learning from reviews has already contributed to developments including implementation of the Multi-Agency Risk Management (MARM) framework, expansion of harm reduction activity, strengthening of non-fatal overdose pathways, improvements in referral processes, workforce development initiatives and wider system discussions regarding safeguarding, multiple exclusion homelessness (MEH) and cumulative risk.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>Taken together, the findings suggest that more effective prevention depends on recognising vulnerability earlier, responding to cumulative risk rather than isolated crises, strengthening coordinated multi-agency responses and ensuring that systems are designed around the realities of people\u2019s lives rather than the boundaries of individual organisations. While no single intervention can prevent all drug- and alcohol-related deaths, the learning from PDARH demonstrates that opportunities exist throughout the system to reduce harm, improve support and strengthen prevention.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br><strong>The central message emerging from this first year is clear: people experienced complex and interconnected challenges, but systems often responded in parts. More effective prevention requires responses that are equally connected, recognising the interaction between housing, trauma, mental health, substance use, relationships, poverty and vulnerability, and working collectively to address them.<\/strong><\/p>\n\n\n\n<h3 id=\"introduction\" class=\"wp-block-heading\">3. Introduction<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The Preventing Drug and Alcohol Related Harm review process (PDARH) began in May 2025 and was established to provide a structured, multiagency approach to learning from drug and alcohol related deaths; to improve practice and strengthen opportunities for prevention across the system, to support reflection on service responses to complex needs and to promote systemwide learning rather than<br>attribute blame.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>PDARH aligns with <a href=\"https:\/\/www.gov.uk\/government\/publications\/preventing-drug-and-alcohol-deaths-partnership-review-process\/preventing-drug-and-alcohol-deaths-partnership-review-process#introduction\" rel=\"noopener\">national guidance<\/a> on partnership responses to drug and alcohol related deaths. Whilst it is not a statutory process and does not hold the formal powers of mechanisms such as <a href=\"https:\/\/www.devonsafeguardingadultspartnership.org.uk\/about\/\" rel=\"noopener\">Safeguarding Adult Reviews<\/a> (SARs) and <a href=\"https:\/\/saferdevon.co.uk\/domestic-homicide-reviews\/\" rel=\"noopener\">Domestic Homicide Reviews<\/a> (DHR). it provides a complementary approach to partnership learning. PDARH is intended to work alongside, rather than duplicate or replace these existing processes with its impact dependent on the strength of partner engagement and the system\u2019s collective commitment to learning and action.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This annual report collates learning from 12 PDARH reviews conducted thus far to highlight key themes and identify priorities for system improvement to support partnership learning and strengthen the collective response to drug and alcohol related harm.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>The primary audience for this report includes Devon Drug and Alcohol Strategic Partnership (DDASP) members, safeguarding and governance boards and system leaders across health, social care, housing, criminal justice and the voluntary, social enterprise and community sector.<\/p>\n\n\n\n<h3 id=\"governance\" class=\"wp-block-heading\">4. Governance<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Public Health Devon coordinates PDARH on behalf of the DDASP. Panels are chaired by the Consultant in Public Health (CPH) who is portfolio lead for drug and alcohol and inclusion health, with officer support provided through a DATRIG1-funded practitioner post.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>The panel reports to the DDASP via the Preventing Deaths and Clinical Safety (PDCS) subgroup, which is responsible for reviewing and disseminating system learning from panels and for overseeing identified system-level actions. Further details can be found in appendix A.<\/p>\n\n\n\n<h3 id=\"methodology\" class=\"wp-block-heading\">5. Methodology<\/h3>\n\n\n\n<h4 id=\"panel-methodology\" class=\"wp-block-heading\"><em>Panel Methodology<\/em><sup>1<\/sup><\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">Detail on the PDARH methodology, case selection framework and review process are provided in Appendix B. As reviews are based on a sample of selected cases and the information available from partner agencies at the time of review, the findings should be interpreted as indicative of wider system issues rather than representative of all drug- and alcohol-related deaths.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><sup>1<\/sup>Drug and Alcohol Treatment and Recovery Improvement Grant<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>Following each PDARH review, themes and subthemes relating to risk, service engagement and system response are agreed by the panel. These are recorded in a structured format to support tracking across panels. Where relevant, they are linked to actions to support translation of learning into practice. Learning and recommendations from reviews are then disseminated to system partners.<\/p>\n\n\n\n<h4 id=\"annual-report-methodology\" class=\"wp-block-heading\">Annual report methodology<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">The annual report comprises learning from 12 cases reviewed through the PDARH process over the period may 25 to April 26. 7 individual reviews were conducted and 5 cases were included as part of an alcohol thematic review. The recommendations from the alcohol thematic review can be found in appendix F.<br><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For the annual report, subthemes from the reviews were compared across cases to capture recurring patterns. This involved grouping related issues, recognising variation of the same underlying problem, and organising them into broader thematic areas. Themes were then refined to ensure they were distinct and<br>system-relevant rather than limited to a single case or service context.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>The resulting themes represent an interpretation of emerging learning rather than a statistical analysis, providing a structured way to translate case-based learning into priorities for system action.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>For the purpose of this report each theme has been presented with a summary of learning, identified good practise, actions taken and system recommendations.<\/p>\n\n\n\n<h3 id=\"the-drug-and-alcohol-harm-landscape\" class=\"wp-block-heading\">6. The Drug and Alcohol Harm Landscape<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">PDARH operates within a complex and evolving environment shaped by changing patterns of drug and alcohol harm, increasing service demand and ongoing system pressures. The data in this section provides important context for interpreting the learning from reviews, with further detail available in Appendix F. Readers may also wish to refer to the<a href=\"\/\/www.devon.gov.uk\/public-health\/about-public-health\/alliances-and-partnerships\/ddasp-annual-report-2024-25\/\"> DDASP needs assessment completed in 2025<\/a> and further reports commissioned or developed by the DDASP.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Nationally, drug-related mortality remains high and continues to increase. In England and Wales, 5,565 deaths related to drug poisoning were registered in 2024, equivalent to 93.9 deaths per million people, continuing the long-term upward trend observed since 2012.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>Locally, 71 drug poisoning deaths were registered across the Devon County Council area in 2024. The Public Health Outcomes Framework indicator for deaths from drug misuse shows a further increase in Devon, rising from 6.0 per 100,000 population in 2021\u201323 to 6.4 per 100,000 in 2022\u201324. District-level variation is evident, with higher rates in Exeter, North Devon and Torridge, although these figures should be interpreted with caution due to small numbers.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">During 2022\u201324, Devon also recorded 278 alcohol-specific deaths, with an age standardised rate of 10.5 per 100,000. This remains lower than both the South West rate (13.0 per 100,000) and the England rate (14.4 per 100,000). While Devon\u2019s relative position is more favourable compared to regional and national comparators, this masks significant challenges which were the focus of the <a href=\"https:\/\/www.devonhealthandwellbeing.org.uk\/aphr\/2024-25\/\" rel=\"noopener\">Director of Public Health\u2019s Annual Report in 2025<\/a>. PDARH reviews consistently identify alcohol as a contributor to complex risk, including poly substance use, fluctuating capacity, safeguarding concerns, housing instability, and repeated crisis presentations.<\/p>\n\n\n\n<h3 id=\"reading-the-themes-context-and-related-system-challenges\" class=\"wp-block-heading\">7. Reading the themes: Context and related system challenges<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The themes presented in this report should be interpreted within the wider context in which drug- and alcohol-related harm occurs. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The reviews repeatedly identified opportunities where systems could have responded differently. However, they also highlighted that people were often navigating significant challenges beyond the control of any single organisation. These included housing shortages, increasing workforce pressures, barriers to service access, changing patterns of substance use and wider social disadvantage.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Three contextual factors were particularly evident throughout the reviews:<\/p>\n\n\n\n<h4 id=\"structural-constraints\" class=\"wp-block-heading\">Structural constraints<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">A shortage of suitable housing, increasing complexity of need and the limitations of threshold-based systems affected the ability of services to respond flexibly to vulnerability. Housing, safeguarding, mental health and treatment services were often required to operate within wider structural constraints not easily resolved at local level and within resource-stretched systems.<\/p>\n\n\n\n<h4 id=\"an-evolving-risk-environment\" class=\"wp-block-heading\">An evolving risk environment<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">The drug market continues to change, including increasing poly-substance use and the emergence of new and more potent substances. This creates additional challenges for assessment, treatment, harm reduction and prevention activity.<\/p>\n\n\n\n<h4 id=\"workforce-and-service-pressures\" class=\"wp-block-heading\">Workforce and service pressures<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">High caseloads, vacancies and increasing demand affected many organisations involved in the reviews. These pressures can reduce continuity, limit opportunities for preventative work and constrain participation in multi-agency activity (strategic and operational). The reviews consistently demonstrated significant commitment from staff working within challenging system conditions but that capacity was a real constraint.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>The thematic findings should therefore be read as opportunities for improvement within a wider system context. Some learning can be addressed through local practice changes and stronger coordination; other issues will require longer-term strategic influence, partnership working and structural change across all levels.<\/p>\n\n\n\n<h4 id=\"stigma-disclosure-and-engagement\" class=\"wp-block-heading\">Stigma, disclosure and engagement<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">The reviews highlighted that stigma associated with substance use, homelessness, mental ill health and social exclusion can influence whether people seek help,disclose risk or remain engaged with support. Fear of judgement, enforcement action, safeguarding consequences or losing important relationships may contribute to hidden need and reduced opportunities for early intervention. Services shouldtherefore be mindful that apparent non-engagement or limited disclosure may reflect underlying barriers rather than a lack of need.<\/p>\n\n\n\n<h3 id=\"overview-of-reviews-undertaken\" class=\"wp-block-heading\">8. Overview of Reviews Undertaken<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The PDARH panel has reviewed 12 individuals to date: seven through individual case reviews (anticipated drug-related deaths) and five through a thematic review of anticipated alcohol-related deaths.<br><br>Cases were selected to maximise opportunities for learning and prevention rather than to represent all drug- and alcohol-related deaths across Devon. Figure A1 summarises the Case Selection Framework.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" width=\"800\" height=\"417\" src=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFig1-800x417.png\" alt=\"PDARH Case selection Framework - Three Columns headed Column 1. Population Risk Factors (Age, Gender, Care Experience, Deprivation IMD 1-2, Neurodiversity.\nCoumn 2. Characteristic Risk Factors (House insecurity, Employment change, Relationship Breakdown\/Bereavement,Armed Forces, Physical &amp; Mental Health Needs, Poly-substance use, Isolation\/died alone, Financial stress, Novel substances. Column 3. Opportunities to intervene (Criminal justice contact, Recent overdose\/naxolone, Safeguarding marker S42\/SAR, Recent discharge from care, Treatment status, Care leaver 18-25).\" class=\"wp-image-5656\" srcset=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFig1-800x417.png 800w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFig1-767x400.png 767w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFig1-300x156.png 300w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFig1-640x334.png 640w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFig1-1024x534.png 1024w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFig1.png 1130w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Due to delays in coronial processes, there can be a significant gap between the date that a person passes away and confirmation of cause of death through inquest. As a result cases are selected where it is suspected that the cause of death is connectedto drug or alcohol use.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>To provide context for the scale and focus of PDARH activity, age standardised 3 year aggregated ONS data on drug and alcohol related deaths provide a useful indication of the wider burden of harm and help assess whether PDARH reviews are broadly proportionate to local need by gender, age and treatment status.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>Figure B1 shows the gender profile of the PDARH cohort reviewed during the reporting period (n=12). ONS data for Devon shows that the rate of deaths related to drug poisoning for the period 2022- 2024 for men is 12.3 per 100,000 and 6.6 for women.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>Data split by gender for Alcohol specific deaths at local authority level is not available however nationally alcohol specific deaths in males are roughly double the rate for females ( 20.2 per 100,000 and 9.7 per 100,000 respectively).<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" width=\"800\" height=\"283\" src=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB1-800x283.png\" alt=\"Figure B1 Gender of PDARH cohort - 12 Counts  - Male: 7 of 12, Female 5 of 12\" class=\"wp-image-5659\" srcset=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB1-800x283.png 800w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB1-300x106.png 300w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB1-768x271.png 768w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB1-640x226.png 640w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB1-1024x362.png 1024w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB1.png 1379w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Figure B2 summarises age at death for individuals reviewed through PDARH (n=12). Nationally, in 2024 the highest rates of drug misuse deaths were in those aged 40 \u201349 (This Gen X cohort have had the highest level of deaths for the last 25 years). The average age at death by drug related causes in England and Wales was 45.5 years for males and 48.5 for females.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" width=\"800\" height=\"278\" src=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB2-800x278.png\" alt=\"Figure B2 - Age at death 12 Counts - Under 40 4 of 12, 40-64 8 of 12.\" class=\"wp-image-5660\" srcset=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB2-800x278.png 800w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB2-300x104.png 300w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB2-768x267.png 768w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB2-640x222.png 640w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB2-1024x356.png 1024w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB2.png 1379w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Figure B3 shows treatment status at the time of death across the reviewed cohort (n=12). Inclusion of cases across different points of the treatment and support pathway reflects PDARH\u2019s system-wide focus and avoids limiting learning to a single service group. 18% of drug misuse deaths occurring in the period 2022-2024 were in treatment at time of death.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" width=\"800\" height=\"236\" src=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB3-800x236.png\" alt=\"Figure B3 Treatment Status at time of death - 12 Counts, In Treatment 5 of 12, Known previously but not engaged 4 of 12, Not known to treatment 3 of 12. \" class=\"wp-image-5661\" srcset=\"https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB3-800x236.png 800w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB3-300x88.png 300w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB3-768x226.png 768w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB3-640x188.png 640w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB3-1024x301.png 1024w, https:\/\/www.devon.gov.uk\/public-health\/wp-content\/uploads\/sites\/191\/2026\/10\/PDARHFigB3.png 1447w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Fuller detail on the cohort profile, case selection rationale and review characteristics is provided in Appendix C.<\/p>\n\n\n\n<h3 id=\"findings\" class=\"wp-block-heading\">9. Findings<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The learning from PDARH reviews has been organised into 13 themes, grouped under three overarching areas:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Understanding People&#8217;s Lives<br><\/strong><\/li>\n\n\n\n<li><strong>Understanding Vulnerability and Risk<br><\/strong><\/li>\n\n\n\n<li><strong>Understanding System Response<\/strong><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Each theme brings together recurring learning identified across reviews and is presented alongside examples of good practice, actions already taken in response to that learning, and opportunities for further system improvement. These themes have informed the recommendations set out later in this report.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The themes should not be viewed in isolation. Across the reviews, housing instability, trauma, substance use, poor physical and mental health, bereavement, social isolation and poverty frequently interacted, creating vulnerabilities that were often cumulative and interconnected. While the themes are presented separately to support analysis and action, they frequently overlapped within the lives of the individuals reviewed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">PDARH is intended to support learning, reflection and improvement rather than attribute blame. The purpose of identifying recurring themes is not to suggest that every death could have been prevented, but to better understand the circumstances in which risk develops, the challenges faced by individuals and services, and the opportunities for systems to respond more effectively to vulnerability, risk and harm.<\/p>\n\n\n\n<h4 id=\"understanding-peoples-lives\" class=\"wp-block-heading\">Understanding People\u2019s Lives<\/h4>\n\n\n\n<h5 id=\"theme-1-housing-and-placement-instability\" class=\"wp-block-heading\">Theme 1: Housing and Placement Instability<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of theme findings<\/td><td>A recurring feature that often disrupted continuity of care, engagement with support and safety leading to escalating vulnerability.<br>. Rough sleeping and homelessness were common experiences <br>. Non-priority housing status often limited housing access despite evident vulnerability.<br>. A lack of suitable available accommodation reduced the system\u2019s ability to respond to complex need.<br>. Difficulty sustaining placements was a recurring barrier tosafety and recovery and repeated evictions contributed to instability and disrupted continuity of support.<br>. Where housing stability was achieved, this appeared to support stronger engagement with services.<br>. Conversely repeated housing transitions disrupted continuity of care, weakened engagement with support services and<br>increased vulnerability during periods of change.<\/td><\/tr><tr><td>Why this matters<\/td><td>Secure housing reduces risk and supports recovery, but this depends on housing being safe, stable and responsive to need. Where housing<br>systems cannot offer suitable provision or where shared understanding of vulnerability and suitability is weak, opportunities for housing to be a protective factor are reduced. The reviews therefore reinforce the importance of housing being treated as a core prevention issue rather<br>than as a background factor.<\/td><\/tr><tr><td>What good looks like<\/td><td>The reviews identified several examples of housing-related practice that promoted safety and stability, including:<br>. Maintaining housing support despite eligibility or contractual challenges.<br>. Providing wrap-around support through Housing and the System Transformation and Recovery (STaR) project in Exeter.<br>. Minimising disruption to placements and reducing unnecessary moves.<br>. Prioritising continuity of support workers, recognising stability as a protective factor.<br>. Using internal review processes to revisit housing decisions following a death and identify learning.<br><br><\/td><\/tr><tr><td>How can the system improve?<\/td><td>In addition to address the macro challenges of a chronic housing shortage within Devon, the findings suggest a need for:<br>. Stronger shared understanding of housing vulnerability and suitability.<br>. Earlier multi-agency involvement in housing decisions.<br>. Greater recognition of housing as a protective factor within prevention planning.<br>. Earlier coordination and intervention when housing instability is identified.<\/td><\/tr><tr><td>What is already happening (PDARH impact)<\/td><td>Practical guidance has been developed to support homelessness applications in Exeter City Council.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-2-trauma-domestic-abuse-and-criminal-justice-contact\" class=\"wp-block-heading\">Theme 2: Trauma, Domestic Abuse and Criminal Justice Contact<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of theme findings<\/td><td><strong>Experiences such as domestic abuse, victimisation, arrest, imprisonment, bereavement and exposure to serious incidents should be recognised as potential periods of heightened<br>vulnerability that may require enhanced support and coordinated intervention.<\/strong> Adverse childhood experiences and trauma, including repeated loss, shaped proceeding vulnerability.<br>.Trauma frequently preceded substance use rather than resulting from it.<br>. Contact with the criminal justice system and police involvement, both as a victim and perpetrator of crime, were recurring features.<br>. Contact with the criminal justice system for sensitive offences introduced additional complexity and vulnerability.<br>. Histories of domestic abuse were evident across cases,including as victim, perpetrator or both.<br>. Witnessing suicide, overdose or other fatal incidents compounded trauma and risk.<br>. Youth offending and imprisonment contributed to cumulative disadvantage and vulnerability.<\/td><\/tr><tr><td>Why this matters<\/td><td>These findings highlight that substance use and drug- and alcohol related harm cannot be understood separately from the wider<br>experiences of trauma, abuse and disadvantage that many individuals had experienced throughout their lives.<br><br>Trauma often shaped how people engaged with services, responded to support and experienced periods of crisis. Without trauma informed approaches, behaviours associated with distress, mistrust, fear or previous experiences of harm can be interpreted as non engagement, rather than as indicators of vulnerability and unmet need.<br><br>The reviews also suggest that experiences such as domestic abuse, victimisation, arrest, imprisonment, bereavement and exposure to <br>serious incidents should be recognised as potential periods of heightened vulnerability that may require enhanced support and coordinated intervention.<\/td><\/tr><tr><td>What good looks like<\/td><td>Good practice was characterised by:<br>. Trauma-informed and person-centred approaches that sought to understand the reasons behind behaviour rather than focusing solely on presenting risk.<br>. Flexible engagement approaches that prioritised trust, relationships and persistence.<br>. Recognition of the long-term impact of trauma, adverse childhood experiences and domestic abuse.<br>. Professional curiosity about how trauma may be influencing current circumstances, engagement and risk.<br>. Multi-agency responses that considered the interaction between trauma, substance use, mental health and social circumstances.<br>. Staff applying trauma stabilisation principles and adapting support to individual circumstances.<\/td><\/tr><tr><td>How can the systemimprove?<\/td><td>. Continue to embed trauma-informed practice across health, social care, housing, policing, criminal justice and substance use services.<br>. Strengthen confidence in recognising and responding to domestic abuse across all genders.<br>. Improve recognition of periods of heightened vulnerability following traumatic events, victimisation, arrest, imprisonment,bereavement or exposure to death and serious harm.<br>. Promote professional curiosity about the cumulative impact of trauma across the life course and its influence on engagement, risk and recovery.<br>. Support more confident multi-agency conversations where trauma, domestic abuse and criminal justice involvement are contributing to vulnerability and risk.<\/td><\/tr><tr><td>What is already happening (PDARH impact)<\/td><td>PDARH learning has already informed workforce development and practice improvement activity, including:<br>. Continued delivery of trauma stabilisation training for Waythrough staff.<br>. Embedding Waythrough workers within Children&#8217;s Social Care to strengthen support at the interface between adversity, trauma and substance use.<br>. Use of PDARH case learning within Adult Social Care leadership events exploring intersectionality, MEH and cumulative vulnerability.<br>. Ongoing partnership discussions to strengthen trauma informed approaches across services supporting people experiencing complex disadvantage<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-3-social-isolation-bereavement-and-relational-loss\" class=\"wp-block-heading\">Theme 3: Social Isolation, Bereavement and Relational Loss<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of theme findings<\/td><td><strong>Social isolation, bereavement and the loss of important relationships increased vulnerability, reduced access to support and often acted as markers of escalating risk.<\/strong><br>. Bereavement was often both a common significant life event and a visible marker of escalating risk.<br>. Social isolation reduced access to both informal and formal sources of support.<br>. Reduced contact or loss of custody of children increased distress and vulnerability.<br>. Relationship breakdown and family estrangement could reduce protective support networks.<br>. Housing moves and wider instability could further weaken social connections.<br>. The absence of supportive relationships often compounded existing challenges associated with substance use, mental ill health and trauma.<\/td><\/tr><tr><td>Why this matters?<\/td><td>Relationships are often, but not always, a critical source of stability, support and protection. Their loss can significantly increase vulnerability.<br><br>The reviews suggest that bereavement, relational loss and increased social isolation should be recognised as indicators of heightened risk.<br>Without recognition of these factors, opportunities for earlier intervention, support and prevention may be missed.<\/td><\/tr><tr><td>What good looks like<\/td><td>Good practice identified by the panel included:<br>. Compassionate and relationship-based approaches to support.<br>. Recognition of bereavement, grief and loneliness as important factors influencing wellbeing and risk.<br>. Active efforts to maintain trust and engagement during periods of loss and instability.<br>. Support that considered the individual&#8217;s wider relationships, support networks and family circumstances.<br>. Openness, compassion and transparency in interactions with individuals and those close to them.<br>. Recognition of families, carers and supportive relationships as important assets in prevention and recovery.<\/td><\/tr><tr><td>How can the system improve?<\/td><td>. Recognise bereavement as both a significant risk factor and a critical opportunity for intervention.<br>. Improve awareness of and access to bereavement support for adults and children affected by drug- and alcohol-related  deaths.<br>. Strengthen recognition of social isolation, loneliness and relationship breakdown as indicators of escalating vulnerability.<br>. Support services to routinely consider social connectedness and protective relationships within assessment, care planning and risk management.<br>.Continue to support individuals to develop and maintain positive social connections, particularly following major life events or periods of relational instability.<\/td><\/tr><tr><td>What is already happening (PDARH impact)<\/td><td>PDARH learning has already informed work to strengthen responses to bereavement and relational loss:<br>. A bereavement support toolkit has been developed for professionals to improve awareness of available support and referral pathways.<br>. The Domestic Homicide Review Coordinator is now screening for cases where bereaved children may not have been referred for support, including where they were not resident at the address where a death occurred.<br>. Bereavement has been increasingly recognised within PDARH learning as both a risk factor and a critical opportunity for preventative intervention.<br><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-4-family-relationships-and-involvement\" class=\"wp-block-heading\">Theme 4: Family Relationships and Involvement<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of theme findings<\/td><td><strong>Families and carers could be important protective factors, but their involvement and support needs were not consistently recognised.<\/strong><br>. Families were not always involved when their contribution may have supported engagement, safety or recovery.<br>. Family relationships were often complex, with differing views about risk, need and appropriate support.<br>. Family members were sometimes perceived as influencing professional understanding of situations, creating uncertainty about how their perspectives should be balanced.<br>. Withdrawal of consent could limit family involvement, even when this reduced opportunities for support and protection.<br>. Carers often experienced strain, fatigue, distress and stigma associated with supporting someone experiencing substance related harm.<br>. Support available to families, carers and bereaved relatives was often unclear or inconsistently accessed.<br>. The needs of families affected by another person&#8217;s substance use were not always recognised in their own right.<\/td><\/tr><tr><td>Why this matters?<\/td><td>Families can play an important role in engagement, advocacy, harm reduction and recovery. They are often the people most aware of<br>changes in circumstances, escalating risk or periods of crisis.<br><br>However, family involvement can also be complicated by strained relationships, differing perspectives and the need to respect autonomy and confidentiality. Where services do not actively consider how families and carers can be appropriately involved, opportunities to strengthen protective relationships may be missed.<br><br>The reviews also highlighted that families and carers are frequently affected by substance-related harm themselves and are often affected by substance-related harm long before and after a death occurs. Without clear pathways for support, many continue to experience significant emotional, practical and financial impacts withlimited access to help. This shows the importance of compassionate responses after harm or death, both for families and for organisational learning.<br><br>Taken together, the findings reinforce the importance of supporting families not only as contributors to someone&#8217;s care, but as individuals<br>with needs of their own.<\/td><\/tr><tr><td>What good looks like<\/td><td>The panel acknowledged examples of:<br>. Meaningful involvement of families and carers where appropriate and consent permitted.<br>. Recognition of families as potential sources of support, advocacy and protective insight.<br>. Recognition of carers as individuals with support needs of their own Open, compassionate and transparent communication with relatives.<br>. Active consideration of family dynamics and their impact on risk, engagement and recovery.<br>. Support offered to carers and family members for their needs including bereavement and carer services.<br>. Support for bereaved families in internal service reviews alongside openness and transparency following a death were identified as positive practice.<\/td><\/tr><tr><td>How can the system improve?<\/td><td>. Strengthen recognition of families and carers as partners in prevention, recovery and risk management where appropriate.<br>. Encourage reflective approaches to consent, ensuring opportunities for family involvement are fully explored while respecting autonomy and confidentiality.<br>. Improve awareness of and access to support for families affected by another person&#8217;s substance use.<br>. Strengthen bereavement support pathways for adults and children affected by drug- and alcohol-related deaths.<br>. Provide clearer information about available support and routes for access.<br>. Increase recognition of carer strain, fatigue and stigma within assessment and care planning processes.<\/td><\/tr><tr><td>What is already happening (PDARH impact)<\/td><td>PDARH learning has already informed work to strengthen support for families and carers:<br>. The Domestic Homicide Review Coordinator is now screening for cases where bereaved children may not have been referred for support because they were not resident at the address where the death occurred.<br>. The PDARH Coordinator has begun discussions with Devon Carers to explore opportunities for stronger joint working and improved support for people caring for someone experiencing<br>substance-related harm.<br>. Learning from reviews has contributed to growing recognition of family and carer support as a prevention issue rather than solely a post-bereavement response.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h4 id=\"understanding-vulnerability-and-risk\" class=\"wp-block-heading\">Understanding Vulnerability and Risk<\/h4>\n\n\n\n<h5 id=\"theme-5-intersecting-vulnerability-and-cumulative-need\" class=\"wp-block-heading\">Theme 5: Intersecting Vulnerability and Cumulative Need<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of theme findings<\/td><td><strong>Many of the themes identified through PDARH are not discrete issues but interconnected aspects of people&#8217;s lives. Housing instability, trauma, mental ill-health, substance use, poverty, relationship breakdown and poor physical health frequently interacted, creating cumulative vulnerability that was greater than the sum of its parts:<\/strong><br>. Substance use, mental ill-health, trauma, housing instability and poverty frequently occurred together.<br>. Multiple vulnerabilities often compounded one another and increased risk over time.<br>. Caring responsibilities and competing demands sometimes created additional barriers to accessing support.<br>. Neurodiversity was identified or suspected in some cases, adding complexity to engagement and service access.<br>. Younger age and transitions into adulthood could amplify vulnerability.<br>. Unemployment and financial hardship contributed to cumulative disadvantage.<br>. Emerging risks, including sourcing substances via the dark web, added complexity and reduced visibility of harm.<br>. Existing pathways and eligibility criteria were not always designed to respond to multiple, intersecting needs.<\/td><\/tr><tr><td>Why this matters<\/td><td>Effective responses to multiple intersecting needs require coordinated, person-centred approaches. Yet many systems remain organised around individual conditions, needs or service thresholds.<br>The PDARH reviews showed that vulnerability rarely stemmed from a single issue, but from the interaction of multiple factors that often cut across organisational boundaries.<br><br>As a result, people with the most complex needs are frequently expected to navigate the most complex systems. The very challenges that increase vulnerability, such as poor mental health, substance use, trauma, poverty, homelessness or social isolation, can also make it harder to engage with fragmented services and meet organisational expectations.<br><br>Taken together, the reviews suggest that preventing harm depends on recognising intersecting vulnerabilities earlier and responding in a coordinated way that reflects the reality of people&#8217;s lives, rather than the structure of services.<\/td><\/tr><tr><td>What good looks like<\/td><td>Good practice was most evident where services:<br>. Maintained engagement despite complexity and instability.<br>. Adapted support to fit people&#8217;s circumstances rather than expecting people to fit services.<br>. Recognised the interaction between housing, health, trauma, mental health, substance use and social circumstances.<br>. Remained alert to hidden risks and cumulative vulnerability.<br>. Worked flexibly across organisational boundaries. <br>. Coordinated support during key transitions and periods of heightened risk.<br>. Applied trauma-informed and person-centred approaches.<br>. Used proactive harm reduction and risk management strategies.<br>. The ongoing work of the Ilfracombe Poverty Truth<br>Commission to embed co-produced principles and standardsthat seek to humanise people who  receive health, social and voluntary care services.<br>Across reviews, positive outcomes were most often associated with responses that reflected the whole person rather than a single presenting issue.<\/td><\/tr><tr><td>How can the system improve?<\/td><td>. Strengthen recognition of cumulative and intersecting vulnerability across all services.<br>. Move beyond single-issue thresholds and service-led definitions of need.<br>. Improve coordinated responses across housing, health, mental health, treatment, safeguarding and criminal justice systems.<br>. Ensure assessment and care planning processes consider the interaction of multiple vulnerabilities.<br>. Embed approaches that identify cumulative risk earlier and support proactive intervention.<br>.Continue developing pathways and frameworks that can respond flexibly to complexity over time.<\/td><\/tr><tr><td>What is already happening (PDARH impact)<\/td><td>PDARH learning has already contributed to wider system discussions about cumulative need and complexity, including:<br>. Implementation of the Multi-Agency Risk Management (MARM) framework to support coordinated responses where risk spans multiple services.<br>. Development of partnership work around co-occurring mental health and substance use needs.<br>. Increased focus on housing instability, cumulative risk and MEH within DDASP workstreams.<br>. Development of a partnership learning and practice event with Adult Social Care and safeguarding partners focused on MEH, substance dependence and safeguarding. . The event will use learning from PDARH reviews to explore how systems recognise vulnerability, respond to cumulative risk and work across organisational boundaries to support people with complex and overlapping needs.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-6-safeguarding-vulnerability-and-multiple-exclusion-homelessness-meh\" class=\"wp-block-heading\">Theme 6: Safeguarding, Vulnerability and Multiple Exclusion Homelessness (MEH)<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of theme findings<\/td><td><strong>People experiencing MEH and substance dependence were frequently recognised as vulnerable, but there was not always a shared understanding of how that vulnerability should translate into action:<\/strong><br><br>. Assessing self-neglect and mental capacity in the context of dependent substance use was often complex.<br>. Differences existed between professional concern and statutory safeguarding criteria.<br>. Understanding of how statutory safeguarding criteria should be applied within the presenting contexts was inconsistent across organisations.<br>. Delays in allocation, communication and feedback sometimes reduced confidence in statutory safeguarding processes.<br>. Leadership and ownership of safeguarding enquiries was not always clear.<br>.Particular challenges were evident where homelessness, substance use, self-neglect and poor health interacted.<\/td><\/tr><tr><td>Why this matters<\/td><td>The reviews repeatedly identified individuals whose vulnerability was widely recognised by professionals but for whom there was uncertainty about the most appropriate route for intervention.<br><br>. Individuals experiencing homelessness, substance dependence, self neglect and co-occurring health problems often presented with<br>significant vulnerability and cumulative risk. . However, there was not always a shared understanding of whether that vulnerability<br>translated to a safeguarding concern or met statutory criteria, or required another form of multi-agency intervention, or support from individual services.<br>. This sometimes left professionals uncertain about available routes for action and weakened collective oversight of risk.<\/td><\/tr><tr><td>What good looks like<\/td><td>The panel considered the following as identified good practice:<br>. A focus on vulnerability rather than organisational thresholds.<br>. Joint discussions bringing together professional perspectives.<br>. Recognition of cumulative risk alongside immediate safeguarding concerns.<br>. Shared understanding of capacity, autonomy and vulnerability.<br>. Timely communication and feedback between statutory and partner agencies.<br>. Collective decision-making informed by housing, health, police and substance use services.<\/td><\/tr><tr><td>How can the system improve?<\/td><td>. Develop a stronger shared understanding of how vulnerability associated with MEH, substance dependence and self neglect should translate into coordinated action.<br>. Improve confidence in applying safeguarding principles where substance use, self-neglect and fluctuating capacity coexist.<br>. Strengthen communication and feedback following statutory safeguarding referrals.<br>. Ensure that not meeting Section 42 criteria does not result in loss of collective oversight.<br>. Develop clear routes for coordinated risk management where statutory safeguarding criteria are not met, including through implementation of the MARM framework.<br>. Create opportunities for joint learning across safeguarding health, housing and substance use services.<\/td><\/tr><tr><td>What is already happening (PDARH impact)<\/td><td>. MARM implementation is providing a structured response where safeguarding criteria are not met but significant concerns remain.<br>.PDARH learning has been used within Adult Social Care leadership events exploring MEH and cumulative vulnerability.<br>. Public Health, Adult Social Care and TDSAP partners are developing a learning event focused on safeguarding, MEH and substance dependence.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-7-capacity-consent-and-ethical-practice\" class=\"wp-block-heading\">Theme 7: Capacity, Consent and Ethical Practice<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of Theme findings<\/td><td><strong>Fluctuating capacity, particularly in the context of alcohol dependence, created significant challenges in balancing autonomy, protection and risk:<\/strong><br>. Fluctuating mental capacity complicated decisions aboutconsent, treatment and safeguarding.<br>. Capacity often changed over time, making single-point assessments difficult.<br>. Financial vulnerability emerged as a particular concern where individuals received large benefit payments alongside substance use and fluctuating capacity.<br>. Professionals reported feeling isolated when making complex decisions about risk, autonomy and intervention.<br>. Professionals often understood the risks but were less certain about the legal and practical options available to manage them.<br>. Consent-based processes sometimes limited opportunities to reduce harm where significant vulnerability remained.<br>. Difficulties were identified in balancing an individual&#8217;s wishes and autonomy with concerns about their safety and wellbeing.<br>, Ethical tensions were most apparent where substance use, self-neglect, homelessness and safeguarding concerns intersected.<\/td><\/tr><tr><td>Why this matters<\/td><td>These findings highlight the challenges of applying concepts such as capacity, consent, autonomy and protection in the context of substance dependence and fluctuating presentations.<br><br>Professionals were frequently required to make decisions in situations where risks were significant, but available legal and safeguarding options were not always clear. Where practitioners lacked confidence or felt isolated, opportunities for proportionate intervention could be missed or decision-making could become overly dependent on individual judgement.<br><br>The reviews suggest a need for greater confidence in applying the Mental Capacity Act, stronger multi-agency discussion of complex ethical dilemmas, and improved understanding of how autonomy,<br>vulnerability and risk interact in the context of severe and multiple disadvantage.<\/td><\/tr><tr><td>What good looks like<\/td><td>The panel recognised good practice as:<br>. Person-centred and trauma-informed approaches to decision making.<br>. Recognition that capacity may fluctuate over time and require ongoing review.<br>. Reflective discussion involving multiple professionals where ethical decisions were complex.<br>. Clear consideration of autonomy alongside risk, vulnerability and wellbeing.<br>. Appropriate use of safeguarding, advocacy and social work expertise.<\/td><\/tr><tr><td>How can the system improve?<\/td><td>. Strengthen understanding of mental capacity, consent and best-interest decision-making in the context of substance use.<br>. Improve confidence in applying the Mental Capacity Act where capacity fluctuates or is affected by alcohol or drug dependence.<br>. Strengthen joined-up approaches to financial safeguarding where large payments, substance use and vulnerability create heightened risk.<br>. Create opportunities for shared reflection and multi-agency discussion of complex ethical dilemmas.<br>. Improve understanding of when safeguarding, advocacy, social work involvement and legal mechanisms such as the Court of Protection may be appropriate.<br>. Ensure practitioners have access to specialist advice and support when making complex decisions about autonomy, protection and risk.<\/td><\/tr><tr><td>What is already happening (PDARH impact)<\/td><td>PDARH learning has already informed work to strengthen understanding of capacity, vulnerability and financial safeguarding:<br><br>.The Department for Work and Pensions (DWP) has used PDARH learning to inform wider practice and guidance.<br>. Good practice identified through St Petrock&#8217;s work on assessing financial vulnerability is being shared with DDASP partners.<br>. Public Health, Adult Social Care and safeguarding partners are developing a joint workshop focused on mental capacity, substance use, safeguarding and MEH.<br>. Learning from PDARH is helping to inform wider discussions about ethical decision-making, financial safeguarding and vulnerability across partnership agencies.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-8-cumulative-risk-and-missed-opportunities\" class=\"wp-block-heading\">Theme 8: Cumulative Risk and Missed Opportunities<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of<br>theme findings<\/td><td><strong>Risk was cumulative and predictable, but responses were often<br>episodic and crisis-driven<\/strong><br>. Poly-substance use, repeated crisis presentations and self discharge were recurring features of escalating risk.<br>. Multiple hospital admissions often represented repeated opportunities for intervention.<br>. Dying alone was a recurring feature.<br>. Recent non-fatal overdoses signalled critical opportunities for prevention.<br>. Deaths following rehabilitation highlighted periods of heightened vulnerability.<br>. Suicidal ideation and previous suicide attempts involvingsubstances were markers of ongoing risk.<br>. Risk frequently accumulated over time rather than emerging suddenly.<\/td><\/tr><tr><td>Why this<br>matters<\/td><td>The reviews highlight a mismatch between how risk develops and how systems are often configured to respond.<br><br>Risk was rarely the result of a single event. Instead, it accumulated<br>through repeated crises, deteriorating circumstances and multiple missed opportunities for intervention. Yet responses were often triggered by individual incidents rather than the wider pattern of vulnerability.<br><br> This reinforces the need to identify and respond to cumulative risk earlier, rather than waiting for crisis points.<\/td><\/tr><tr><td>What good<br>looks like<\/td><td>Effective risk management was characterised by:<br>. Proactive provision of naloxone.<br>.Recognition of non-fatal overdose as a critical intervention opportunity.<br>. Regular harm reduction conversations.<br>. Discussion of poly-substance use and emerging drug threats.<br>. Persistent engagement during periods of heightened vulnerability.<br>. Flexible support that adapted to changing levels of risk and readiness to engage.<\/td><\/tr><tr><td>How can the<br>system<br>improve?<\/td><td>. Treat hospital admissions and non-fatal overdoses as opportunities for intervention.<br>. Strengthen pathways between hospital, community and treatment services.<br>. Improve recognition of cumulative risk and repeated warning signals.<br>. Develop proactive approaches to risk management before crisis occurs.<br>. Ensure assessment processes recognise fluctuating presentation and readiness for change.<br>. Embed harm reduction and overdose prevention across the wider system.<\/td><\/tr><tr><td>What is already<br>happening<br>(PDARH impact)<\/td><td>. PDARH learning has informed the DDASP Naloxone Strategy.<br>. Public Health has developed the Widening Access to Harm Reduction Programme.<br>. Non-fatal overdose pathways are being adapted for the Devon footprint based on learning from Plymouth.<br>. Overdose prevention and harm reduction activity is being expanded beyond specialist treatment settings.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h4 id=\"understanding-system-response\" class=\"wp-block-heading\">Understanding system response<\/h4>\n\n\n\n<h5 id=\"theme-9-supporting-engagement-access-and-autonomy\" class=\"wp-block-heading\">Theme 9: Supporting Engagement, Access and Autonomy<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of<br>theme findings<\/td><td><strong>What was often perceived as non-engagement reflected unmet<br>need, instability or structural barriers rather than a lack of<br>motivation to seek support.<\/strong> <br>. Non-engagement often reflected trauma, mental ill health, homelessness, neurodiversity or other barriers rather than unwillingness to engage.<br>. Service responses did not always adapt when engagement became difficult, leading to premature closure of support.<br>. Complex needs could themselves create barriers to accessing and sustaining support.<br>. Transitions between services, particularly from children&#8217;s to adult services, increased vulnerability and disrupted continuity of care.<br>. Digital exclusion, mobility issues and unstable living circumstances made engagement more difficult.<br>. Balancing individual autonomy with concerns about vulnerability and risk was a recurring challenge.<br>. Maintaining opportunities for support is not the same as repeatedly pursuing engagement at all costs.<br>. Some service models relied on individuals being contactable or assessable at a single or within a small window of time.<br>.GP registration arrangements could create unintended barriers to accessing specialist support.<br>. Abstinence sometimes restricted access to treatment despite ongoing risk of relapse.<br>. Mental health pathways were often difficult to access, navigate and sustain.<\/td><\/tr><tr><td>Why this<br>matters<\/td><td>The reviews suggest that engagement is often treated as a prerequisite for support rather than an outcome that services actively work to build and sustain.<br><br>For people experiencing substance dependence, trauma and multiple disadvantage, barriers to engagement are frequently part of the presenting need. However, the learning also highlighted the importance of respecting individual autonomy and recognising that people may not always want the support that professionals believe<br>would be beneficial.<br><br>This creates a tension for practitioners, who are required to balance respect for personal choice with concerns about vulnerability and escalating risk. Effective practice is therefore not about repeatedly pursuing engagement at all costs, nor withdrawing support when engagement fluctuates. Rather, it is about maintaining appropriate opportunities for support, remaining curious about underlying barriers, and ensuring that access to help is not dependent on an individual&#8217;s ability to engage consistently on the service&#8217;s terms .<\/td><\/tr><tr><td>What good<br>looks like<\/td><td>Good practice was characterised by:<br>. Good practice balanced persistence with respect for autonomy, ensuring support remained available without disregarding individual\u2019s wishes.<br>. Persistent but proportionate efforts to maintain engagement. <br>. Respect for autonomy alongside continued concern for wellbeing and safety.<br>. Relationship-based approaches that prioritised trust over compliance.<br>. Flexibility in how support was offered and accessed.<br>. Recognition that engagement may fluctuate over time.<br>. Services remaining available and responsive, even when individuals chose not to engage consistently.<br>. Use of assertive outreach and Blue Light approaches where these were appropriate and proportionate.<\/td><\/tr><tr><td>How can the<br>system<br>improve?<\/td><td>. Recognise disengagement as a potential indicator of increased risk and unmet need rather than a reason to withdraw support.<br>. Ensure service closure policies promote persistence, flexibility and multiple attempts at engagement before discharge.<br>. Address structural barriers to engagement, including digital exclusion, homelessness, rural isolation and mobility issues.<br>. Strengthen support during key transitions, including transitions from child to adult services, housing transitions, hospital discharge and bereavement.<br>. Continue to balance respect for individual autonomy with proactive efforts to maintain engagement where vulnerability exists.<br>. Promote flexible and trauma-informed approaches that adapt to people&#8217;s circumstances rather than expecting people to adapt to services.<br>. Promote professional referral routes alongside self-referral, recognising that people may not be able to initiate or sustain engagement independently.<br>. Reduce barriers created by service access criteria, referral processes and GP registration arrangements.<br>. Develop assessment and engagement models that accommodate fluctuating need and do not rely on individuals being contactable or fully assessable at a single point in time<\/td><\/tr><tr><td>What is already<br>happening<br>(PDARH impact)<\/td><td>PDARH learning has already informed changes aimed at reducing barriers to engagement and improving continuity of support:<br>. CoLab has expanded catchment arrangements so that individuals moving beyond Exeter can continue to access support.<br>. The PDARH Coordinator now regularly attends the Common Ground Lived Experience Forum, strengthening understanding of barriers to engagement and ensuring learning from reviews informs lived experience discussions.<br>. Waythrough actively promoting professional referral routes alongside self-referral to improve access for individuals who may struggle to engage independently.<br>. Waythrough has amended training and practice guidance to ensure people who are abstinent but remain at risk can continue to receive support.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-10-access-and-coordination-of-care\" class=\"wp-block-heading\">Theme 10: Access and Coordination of Care<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of<br>theme findings<\/td><td><strong>Access to care was frequently constrained by fragmented<br>pathways, delays and service thresholds reducing opportunities<br>for timely intervention:<\/strong><br>. Critical windows for intervention, particularly during hospital admissions, were not consistently maximised.<br>. Delays in accessing residential treatment disrupted continuity between hospital, detoxification and rehabilitation services.<br>. Assessment bottlenecks and fragmented referral processes delayed care.<br>. In one case, unrecognised veteran status contributed to unmet support needs and missed opportunities for specialist assistance.<br>. Some service models relied on individuals being contactable or assessable at a single or within a small window of time.<br>. General practice (outside of specialist inclusion health services) was not consistently operating as a coordination point for people experiencing intersecting health vulnerabilities, despite often being the only service with a longitudinal view of need.<\/td><\/tr><tr><td>Why this<br>matters<\/td><td>These findings highlight a mismatch between system expectations and the realities of people living with dependency and severe and multiple disadvantage. Too often, access to support depends on individuals being able to engage at a single point in time. When they cannot, opportunities for intervention are lost.<br><br>The reviews also highlighted an important but often underdeveloped role for primary care. People experiencing homelessness, substance dependence, mental ill health and other forms of severe disadvantage often require continuity, coordination and proactive management. While specialist inclusion health primary care services demonstrated this approach, there wasn\u2019t evidence of similar oversight within mainstream primary care pathways, despite general practice often being the only<br>service with a longitudinal view of a person&#8217;s needs, risks and contacts with other services.<br><br>Challenges in aligning care across organisations in a timely manner can lead to gaps in service delivery and missed opportunities to provide coordinated pathways.<br><br>This reinforces the need for flexible, repeated and jointly delivered approaches to assessment and engagement that recognise fluctuating need, support sustained access to care, and understand the value of adapting clinical responses to individual need<\/td><\/tr><tr><td>What good<br>looks like<\/td><td>Where pathways worked well, there was clear coordination acrossservices, particularly at points of transition, including:<br>. Pre-arranged appointments prior to discharge to minimise gaps in support.<br>. Active coordination between residential and community treatment services.<br>. Flexible approaches to service delivery, adapting location, frequency and format to individual need.<br>. Adjustments to improve access for people living in rural areas.<br>. Continuity of prescribing where dependency had been identified.<br>. Proactive follow-up to support sustained engagement and continuity of care.<br>. Examples such as community benzodiazepine detoxification and Opiate Safe Clinic arrangements were identified as positive for people with lower levels of engagement.<br>. Together Hospital Liaison Workers were identified as having a positive impact on discharge planning and transition fromHospital to community.<\/td><\/tr><tr><td>How can the<br>system<br>improve?<\/td><td>, Strengthen pathways from hospital and mental health settings to maximise critical windows for intervention and reduce gaps in support.<br>. Improve coordination between primary care, secondary care,mental health and specialist treatment services to support continuity of care.<br>. Promote professional referral routes alongside self-referral, recognising that people may not be able to initiate or sustain engagement independently.<br>. Develop assessment and engagement models that accommodate fluctuating need and do not rely on individuals being contactable or fully assessable at a single point in time<\/td><\/tr><tr><td>What is<br>already<br>happening<br>(PDARH<br>impact)<\/td><td>PDARH learning has already informed several tangible changes across the system, including:<br>. Amendments to the NHS Devon formulary to support GP referral into drug and alcohol treatment services.<br>. Collaboration between Clock Tower Surgery and supported accommodation providers to identify residents who could benefit from specialist inclusion health support but are not registered with the practice.<br>. Changes to training and staff guidance to ensure individuals who are abstinent but remain at risk of relapse can access appropriate support.<br>. Greater awareness of veteran status as a factor influencing support needs, alongside improved signposting to specialist veteran services.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-11-professional-curiosity-and-hidden-harm\" class=\"wp-block-heading\">Theme 11: Professional Curiosity and Hidden Harm<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of<br>Theme<br>Findings<\/td><td><strong>Significant harm was sometimes hidden by partial information,<br>limited disclosure or assumptions about an individual&#8217;s circumstances.<\/strong><br>. Hidden harm was not always hidden because people concealed it; in some cases it remained hidden because enquiry stopped too early.<br>. Hidden or undisclosed substance use masked significant underlying risk.<br>. Presentations that appeared stable or manageable could obscure escalating vulnerability.<br>. Periods of abstinence or reduced contact sometimes led to assumptions that risk had reduced.<br>. Limited engagement sometimes reduced opportunities to identify hidden harm.<br>. Opportunities for further enquiry were occasionally missed where information was incomplete or ambiguity remained.<br>. Withdrawal of consent for family involvement could limit access to important perspectives and protective factors.<br>. For individuals experiencing homelessness and substance dependence, physical health deterioration can become normalised by both professionals and the individual, creating a risk that emerging health needs are overlooked.<\/td><\/tr><tr><td>Why this<br>matters<\/td><td>People experiencing substance dependence, trauma, domestic abuse, mental ill-health or MEH do not always disclose the full extent of their circumstances, and significant harm may remain hidden from individual services.<br><br>The reviews suggest that risk can be underestimated when assessments rely heavily on self-disclosure, presenting behaviour or limited information. Equally, while autonomy and confidentiality must be respected, decisions such as withdrawing consent for family involvement may warrant further reflection where significant concerns remain.<br><br>Taken together, these findings highlight the importance of professional curiosity as a safeguard against hidden harm. This includes maintaining an open and questioning approach, exploring inconsistencies, and recognising that limited information should notautomatically be interpreted as an absence of risk. <\/td><\/tr><tr><td>What good<br>looks like<\/td><td>Good practice was characterised by:<br>. Persistent, compassionate engagement that sought to understand the person&#8217;s wider circumstances.<br>. Professional curiosity about changes in behaviour, presentation or engagement.<br>. Exploration of underlying causes rather than reliance on initial explanations.<br>. Recognition that risk may remain present despite periods of apparent stability or abstinence.<br>. Routine consideration of trauma, domestic abuse, coercion, self-neglect and hidden substance use.<br>. Practitioners remaining open to new information and adapting their understanding as circumstances changed.<br>. Across several reviews, services identified hidden harm because practitioners maintained engagement, sought additional information and remained curious about what might not yet be known.<\/td><\/tr><tr><td>How can the<br>system<br>improve?<\/td><td>. Strengthen professional curiosity across assessment, review and risk-management processes.<br>. Improve routine screening for poly-substance use, trauma, self-neglect and financial vulnerability.<br>. Support practitioners to recognise warning signs of hidden harm, coercion, exploitation and non-disclosed substance use.<br>. Promote reflective discussion where information is incomplete, contradictory or suggests escalating risk.<br>. Ensure withdrawal of consent prompts further reflection where significant vulnerability remains, rather than prematurely closing down professional enquiry.<br>. Continue to embed curiosity, critical thinking and reflective practice across the workforce<\/td><\/tr><tr><td>What is<br>already<br>happening<br>(PDARH<br>impact)<\/td><td>PDARH learning has already informed activity aimed at improving the<br>identification of hidden harm and vulnerability:<br>. Together\/Waythrough are undertaking an audit of poly-drug use screening practices to identify opportunities for improvement.<br>. PDARH case learning has been used within Adult Social Care leadership events exploring intersectionality, vulnerability and MEH.<br>. Learning from reviews is informing wider discussions about screening, assessment and professional curiosity across partner agencies.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-12-coordination-communication-and-shared-ownership-of-risk\" class=\"wp-block-heading\">Theme 12: Coordination, Communication and Shared Ownership of Risk<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of<br>theme findings<\/td><td><strong>Multi-agency responses were often hindered by fragmented communication, inconsistent information sharing and a lack of systematic coordination, leaving effective risk management dependent on individual relationships and effort.<\/strong><br>. Ownership of ongoing risk was often unclear, particularly where multiple agencies were involved.<br>. Opportunities for joint working between substance use, mental health, housing, hospital and welfare services were not consistently realised.<br>. Difficulties convening multi-disciplinary discussions limited shared understanding of risk and delayed action.<br>. Services often operated in parallel rather than through coordinated pathways.<br>. Coordination frequently relied on individual practitioners rather than embedded systems and processes.<br>. Outside of specialist primary care services, the reviews identified limited evidence of primary care acting as a consistent coordinating partner of health-related need and risk despite them being uniquely place to recognise cumulative risk and interaction between co-occurring needs<br>. Data-sharing barriers and poor information flow reduced shared visibility of risk.<br>. Updates and decisions were not always recorded in a clear and traceable way.<br>. Feedback to referring agencies was inconsistent, limiting assurance and collective learning.<br>. Relevant services were not always informed of significant incidents or deaths, reducing opportunities for coordinated support and review.<\/td><\/tr><tr><td>Why this<br>matters<\/td><td>People experiencing substance dependence, mental ill-health, homelessness and other forms of disadvantage rarely fit neatly within a single service. Effective support therefore depends on organisations working together, sharing information and maintaining collective ownership of risk. Reviews repeatedly highlighted situations where risk was recognised by multiple agencies, but challenges hindered single agencies\u2019 ability to coordinate the response.<br><br>Where communication was fragmented, information was not consistently shared, or responsibility was unclear, opportunities for prevention were missed and responses became increasingly reliant on individual practitioners holding systems together.<br><br>These findings suggest that more reliable prevention requires integrated working, systematic approaches to information sharing and case discussion, and clear shared ownership of risk across agencies.<\/td><\/tr><tr><td>What good<br>looks like<\/td><td>Even before the introduction of the Multi-Agency Risk Management (MARM) framework, the reviews identified examples of effective multi agency working, characterised by:<br>. Timely communication and information sharing between partner agencies.<br>. Multi-agency meetings convened to develop a shared understanding of risk and coordinate responses.<br>. Proactive advocacy and care coordination to help individuals remain connected to support.<br>. Contributions from housing, health, substance use and criminal justice partners to build a more complete picture of need.<br>. Shared ownership of risk rather than services working in isolation.<br>. Flexible working across organisational boundaries to overcome barriers and maintain engagement.<br>. Clear communication of decisions, actions and responsibilities.<br>Examples included specialist primary care services at Clock Tower Surgery taking a persistent advocacy role in coordinating care and referrals, housing providers undertaking proactive safeguarding and welfare functions, and information sharing between police, health and housing services that strengthened decision-making and collective oversight of risk.<\/td><\/tr><tr><td>How does the<br>system need<br>to change<\/td><td>. Facilitate timely multi-disciplinary discussion for people experiencing intersecting risks.<br>. Strengthen joint working between treatment, housing, mental health, primary care and criminal justice services.<br>. Embed the MARM framework to support systematic approaches to shared risk management.<br>. Strengthen feedback loops so agencies raising concerns receive responses and outcomes.<br>. Improve the quality and traceability of information sharing and referrals.<br>. Ensure relevant agencies are informed of significant incidents and<br>deaths where appropriate.<\/td><\/tr><tr><td>What is<br>already<br>happening<br>(PDARH<br>impact)<\/td><td>PDARH learning has already contributed to developments aimed at strengthening multi-agency coordination, communication and shared risk management:<br>. Partners have begun implementing the Multi-Agency Risk Management (MARM) framework, creating a more systematic approach to shared case discussion, risk management and coordinated action.<br>. PDARH panels have provided an opportunity for partners to  reflect on MARM implementation and identify barriers to effective multi-agency working.<br>. Together\/Waythrough are exploring co-location within supported accommodation settings to improve access to support and strengthen day-to-day collaboration.<br>. The STaR team and Neighbourhood Policing teams are strengthening information sharing around episodes of custody and vulnerability.<br>. Devon County Council and Waythrough have commenced work with Devon Partnership Trust (DPT) to develop a joint protocol for people with co-occurring mental health and substance use needs.<br>. Improving referral quality and feedback mechanisms has been identified as a system-wide priority through PDARH learning.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"theme-13-workforce-capacity-and-pressures\" class=\"wp-block-heading\">Theme 13: Workforce Capacity and Pressures<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Summary of<br>theme findings<\/td><td><strong>Relationship-based support depends on workforce stability. Workforce pressures reduced continuity of care, limited proactive intervention and weakened the relationship-based support needed for people with complex needs<\/strong>.<br>. Resource constraints and recording gaps affected consistency of support.<br>. High caseloads, vacancies and staff turnover limited capacity for preventative work.<br>. Changes in key workers disrupted trusted relationships and continuity of care.<br>. Workforce pressures contributed to delays in assessment,safeguarding responses and follow-up.<br>. Limited capacity increased reliance on reactive crisis responses rather than earlier intervention.<br>. Staff were frequently supporting people with high levels of complexity, trauma and risk.<\/td><\/tr><tr><td>Why this<br>matters<\/td><td>People with complex needs require relationship-based support, and relationship-based support requires workforce stability.<br><br>Across the reviews, workforce pressures affected not only service capacity but also the ability to maintain the relational approaches that support engagement, risk management and recovery. Staff wellbeing was also a consideration, with many professionals managing high caseloads, complex decision-making and potential exposure to vicarious trauma.<br><br>Taken together, the findings suggest that effective prevention depends not only on workforce skills and training, but also on sufficient capacity, stability and support for staff to sustain engagement over time. <\/td><\/tr><tr><td>What good<br>looks like<\/td><td>Good practice was characterised by:<br>. Continuity of key workers and trusted professional relationships.<br>. Manageable caseloads that allow proactive rather than purely reactive support.<br>. Clear handovers and communication when staff changes occur.<br>. Access to supervision, reflective practice and professional support.<br>. Workforce development that builds confidence in responding to complexity.<br>. Organisational cultures that recognise staff wellbeing as essential to safe and effective practice. <br>The PDARH review process itself was identified as a valuable space for reflection and shared learning, helping practitioners process complex cases and support more consistent practice.<\/td><\/tr><tr><td>How the<br>system needs<br>to change<\/td><td>. Workforce stability should be recognised as a prerequisite for continuity of care.<br>. Continue investment in workforce recruitment, retention and wellbeing.<br>. Strengthen confidence in trauma-informed practice, co-occurring mental health and substance use, fluctuating capacity, domestic abuse and financial vulnerability.<br>. Protect opportunities for reflective practice, supervision and shared learning.<br>. Promote cross-system understanding through joint training and partnership development.<br>. Reduce the impact of staff turnover through stronger handover arrangements and more embedded pathways for coordinated care.<br>. Recognise workforce stability as a prerequisite for sustained engagement, continuity of care and prevention-focused practice.<\/td><\/tr><tr><td>What is<br>already<br>happening<br>(PDARH<br>impact)<\/td><td>PDARH learning has already informed workforce development activity across the partnership, including:<br>. An uplift in remuneration within Together\/Waythrough to support recruitment, retention and workforce stability. Continued investment in trauma stabilisation training for support workers.<br>. Embedding Together\/Waythrough workers within Children&#8217;s Social Care to strengthen understanding of trauma, adversity and substance use across services.<br>. Use of PDARH learning to inform workforce development priorities across DDASP partners.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h3 id=\"10-pdarh-in-practice-role-value-and-maximising-impact\" class=\"wp-block-heading\">10. PDARH in practice: role, value and maximising impact<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>What value has PDARH added?<\/strong><br>During its first year, PDARH has demonstrated its value in five main ways <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Providing evidence for system change<\/strong><br>PDARH has generated locally grounded evidence that has helped partners to identify recurring system challenges, support strategic discussions and influence change. Learning from reviews has informed work relating to safeguarding and MEH, harm reduction, non-fatal overdose pathways, workforce development, financial vulnerability and co-occurring needs.<br><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Creating momentum for partnership action<\/strong><br>PDARH has helped bring agencies together around challenges that sit across organisational boundaries. Learning has contributed to collaborative work on safeguarding and MEH, implementation of the MARM framework and wider discussions regarding housing, cumulative vulnerability and coordinated risk management.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br><strong>Translating learning into action<\/strong><br>PDARH is not solely a learning process. Themes identified through reviews are recorded, tracked and reviewed through a dedicated system action log and reported through existing governance arrangements. This has enabled learning to be translated into tangible activity, including work on naloxone provision, bereavement pathways, housing vulnerability, mental capacity, safeguarding, workforce development, referral quality, non-fatal overdose responses and polydrug use screening.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Supporting practice development<\/strong><br>Learning from reviews has informed changes to policy, procedures and operational practice within partner organisations. Examples include changes to referral pathways, access arrangements, workforce development programmes, harm reduction initiatives, financial vulnerability policies and support for families affected by substance-related harm.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br><strong>Providing a reflective space<\/strong><br>Partners participating directly in panels identified the value of PDARH as a structured space for collective reflection. He process enables practitioners to consider cases from a whole system and single agency perspective, supports reflective practice and helps individuals, teams and organisations process difficult events in a constructive and learning-focused environment. Several participants<br>described the process as reassuring and protective, creating opportunities for reflection and challenge that were not previously available.<br><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Maximising the impact of PDARH<\/strong><br>PDARH is a non-statutory review process. This gives it important flexibility to focus on learning, prevention and system improvement within the formal requirements associated with statutory review mechanisms. However it also means its impact depends on partner participation, transparency and organisational commitment to act on learning.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br>The first year has highlighted three key priorities for maximising impact:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br><strong>Strengthening organisational commitment<\/strong><br>PDARH is most effective when learning is viewed as a shared system responsibility rather than the responsibility of individual agencies. Continued commitment from senior leaders and operational partners is necessary to ensure we both learn effectively and that learning translates into sustained service and system improvement.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br><strong>Improving participation and information sharing<\/strong><br>The quality of reviews depends on agencies contributing information and participating in panel discussions. Capacity pressures and a range of operating models have occasionally limited attendance and quality of information returned, particularly from services outside the core panel. To mitigate this, PDARH is introducing more flexible approaches to participation, including acceptance of alternative information sources such as coroner summaries from primary care where full chronology submissions are not practical. Further work is underway to strengthen engagement from all relevant<br>partners. Panel Membership is shown in Appendix D.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><br><strong>Embedding learning within existing governance<\/strong><br>PDARH has greatest influence when learning is connected directly to existing governance, safeguarding, commissioning and quality improvement processes. Continued alignment with DDASP, safeguarding adult processes, MARM implementation and wider strategic work will help ensure learning contributes to meaningful change across the system.<\/p>\n\n\n\n<h3 id=\"11-limitations-of-the-findings\" class=\"wp-block-heading\">11. Limitations of the Findings<\/h3>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\" \/>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Cases for PDARH were selected for learning and are not representative of all drug and alcohol related deaths in Devon.<\/li>\n\n\n\n<li>Reviews rely on information provided by participating agencies at the point of review.<br>Quality may vary.<\/li>\n\n\n\n<li>PDARH identifies themes and opportunities for improvement but cannot determine<br>causation.<\/li>\n\n\n\n<li>Wider structural factors including housing supply, workforce pressures and service<br>demand influence what can reasonably be achieved through local action alone.<\/li>\n<\/ul>\n\n\n\n<h3 id=\"12-recommendations-for-ddasp\" class=\"wp-block-heading\">12 Recommendations for DDASP<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Learning from PDARH reviews indicates the following 5 priority areas for DDASP to consider at Strategic planning, commissioning and governance level.<\/p>\n\n\n\n<h5 class=\"wp-block-heading has-text-align-center\" id=\"ddasp-priority-area-1-recognise-intersecting-vulnerability\">DDASP Priority Area 1: Recognise Intersecting Vulnerability<\/h5>\n\n\n\n<div class=\"wp-block-group is-layout-constrained wp-block-group-is-layout-constrained\">\n<figure class=\"wp-block-table\"><table><thead><tr><th scope=\"col\">Recommendation (By next annual report)<\/th><th scope=\"col\">Recommendation<br>area<\/th><th scope=\"col\">Relevant DDASP<br>deliverables<\/th><th scope=\"col\">How success will be<br>measured<\/th><\/tr><\/thead><tbody><tr><td>1.1 DDASP partners should support a shared multi-agency approach to recognising intersecting vulnerability and cumulative risk, including development and dissemination of a practice briefing which identifies key indicators for earlier escalation and intervention.<\/td><td>Intersecting<br>vulnerability and<br>cumulative risk<\/td><td>4.6 \u2013 Establish mechanisms<br>to embed system learning<br>from drug and alcohol related deaths; <br>6.1 \u2013 Develop local understanding of drug and alcohol need and progress<br>against national strategy through local data and<br>intelligence; <br>6.2 \u2013 Ensure our local approach is<br>informed by the best available evidence.<\/td><td>Partner awareness and<br>evidence through PDARH<br>learning or subgroup review that<br>cumulative risk is being<br>recognised and acted on more<br>consistently.<\/td><\/tr><tr><td><strong>1.2 DDASP, NHS Devon and primary care partners<br>should explore how mainstream general practice<br>can strengthen its role as a provider of whole<br>person care for people experiencing co-occurring<br>substance use, mental health and physical health<br>needs, recognising the importance of continuity,<br>coordination and proactive identification of<br>vulnerability.<\/strong><br>This should include continuity of care for individuals<br>experiencing intersecting vulnerabilities, coordinated<br>management of multiple health needs, effective<br>professional escalation routes, and appropriate<br>involvement of primary care within multi-agency risk<br>management arrangements.<\/td><td><strong>Intersecting<br>vulnerability and<br>cumulative risk<\/strong><\/td><td>Priority 7: Develop effective ways of working to support<br>individuals with multiple disadvantage and co occurring needs through partnership and integrated working<br>7.2 Improve response to the physical, mental, social and<br>emotional needs of people living with alcohol and other<br>drug dependency.<br>7.3 Develop and implement the Devon inclusion health action plan across the Devon Integrated Care System (ICS).<br>Priority 10: Work as a<br>system to meet the health, social and community needs of people with drug and alcohol dependence<\/td><td>Inclusion Health identified as a priority within Neighbourhood<br>health arrangements including adoption of recommended IH<br>specification and subsequent monitoring of implementation and impact. Increased identification of inclusion health populations<br>through primary care data as evidenced within the One Devon<br>Dataset Inclusion Health<br>Segment.<br>Engagement of Primary care<br>with MARM process.<\/td><\/tr><tr><td><strong>1.3 DDASP partners should use Partnership learning to strengthen recognition of housing<br>instability as a core risk and prevention issue within its strategic oversight. This should include<br>promoting approaches that reduce repeated moves, improve coordination during transitions and promoting shared understanding of vulnerability, suitability and<br>priority housing need.<\/strong><\/td><td><strong>Housing<br>Placement and<br>Stability<\/strong><\/td><td>10.1 \u2013 Work with partners to advocate for effective housing solutions for people<br>with drug and alcohol need;<br>4.3 \u2013 Improve recovery outcomes for those accessing treatment.<\/td><td>Housing instability is reflected more clearly in DDASP discussions and planning,<br>relevant partners can evidence action to strengthen coordination at transitions, and examples are identified where<br>housing-related risk is<br>considered earlier in prevention planning.<br>DDASP representation through rough sleeping plans.<\/td><\/tr><tr><td><strong>1.4 DDASP partners should strengthen system responses to identifiable periods of heightened<br>vulnerability, including hospital admission, nonfatal overdose, bereavement, housing instability and transition between services.<\/strong><br>This should include promoting timely, coordinated and<br>flexible responses, including stronger hospital-to community and hospital-to-rehabilitation coordination where appropriate.<\/td><td><strong>Cumulative Risk<br>and Missed<br>Opportunities<\/strong><\/td><td>4.4 \u2013 Enhance the<br>specialist service offer<br>through partnership working across the health and social care system; <br>4.5 \u2013 Deliver an effective response to<br>drug related harm incidents.<\/td><td>Relevant pathways or agreed approaches have been clarified<br>at critical transitions such as within secondary care, mental health services and loss of stable housing, partners can<br>evidence stronger coordination at key transition points, and<br>PDARH learning identifies fewer missed opportunities linked to these periods of heightened risk.<\/td><\/tr><\/tbody><\/table><\/figure>\n<\/div>\n\n\n\n<h5 class=\"wp-block-heading has-text-align-center\" id=\"ddasp-priority-area-2-strengthen-shared-ownership-of-risk\">DDASP Priority Area 2: Strengthen Shared Ownership of Risk<\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><thead><tr><th scope=\"col\">Recommendation (By next annual report)<\/th><th scope=\"col\">Recommendation<br>area<\/th><th scope=\"col\">Relevant DDASP<br>deliverables<\/th><th scope=\"col\">How success will be<br>measured<\/th><\/tr><\/thead><tbody><tr><td><strong>2.1 DDASP partners should have promoted a more consistent multi-agency approach to coordination and accountability by strengthening shared ownership of risk, supported by implementation of the MARM framework where appropriate and strengthening pathways for people with co-<br>occurring mental health and drug and alcohol<\/strong><br>need. This should include clearer expectations for referral outcomes, enquiry leadership and<br>responsibilities across Adult Social Care, Adult<br>Safeguarding and partner agencies.<\/td><td><strong>Coordination,<br>Communication<br>and Shared<br>Ownership of Risk<\/strong><\/td><td>7.1 \u2013 Develop effective ways of working to support individuals with co-occurring mental health and drug and alcohol need.<\/td><td>Evidence that the MARM<br>framework is being used<br>consistently, partners report full engagement, positive impact<br>and clearer understanding of<br>roles and responsibilities.<br>Feedback loops between Adult<br>Social Care, Adult Safeguarding<br>and partner agencies are more<br>visible through audit, review or<br>case learning.<\/td><\/tr><tr><td><strong>2.2 DDASP partners should continue to strengthen<br>system-wide harm reduction practice by implementing wider naloxone availability as agreed<br>via the DDASP Naloxone Strategy, improved awareness of poly-substance risk and more consistent responses to emerging substances and overdose risk beyond specialist treatment settings alone<\/strong>.<\/td><td><strong>Cumulative Risk<br>and Missed<br>Opportunities<\/strong><\/td><td>5.1 \u2013 Ensure high quality information about drug risk<br>and harm minimisation<br>reaches the right people at the right time; <br>5.2 \u2013 Ensure<br>availability and accessibility<br>of a suite of evidence based harm minimisation<br>interventions; <br>5.3 \u2013 Promote and deliver suite of<br>evidence-based harm reduction measures; <br>5.4 \u2013 Ensure availability and<br>accessibility of a suite of evidence-based harm minimisation interventions.<\/td><td>Naloxone access has widened.<br>Harm reduction messaging<br>through qualitative insights from<br>treatment agencies and partners can evidence stronger<br>awareness of poly-substance<br>and emerging substance risk.<\/td><\/tr><tr><td><strong>2.3 DDASP partners should work together and with wider safeguarding, housing, health and criminal justice partners, to strengthen a joined up<br>approach to safeguarding where substance use and wider multiple and severe disadvantages increase risk. <\/strong>This should include developing a shared understanding of vulnerability, safeguarding<br>responsibilities, risk ownership and appropriate intervention pathways where concerns escalate.<br>Learning from the planned multi-agency safeguarding and multiple exclusion homelessness event should be used to develop shared principles, improve consistency<br>of decision-making and strengthen multi-agency responses where vulnerability is recognised but<br>statutory safeguarding thresholds may not be met.<\/td><td><strong>Safeguarding,<br>Vulnerability and<br>Multiple Exclusion<br>Homelessness<br>(MEH)<\/strong><\/td><td>6.2 \u2013 Ensure our local approach is informed by the<br>best available evidence;<br>7.1 \u2013 Develop effective ways of<br>working to support<br>individuals with co-<br>occurring mental health and drug and alcohol need; 8.2 \u2013 Support the development of system wide trauma informed workplaces and<br>workforces.<\/td><td>Partners report clearer<br>understanding of approaches to<br>supporting individuals to<br>address and reduce risk.<br>Communication between<br>agencies collectively managing<br>risk has improved, and PDARH<br>or subgroup learning shows<br>stronger joined-up responses<br>where vulnerability is escalating.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 class=\"wp-block-heading has-text-align-center\" id=\"ddasp-priority-area-3-improve-engagement-and-access-to-care\"><strong>DDASP Priority Area 3: Improve Engagement and Access to Care<\/strong><\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><thead><tr><th scope=\"col\">Recommendation (By next annual report)<\/th><th scope=\"col\">Recommendation<br>area<\/th><th scope=\"col\">Relevant DDASP<br>deliverables<\/th><th scope=\"col\">How success will be<br>measured<\/th><\/tr><\/thead><tbody><tr><td><strong>DDASP partners should advocate for and apply a shared approach to barrier-informed re-engagement across relevant services.<\/strong> This should include recognition of non-engagement as a potential indicator of heightened need and risk, and promote approaches that respond to barriers such as trauma, poor mental health, digital exclusion, neurodiversity and instability rather than service withdrawal.<\/td><td><strong>Supporting Engagement, Access and Autonomy<\/strong><\/td><td><em>4.1 \u2013 Maintain numbers in treatment in line with 2024 baseline; <\/em><br><em>4.2 \u2013 Improve treatment outcomes for those in treatment; <\/em><br><em>4.3 \u2013 Improve recovery outcomes for those accessing treatment.<\/em><\/td><td>A shared approach has been developed and advocated for amongst services, relevant services can evidence dissemination or briefing, and examples can be identified of more flexible re-engagement responses being used in place of routine closure.<\/td><\/tr><tr><td><strong>DDASP, NHS Devon and primary care partners should work together to consider how to strengthen access to and engagement with Primary Care for health inclusion groups.<\/strong> This should include <strong>r<\/strong>ecognition of Primary Cares\u2019s pivotal role in coordinating care particularly within multiple and complex health needs.<\/td><td><strong>Access and Coordination of Care<\/strong><\/td><td><em>Priority 7: Develop effective ways of working to support individuals with multiple disadvantage and co-occurring needs through partnership and integrated working<\/em><br><em>7.2 Improve response to the physical, mental, social and emotional needs of people living with alcohol and other drug dependency.<\/em><br><em>7.3 Develop and implement the Devon inclusion health action plan across the Devon Integrated Care System (ICS).<\/em><br><em>Priority 10: Work as a system to meet the health, social and community needs of people with drug and alcohol dependence<\/em><\/td><td>Inclusion Health identified as a priority within Neighbourhood health arrangements including adoption of recommended IH specification and subsequent monitoring of implementation and impact.&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 class=\"wp-block-heading has-text-align-center\" id=\"ddasp-priority-area-4-support-family-and-communities\"><strong>DDASP Priority Area 4: Support Family and Communities<\/strong><\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><thead><tr><th scope=\"col\">Recommendation (By next annual report)<\/th><th scope=\"col\">Recommendation<br>area<\/th><th scope=\"col\">Relevant DDASP<br>deliverables<\/th><th scope=\"col\">How success will be<br>measured<\/th><\/tr><\/thead><tbody><tr><td><strong>DDASP partners should recognise families and carers both as potential protective factors and as people with support needs of their own.<\/strong> &nbsp;This should include improving the visibility and accessibility of support for families and carers, recognising the impact of strain, stigma and carer fatigue, and promoting more thoughtful approaches where family involvement may be supportive but is not straightforward.<\/td><td><strong>Family Relationships and Involvement<\/strong> <\/td><td><em>12.3 \u2013 Children affected by parental substance misuse and other parental risk factors are effectively supported; <\/em><br><em>6.4 \u2013 Work with people with lived experience to inform and deliver the ambitions of DDASP.<\/em><\/td><td>Carers\u2019 support is more visible through communications, pathway information or partnership activity, and examples can be identified of families and carers being more consistently recognised within service planning, learning or support discussions.<\/td><\/tr><tr><td><strong>DDASP partners should strengthen recognition of bereavement as both a critical intervention window and a significant risk factor in its own right<\/strong>. This should include promoting awareness of available bereavement support for adults and children affected by drug- and alcohol-related deaths and improving clarity about how that support can be accessed<\/td><td><strong>Social Isolation, Bereavement and Relational Loss<\/strong><\/td><td><em>4.5 \u2013 Deliver an effective response to drug related harm incidents; <\/em><br><em>12.3 \u2013 Children affected by parental substance misuse and other parental risk factors are effectively supported.<\/em><\/td><td>Bereavement is more clearly reflected in DDASP learning and planning, support routes are more visible and better communicated, and examples can be identified of bereavement being recognised earlier as a factor in risk and support discussions.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 class=\"wp-block-heading has-text-align-center\" id=\"ddasp-priority-area-5-build-workforce-capacity\"><strong>DDASP Priority Area 5: Build Workforce Capacity<\/strong><\/h5>\n\n\n\n<figure class=\"wp-block-table\"><table><thead><tr><th scope=\"col\">Recommendation (By next annual report)<\/th><th scope=\"col\">Recommendation<br>area<\/th><th scope=\"col\">Relevant DDASP<br>deliverables<\/th><th scope=\"col\">How success will be<br>measured<\/th><\/tr><\/thead><tbody><tr><td><strong>DDASP partners should develop a shared vision for workforce stability, continuity of care and relationship-based practice, and use its influence to advocate for these principles across partner organisations.<\/strong><br><strong>&nbsp;&nbsp;<\/strong><br><strong>DDASP partners should support collaborative workforce development activity that strengthens confidence in trauma-informed practice, co-occurring mental health and substance use, fluctuating capacity, domestic abuse and financial vulnerability.<\/strong> This should also promote shared learning, reflective practice and cross-system understanding to support sustained workforce capability.<\/td><td><strong>Workforce Capacity and Pressures<\/strong><\/td><td><em>8.1 \u2013 Develop a Devon Workforce Strategy following publication of the OHID capability framework; <\/em><br><em>8.2 \u2013 Support the development of system wide trauma informed workplaces and workforces.<\/em><\/td><td>Improved workforce retention and continuity of key workers in core services.<br>&nbsp;<br>Relevant collaborative training or learning activity has been delivered, partners can evidence participation or dissemination, and feedback or review indicates improved confidence and shared understanding across services.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h3 id=\"13-recommendations-for-pdarh-process\" class=\"wp-block-heading\"><a>13<\/a>&nbsp; Recommendations for PDARH Process<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Learning from reviews and partner feedback has identified the following recommendations to strengthen the PDARH process.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><thead><tr><th scope=\"col\"><strong>Recommendation area<\/strong><\/th><th scope=\"col\"><strong>Recommendation<\/strong><\/th><th scope=\"col\"><strong>Suggested timeframe<\/strong><\/th><th scope=\"col\"><strong>How success will be measured<\/strong><\/th><\/tr><\/thead><tbody><tr><td><strong>Evaluating the Effectiveness of PDARH<\/strong><\/td><td><strong>The partnership should develop a proportionate approach to evaluating the effectiveness of the PDARH process itself, utilising OHID guidelines in relation to Drug and Alcohol Related Deaths Reviews<\/strong>. This should include consideration of partner participation and consistency, timeliness of reviews, quality of information returned, evidence of ongoing action taken in response to learning, and feedback from panel members, partners and lived experience routes where appropriate. This will help the partnership assess whether PDARH is achieving its intended aims and where further refinement is needed.<\/td><td>Within 6 months<\/td><td>An evaluation framework is agreed and used, with an initial summary of findings reviewed through PDCS before the next annual report.<\/td><\/tr><tr><td><strong>Strengthening Links with Safeguarding Adults and Domestic Homicide Review Processes<\/strong><\/td><td><strong>PDARH should continue to strengthen links with related review mechanisms, including Safeguarding Adults Reviews (SARs) and Domestic Homicide Reviews (DHRs) where relevant, in order to improve shared learning, reduce duplication and strengthen the influence of PDARH within the wider safeguarding context.<\/strong><br><br>Exploration of formal mechanisms for joint learning across review processes should continue, for example through identifying shared themes across SARs, PDARH and other review activity and scoping of a dedicated learning session or joint learning events which could support wider dissemination and system reflection. As the process matures, presentation of the annual PDARH report to the SARs Operational Delivery Group (OPG) may also provide an opportunity to strengthen strategic oversight and support collective ownership of the learning.<\/td><td>Within 6 months, with presentation by the next annual report<\/td><td>At least one formal mechanism for shared learning is agreed, shared themes are mapped, and the annual report is presented through the relevant safeguarding forum.<br><em>The PDARH Coordinator is already engaged in review work with the Torbay and Devon Safeguarding Adults Service Manager to highlight recommendations from SARs in the last 3 years, that overlap with the work PDARH are undertaking.<\/em><br><em>The PDARH coordinator has already presented findings from the Thematic Review into Alcohol Related Deaths to the OPG and will be due to provide an update in late Autumn 2026.<\/em><\/td><\/tr><tr><td><strong>Exploring Inclusion of Near-Fatal Overdose Reviews in PDARH Reviews<\/strong><\/td><td><strong>In line with the wider intent of national guidance, the partnership should consider whether there is scope over time to include selected near-fatal overdose cases within the review process.<\/strong> This could strengthen opportunities for prevention by identifying learning from serious incidents before a death occurs, while recognising the need for a proportionate and manageable local approach. National monitoring intelligence is available through the Early Warning System (EWS), while local pathways to improve understanding of the frequency and circumstances of non-fatal overdoses are currently being explored.<\/td><td>By the next annual report<\/td><td>A scoping exercise is completed, with options, risks and resource implications set out and a recommendation made on whether to pilot this approach.<\/td><\/tr><tr><td><strong>Strengthening System-Wide Learning Through a Thematic Assurance Approach<\/strong><\/td><td><strong>To support long-term system learning, PDARH should adopt a thematic learning and assurance framework that is theme-based rather than action-based.<\/strong> This recognises that much of the learning identified through reviews is cumulative and persistent, requiring sustained system change rather than one-off actions. The framework should focus on learning, reflection and continuous improvement rather than performance management, and should be explicitly linked to DDASP priorities and governance arrangements to ensure learning informs strategic oversight and accountability.<\/td><td>Within 6 months<\/td><td>The thematic framework and register are already in place and ownership is assigned. At least one update has been presented through PDCS before the next annual report. Attributing a risk rating to each theme would support selection of spotlighting and guide priority<\/td><\/tr><tr><td><strong>Using Thematic Spotlight Reviews to Support Action Tracking<\/strong><\/td><td><strong>Each year, DDASP should identify two to three priority themes for thematic spotlighting as part of a proportionate approach to tracking long-term PDARH learning.<\/strong> For these spotlight themes, learning from PDARH reviews over multiple years (once established) would be considered together to support a deeper understanding of whether and how system responses are changing over time.<br><br>Partners would be invited to reflect on where learning has translated into sustained changes in practice and where recurrence remains evident, including the factors that may be limiting progress. Progress and challenge would be discussed through the Preventing Deaths and Clinical Safety Subgroup, providing a structured forum for shared reflection. Where learning remains persistent despite previous action, themes would be escalated through DDASP governance routes and initiatives revisited.<\/td><td>Themes identified within 6 months; review by the next annual report<\/td><td>Two to three spotlight themes are agreed, reviewed through PDCS, and reflected in annual reporting or escalation where recurrence remains evident.<\/td><\/tr><tr><td><strong>Strengthening Core Panel Participation<\/strong><\/td><td><strong>Further work should continue to establish and maintain a consistent core multi-agency panel.<\/strong> This should include regular review of core membership and consideration of where additional partner agencies should be involved to strengthen consistency, support shared learning and ensure that relevant system perspectives are represented.<\/td><td>Within 3 months, then ongoing<\/td><td>Core panel membership and expectations are confirmed, attendance is monitored, and recurring gaps are identified and escalated through PDCS where needed.<\/td><\/tr><tr><td><strong>Preparing Contributors for PDARH Panels<\/strong><\/td><td>The PDARH process may include specific professionals who worked with the individual prior to their death, alongside core panel members. It is therefore important to ensure that contributors are appropriately prepared for what to expect from the review process and understand that the panel is intended to provide a safe, reflective space for shared learning rather than individual accountability or proportionating blame. <strong>Standardised preparation materials, clear expectations and early presentation of emerging case themes may help contributors feel supported to participate, maximise reflective discussion, strengthen the quality of contribution and improve the consistency of panel participation.<\/strong><\/td><td>Within 3 months<\/td><td>A standard contributor briefing is developed and used, and feedback indicates contributors feel clearer about the purpose and expectations of the process.<\/td><\/tr><tr><td><strong>Strengthening Lived Experience and Family Involvement<\/strong><\/td><td><strong>The Prevention of Death and Clinical Safety subgroup should continue to explore safe, trauma-informed and proportionate ways of strengthening family and lived experience involvement in the PDARH process.<\/strong> This should include how insight is gathered, supported and reflected in learning. There should also be clear written protocols that can be provided to individuals at the outset of involvement. Further development should ensure that participation remains appropriately supported and does not create additional harm.<\/td><td>Within &nbsp;12 months<\/td><td>A clear, trauma-informed approach is agreed, including principles and participation routes, and there is evidence that lived experience or family insight is being considered appropriately in learning. A protocol for engaging family and those with lived experience is in place and utilised to provide consistency and maintaining professional boundaries.<\/td><\/tr><tr><td><strong>Developing Presentation and Dissemination of PDARH Learning<\/strong><\/td><td><strong>As the process matures, continued attention should be given to how learning is presented and shared. This includes strengthening the \u201clearning on a page\u201d format, ensuring recommendations are clear and actionable and improving how learning is disseminated to both strategic and operational audiences so that it supports reflection, ownership and practical improvement.<\/strong><br>&nbsp;<br>A standard template should be developed, and accessible formats, including easy read versions where appropriate, should be made available. This would enable individual learning reports to stand alone where needed, while also supporting their inclusion within the annual PDARH report and secure storage on the DDASP SharePoint site.<\/td><td>Template within 3 months; wider use by the next annual report<\/td><td>A standard template is in place, learning is shared in a more consistent format, and accessible or adapted formats are available where relevant.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h3 id=\"14-conclusion\" class=\"wp-block-heading\"><a>14. Conclusion<\/a><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">This first annual report demonstrates the importance of the Preventing Drug and Alcohol Related Harm (PDARH) process as a structured, partnership-based approach to learning from drug- and alcohol-related deaths.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The reviews undertaken during the year show that deaths rarely arise from a single event or isolated service failure. Rather, they are shaped by cumulative and intersecting vulnerabilities, including housing instability, trauma, bereavement, social isolation, mental and physical health, barriers to engagement and fragmented support at key points of transition. However, services often respond in isolation or at points of crisis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The challenge for the system is to respond to need in an integrated way that acknowledges the cumulative nature of the challenges faced. Effective prevention depends not on improving individual pathways in isolation, but on developing coordinated responses capable of recognising and responding to intersecting need.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">At the same time, the reviews also identified clear examples of compassionate, persistent and trauma-informed practice across the system, reinforcing the importance of flexible engagement that meets people \u2018where they are\u2019, strong harm reduction and effective multi-agency working.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">PDARH provides an important mechanism for reflection, shared learning, strategic oversight and collective ownership of improvement. Reducing drug- and alcohol-related harm will require sustained partnership commitment, a willingness to respond to recurring themes with coordinated action and a continued focus on prevention, equity and earlier intervention.<\/p>\n\n\n\n<h3 id=\"15-acknowledgements\" class=\"wp-block-heading\"><a>15<\/a>&nbsp;&nbsp;&nbsp; Acknowledgements<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">We would like to thank all partner agencies and colleagues who contributed to the Preventing Drug and Alcohol Related Harm (PDARH) process and continue to engage in the process. This includes members of the Devon Drug and Alcohol Strategic Partnership (DDASP), the Preventing Deaths and Clinical Safety Subgroup and representatives from health, social care, housing, treatment services, criminal justice, primary care, mental health services, and the voluntary and community sector who contributed information, reflection and learning to the review process.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Special acknowledgement is for the 12 individuals whose stories helped to shape this report.<\/p>\n\n\n\n<h3 id=\"appendices\" class=\"wp-block-heading\"><a><strong>Appendices<\/strong><\/a><\/h3>\n\n\n\n<h5 id=\"appendix-a-governance\" class=\"wp-block-heading\"><a><strong>Appendix A: Governance<\/strong><\/a><\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">The Preventing Drug and Alcohol Related Harm (PDARH) process reports to the Devon Drug and Alcohol Strategic Partnership (DDASP). DDASP meetings are chaired by the Director of Public Health and attended by strategic partnership members.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The DDASP was formed in November 2022, following the requirement by central government for local areas to report progress towards achieving the recommendations of the national drugs strategy, <em>From Harm to Hope<\/em>, to the National Combating Drugs Unit. Combatting Drugs Partnerships operate under this 10-year strategy, which emphasises reducing harm, promoting recovery and improving community safety. The strategy is supported by the National Combating Drugs Outcomes Framework, which tracks progress across local and national levels.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The key aims of DDASP are to deliver the ambitions of the national drugs strategy, improve integration of provision and, in particular:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Increase numbers of people in treatment<\/li>\n\n\n\n<li>Reduce alcohol and drug related deaths<\/li>\n\n\n\n<li>Improve continuity of care for people engaged in the criminal justice system<\/li>\n\n\n\n<li>Reduce the supply and demand for illicit substances<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Oversight of PDARH activity is provided through the DDASP governance structure, ensuring that learning, themes and priorities arising from reviews are considered within established strategic and delivery forums. Learning reports are produced and presented to the DDASP Preventing Deaths and Clinical Safety subgroup. This enables alignment between PDARH learning, partnership priorities and prevention activity across the system. This governance structure provides a clear route for escalation of significant themes or risks, where required, to inform partnership priorities and system response.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The process relies on active engagement from partner organisations, reflecting a shared responsibility for preventing drug- and alcohol-related harm.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">An annual report is presented each autumn to provide an overview of emerging themes, review progress against DDASP priorities and monitor delivery of the strategic action plan. This approach ensures that learning from reviews is translated into meaningful system improvement, supports accountability for action and promotes continuous learning to reduce future drug- and alcohol-related harm and deaths.<\/p>\n\n\n\n<h5 id=\"appendix-b-methodology\" class=\"wp-block-heading\"><a><strong>Appendix B: Methodology<\/strong><\/a><\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">The Devon PDARH process has been developed in line with <a href=\"https:\/\/www.gov.uk\/government\/publications\/preventing-drug-and-alcohol-deaths-partnership-review-process\/preventing-drug-and-alcohol-deaths-partnership-review-process\" rel=\"noopener\">OHID guidance<\/a>, while being adapted to local governance arrangements, system capacity, and partnership priorities. Devon\u2019s PDARH process is currently focused on deaths and there is scope to develop the process to include near fatal overdoses in future. For more information about the PDARH process, case selection criteria and involvement of people with lived experience please refer to the <a href=\"https:\/\/devoncc.sharepoint.com\/:b:\/r\/sites\/Substancemisuse\/Drugs%20and%20Alcohol\/Prevention%20of%20Drug%20and%20Alcohol%20Related%20Deaths%20(PDARH)%20Review%20Panels\/Devon%20Prevention%20of%20Drug%20and%20Alcohol%20Related%20Harms%20Review%20Panel%20Process.pdf?d=we240096f12114b6391d6057ffb0d5d9a&amp;csf=1&amp;web=1&amp;e=r6tkiy\" rel=\"noopener\">Devon Prevention of Drug and Alcohol Related Harms Review Panel Process<\/a><\/p>\n\n\n\n<h6 id=\"limitations-in-relation-to-methodology\" class=\"wp-block-heading\"><strong>Limitations in relation to Methodology<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">The interpretation of findings and learning in this report should be informed by an understanding of the PDARH methodology, scope and limitations.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Cases reviewed through the PDARH process are selected using predefined criteria and therefore may not be representative of all drug- and alcohol-related deaths across the Devon footprint. Findings should be interpreted as indicative of wider system issues rather than generalisable to the wider population.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Reviews are based on information available at a specific point in time and rely on records and contributions provided by partner agencies. As a result, the level of detail available may vary between cases. Variability in data quality, recording practices and information sharing across agencies may influence the depth and consistency of information reviewed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Learning arising from the PDARH process is indicative rather than statistical meaning at times it may not be possible to track progress in short term, such as is appropriate in relation to targeted interventions. It is intended to highlight recurring themes, system risks and opportunities for prevention, rather than to provide quantitative analysis or definitive conclusions about causality.<\/p>\n\n\n\n<h6 id=\"mitigation\" class=\"wp-block-heading\"><strong>Mitigation<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">To address the limitations outlined above, the following mitigations are in place or under development as part of the PDARH process.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">While cases are not representative of all deaths, the use of clear, predefined selection criteria supports consistency in relation to focused exploration of system risks, inequalities and opportunities for prevention.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Information is drawn from multiple partner agencies wherever possible to support a more complete understanding of engagement, risk and service involvement and to mitigate reliance on single\u2011source records.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Learning is intentionally thematic and system\u2011focused, enabling insight to be drawn from patterns across cases rather than relying on short\u2011term quantitative indicators. This supports learning where measurable outcomes may take longer to emerge.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Public Health continues to work with partners, to strengthen awareness of the PDARH process, improve participation, and support timely contributions to reviews. We have agreed a core panel of representatives, including specialist inclusion group primary care services, adult safeguarding and social care, drug and alcohol treatment services, housing, commissioning and department of work and pensions (DWP), to support consistency within the panel. We have an arrangement in place with DPT where learning reports and recommendations are incorporated directly into quarterly mortality review reports. We are also seeking other opportunities to engage with our primary care partners, via forums and training opportunities.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Challenges relating to partner participation are reported through DDASP governance structures to support shared ownership and system\u2011level resolution.<\/p>\n\n\n\n<h5 id=\"appendix-c-overview-of-reviews-undertaken\" class=\"wp-block-heading\"><a><strong>Appendix C: Overview of Reviews Undertaken<\/strong><\/a><\/h5>\n\n\n\n<h6 id=\"c-1-overview\" class=\"wp-block-heading\"><strong>C.1 Overview<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">This section provides an overview of the individuals reviewed through the Prevention of Drug and Alcohol Related Harm (PDARH) process during the reporting period. It is intended to support transparency around who was reviewed, the characteristics of the cohort and how cases were selected for review.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The PDARH process is not designed to review every drug\u2011 or alcohol\u2011related death. Cases are selected using predefined criteria to maximise system learning and to identify opportunities for prevention and service improvement. This section should be read alongside the PDARH methodology and limitations sections of this report.<\/p>\n\n\n\n<h6 id=\"c-2-case-selection-rationale\" class=\"wp-block-heading\"><strong>C.2 Case Selection Rationale<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">Case selection is informed by:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>The presence of population\u2011level vulnerabilities;<\/li>\n\n\n\n<li>Characteristic risk factors associated with increased drug\u2011 or alcohol\u2011related; harm<\/li>\n\n\n\n<li>Opportunities for multi\u2011agency intervention prior to death.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">As a result, cases reviewed are not representative of all drug and alcohol related deaths in the Devon footprint, but instead reflect a targeted approach designed to support meaningful learning, service improvement and prevention activity across the system.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The PDARH review panel considered 12 individuals, 7 individual cases and 5 cases reviewed together as part of a thematic review of alcohol related death.<\/p>\n\n\n\n<h6 id=\"c-3-demographic-profile-of-the-cohort\" class=\"wp-block-heading\"><strong>C.3 Demographic Profile of the Cohort<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">Male: 7 (58.3%)<br>Female: 5 (41.7%)<br>Trans or non\u2011binary: 0 recorded<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Gender identity is reported as recorded within partner agency documentation. Absence of recording reflects limitations in source data rather than exclusion.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Age at Death<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Age was recorded for all individuals reviewed<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Under 40 years: 4 (33.3%)<br>40\u201364 years: 8 (66.7%)<br>65 years and over: 0<\/p>\n\n\n\n<h6 id=\"c-4-population-risk-factors\" class=\"wp-block-heading\"><strong>C.4 Population Risk Factors<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">Population\u2011level vulnerabilities were considered as part of case selection where they were clearly evidenced in available records. Within this cohort:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Parents or primary caregivers: 8 (75.0%)<br>Care\u2011experienced adults (explicitly recorded): 1 (8.3%)<br>Neurodiversity (diagnosed): 2 (16.7%)<br>Living in areas of high deprivation (IMD decile 1\u20132): 1 (8.3%)* \u2013 this is likely to be higher as IMD decile could not be consistently assigned for all cases, as postcode\u2011level data was not routinely captured within Known to Services returns and a number of individuals were listed as \u2018no fixed abode\u2019.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">These factors were not used as exclusionary criteria but helped prioritise cases where wider system learning could be achieved.<\/p>\n\n\n\n<h6 id=\"c-5-characteristic-risk-factors\" class=\"wp-block-heading\"><strong>C.5 Characteristic Risk Factors<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">A range of characteristic risk factors were identified across the cohort, based on explicit evidence within agency records:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Unemployment or recent employment instability: at least 9 individuals (\u226575%)<br>Accommodation instability (including rough sleeping, sofa surfing, supported accommodation or eviction risk): at least 6 individuals (\u226550.0%)<br>History of domestic abuse (as a victim, perpetrator, or both): 4 individuals (33.3%)<br>Diagnosed mental health condition or significant mental health need: evident across the majority of cases<br>Poly\u2011substance use or high\u2011risk substance combinations: evident across majority of cases.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Some factors, such as loneliness, social isolation, financial stress, or whether substances were used alone, were not consistently captured across all agencies and are therefore described qualitatively rather than quantified.<\/p>\n\n\n\n<h6 id=\"c-6-opportunities-for-intervention\" class=\"wp-block-heading\"><strong>C.6 Opportunities for Intervention<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">An important element of PDARH case selection is the presence of identifiable opportunities where earlier or different intervention may have altered risk. Within this cohort:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Contact with the criminal justice system (including police contact, custody, or probation): 5 individuals (\u226541.7%)<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Recent non\u2011fatal overdose and\/or naloxone administration: at least 4 individuals (\u226533.3%) (number may have been higher as services may not have known about recent non-fatal overdoses or naloxone administration)<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Drug and alcohol treatment status at time of death:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Engaged in treatment: 5 (41.7%)<\/li>\n\n\n\n<li>Known previously but not engaged at time of death: 4 (33.3%)<\/li>\n\n\n\n<li>Not known to drug and alcohol treatment services: 3 (25.0%)<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">The inclusion of cases across different points of the treatment and support pathway reflects PDARH\u2019s system\u2011wide focus and avoids limiting learning to a single service group.<\/p>\n\n\n\n<h5 id=\"appendix-d-core-panel-membership\" class=\"wp-block-heading\"><a><strong>Appendix D: Core Panel Membership<\/strong><\/a><\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">The table below identifies the PDARH core panel correct at 26\/08\/26. This does not reflect the full aspiration of the core panel membership. There is an absence of ICB and coronial representation and we continue to work towards establishing these links. Additional panel members are invited to attend dependent upon whether the case being reviewed is known to their service. Examples are shown in the following table:<\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong>PDARH Core Panel Membership<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td>Consultant in Public Health (Chair)<\/td><td>Devon Public Health<\/td><td>Lex Gainsbury<\/td><\/tr><tr><td>PDARH Co-ordinator<\/td><td>Devon Public Health<\/td><td>Katherine Oliverio<\/td><\/tr><tr><td>Substance Misuse Commissioner<\/td><td>Devon Public Health<\/td><td>Rich Merrifield<\/td><\/tr><tr><td>Drug and Alcohol Treatment Provider Senior Manager \/ Health Improvement Lead<\/td><td>Together (Way Through)<\/td><td>Fran Bendall \/ Ben Holden<\/td><\/tr><tr><td>Patient Safety Investigation Lead<\/td><td>DPT<\/td><td>Sam Underwood<\/td><\/tr><tr><td>Adult Social Care representative<\/td><td>Devon County Council<\/td><td>Tbc<\/td><\/tr><tr><td>GP with specialism in drug and alcohol treatment<\/td><td>Clock Tower Surgery<\/td><td>Dr Sam Cole<\/td><\/tr><tr><td>Drug and Alcohol Prevention Lead<\/td><td>Devon and Cornwall Police<\/td><td>Becca Turner<\/td><\/tr><tr><td>JCP Operational Leader D&amp;C<\/td><td>Department of Work and Pensions<\/td><td>Stephanie Deakin<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong>Case Specific Membership<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td>Primary Care GP<\/td><td>Primary Care GP<\/td><\/tr><tr><td>DPT Case workers<\/td><td>DPT<\/td><\/tr><tr><td>Learning From Death Coordinator\/ Lead<\/td><td>South West Ambulance Service<\/td><\/tr><tr><td>Homeless Strategy and Housing Leads<\/td><td>District Councils<\/td><\/tr><tr><td>Head of Practise and Operations<\/td><td>Co-Lab<\/td><\/tr><tr><td>Project Co-ordinator<\/td><td>STaR<\/td><\/tr><tr><td>Housing and Rough Sleeping support Providers<\/td><td>BCHA\/\/ Guinness\/ Westward\/ Sanctuary Supported Living\/ St Petrocks\/ ECCT\/ Homegroup<\/td><\/tr><tr><td>Death in Custody Investigation Lead<\/td><td>HM Probation and Prison Service<\/td><\/tr><tr><td>SSID Data Analyst<\/td><td>Pete\u2019s Dragons<\/td><\/tr><tr><td>Hospital Representatives<\/td><td>RDUH<\/td><\/tr><tr><td>Regional OHID representative (DARD lead)<\/td><td>OHID<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h5 id=\"appendix-e-alcohol-related-deaths-thematic-review-recommendations\" class=\"wp-block-heading\"><a><strong>Appendix E: Alcohol-Related Deaths Thematic Review Recommendations<\/strong><\/a><\/h5>\n\n\n\n<h6 id=\"e-1-introduction\" class=\"wp-block-heading\"><a>E.1 Introduction<\/a><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\">Nine key recommendations arose out of the learning from the alcohol related death thematic review in which 5 cases were considered.&nbsp;<\/p>\n\n\n\n<h6 id=\"e-2-recommendations\" class=\"wp-block-heading\"><strong>E.2 Recommendations<\/strong><\/h6>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 1<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Exeter City Council should develop and share clear guidance on how vulnerability is assessed for housing priority, what constitutes suitable accommodation, and how individuals and professionals can contribute to a person\u2011centred understanding of suitability. As part of this work, the Council should also explore opportunities for wider partners\u2014including health and other relevant professionals\u2014to contribute to decision\u2011making around priority and suitability. Once developed, this guidance should be reviewed by the Preventing Death and Clinical Safety Subgroup and other appropriate forums to support a shared understanding and provide constructive critical challenge.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Exeter City Council to provide guidance regarding how vulnerability is assessed to inform.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 2<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Clock Tower Surgery will now work with supported living accommodation settings to identify individuals who are not registered with the surgery but would benefit from STaR and other support usually accessed via CTS registration. This will address the gap to refer to appropriate support services when an individual is not registered with Clock Tower Surgery.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 3<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Together\/Waythrough and supported accommodation providers should consider ways of strengthening joint working, including the potential role of co-location. This is an ongoing aspiration, and the panel noted the challenging context of current funding reviews for supported accommodation provision due to be concluded in April 2026.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a><\/a><a><strong>Recommendation 4<\/strong><\/a><strong>&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Improving referral to drug and alcohol service information quality by encouraging professionals to provide comprehensive referral information. Together\/Waythrough to consider system-wide communication to reinforce this. <em>This is a system wide recommendation but has already been taken forward by Together\/Waythrough Drug and Alcohol treatment services.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 5&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Opportunities to develop a pathway to Tier 4 rehab services following a mental health hospital discharge should be explored through the Devon Partnership Trust and Together\/Waythrough joint working meetings currently in place. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 6&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Addressing the gap in understanding available support when an individual seeks to engage with drug and alcohol services at point of abstinence with risk of relapse, through further training and clarification of eligibility criteria for support by Drug and Alcohol treatment support workers.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 7<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Effective and coordinated ownership to enact a risk management framework, by embedding the MARM framework into practice, as a tool for supporting partner organisations to lead risk management meetings and coordination in circumstances where high risk for an individual in crisis has been identified. This may sit outside of the statutory bodies such as the Local Authority but still require a multi-agency collaborative approach. Support will be offered to partner organisations, when the framework is published in March 2026. A MARM Oversight group will meet regularly to maintain a consistent review of effectiveness.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 8<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The need for multi-agency staff to understand Mental Capacity, in relation to fluctuating capacity concerns regarding alcohol use. This will empower support staff to have open conversations around capacity with individuals, whilst understanding the limitations that also exist.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Conversations are already underway with Workforce Development, the Mental Capacity Lead in Adult Social Care, and Public Health Commissioning regarding Drug and Alcohol screening and support for ASC staff. This work also presents an opportunity to develop a two-way training offer.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Recommendation 9<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The need for effective polydrug use screening as a system and embedding this into practice to mitigate risk and provide effective treatment. The first step is around scoping what screening tools and methods are currently in place and identifying opportunities for improvement.&nbsp;<\/p>\n\n\n\n<h5 id=\"appendix-f-strategic-indicators-detailed-context-data\" class=\"wp-block-heading\"><a><strong>Appendix F: Strategic Indicators (Detailed Context Data)<\/strong><\/a><\/h5>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>F.1 Overview and purpose<\/strong><br>This appendix provides the detailed national, regional, county and district-level indicator narrative referenced in Section 6. The indicators are included to contextualise PDARH learning and support DDASP strategic oversight; they do not measure the direct impact of PDARH. Some datasets are subject to time lag or disclosure restrictions; interpretation should be exercised with caution.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>F.2 Data sources \u2013 National, County and District Level<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">National data sources are used within the Preventing Drug and Alcohol Related Harm (PDARH) process to provide context for local findings and to support understanding of wider trends. These include Office for National Statistics (ONS) mortality data on drug-related and alcohol-specific deaths, Public Health Outcomes Framework (PHOF) indicators, and Office for Health Improvement and Disparities (OHID) profiling tools. Together, these datasets help place local patterns within a wider national and regional context and support strategic oversight of progress in reducing drug- and alcohol-related harm.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">ONS data on deaths related to drug poisoning show that, in England and Wales, 5,565 such deaths were registered in 2024, equivalent to 93.9 deaths per million people. This was higher than the rate recorded in 2023 (93.0 deaths per million; 5,448 deaths). The age-standardised mortality rate for deaths related to drug poisoning has risen every year since 2012.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Among males, there were 128.7 drug-poisoning deaths per million in 2024 (3,710 deaths), compared with 60.6 deaths per million among females (1,855 deaths). Just under half of all drug-poisoning deaths registered in 2024 were confirmed to involve an opiate or opioid (47.1%; 2,621 deaths). In addition, 195 deaths involved a nitazene, almost four times higher than in 2023.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In the South West, 392 deaths related to drug poisoning were registered in 2024, equivalent to 70.9 deaths per million people. This was lower than the rate recorded in 2023 (88.2 deaths per million; 486 deaths).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Alcohol-specific mortality&nbsp; in England recorded &nbsp;23,861 deaths and an age-standardised rate of 14.4 per 100,000 in 2022\u201324. The South West recorded 2,298 deaths, with a lower rate of 13.0 per 100,000. Devon recorded 278 deaths and the lowest rate of the three areas at 10.5 per 100,000, indicating that alcohol-specific mortality in Devon was below both the South West and England averages during the latest rolling three-year period.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The PHOF indicator for deaths from drug misuse shows that Devon had a rate of 6.4 per 100,000 in 2022\u201324, compared with 6.0 in 2021\u201323. This reflects a gradual increase over the last five reporting periods.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Exeter has the highest age\u2011standardised rate of deaths from drug misuse in Devon, at around 13 deaths per 100,000 population, followed by North Devon at approximately 9 per 100,000, with Torridge also elevated at around 7 per 100,000 (based on the latest 3\u2011year rolling averages). These district\u2011level patterns sit within a wider context of sustained increases in drug\u2011related deaths both locally and nationally in recent years. However, due to small numbers at district level, caution is required when interpreting short\u2011term trends, and these figures are best considered as indicators of relative burden rather than precise year\u2011on\u2011year change.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For under-75 mortality from liver disease, Devon recorded a directly standardised rate of 14.6 per 100,000 in 2024. This has remained stable and is statistically lower than the England rate of 20.1. Higher district rates were recorded in Exeter (20.3), South Hams (17.3) and East Devon (16.3).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Restricted National Drug Treatment Monitoring System (NDTMS) data cannot be published. However, the Department of Health and Social Care (DHSC) collates analysis on ambulance callouts involving naloxone administration. Between October 2024 and September 2025, the average number of callouts per month across the Devon County Council footprint was 20. This represents an increase of 33.3% compared with the previous reporting period (average 15 per month). Interpretation should be exercised with caution, as this is a proxy measure and may not reflect the full picture of non-fatal overdoses or opioid use.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Taken together, these national, regional and local indicators provide important context for the learning emerging from the PDARH process. They highlight continued increases in drug-related mortality nationally, persistent inequalities by sex and geography, and emerging risks associated with novel substances, alongside locally rising rates of drug misuse deaths in parts of Devon.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">While some datasets remain restricted or subject to time lag, this contextual intelligence helps situate PDARH learning within wider trends and supports DDASP strategic oversight.<\/p>\n\n\n\n<h5 id=\"auith\" class=\"wp-block-heading\">Document Authors<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">Lex Gainsbury (Consultant in Public Health),<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Laura Stonelake (Advanced Public Health Practitioner),<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Katherine Oliverio (Advanced Public Health Practitioner)<\/p>\n\n\n\n<div class=\"wp-block-group is-layout-constrained wp-block-group-is-layout-constrained\"><div class=\"document-meta-acf-block clearfix \" id=\"block_acf-block-6ae3449d676ff\"><div class=\" dcc-documents-meta\"><div class=\"dcc-documents-widget dcc-documents-widget-block\"><div class=\"dcc-documents-widget-box2\"><p class=\"dcc-documents-published\"><span>Published<\/span> <time datetime=\"2026-10-29T13:05:33+00:00\">29\/10\/2026 1:05pm<\/time><\/p><p class=\"dcc-documents-updated\"><span>Last Updated<\/span> <time datetime=\"2026-10-29T13:05:35+00:00\">29\/10\/2026 1:05pm<\/time><\/p><\/div><\/div><\/div><\/div><\/div>\n<\/div>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Annual Report, May 2026 1. Foreword As Director of Public Health for Devon County Council and Senior Responsible Officer for the Devon Drug and Alcohol Strategic Partnership (DDASP), I welcome this first annual report of the Devon Prevention of Drug and Alcohol Related Harm panel (PDARH) Drug- and alcohol-related deaths are among the most complex [&hellip;]<\/p>\n","protected":false},"author":2469,"featured_media":0,"parent":3084,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"longdocument-template.php","meta":{"_acf_changed":false,"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-5633","page","type-page","status-publish","hentry"],"acf":{"updated":"","dccdocs_documents":null,"section-guidance":"","sections":null},"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"_links":{"self":[{"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/pages\/5633","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/users\/2469"}],"replies":[{"embeddable":true,"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/comments?post=5633"}],"version-history":[{"count":5,"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/pages\/5633\/revisions"}],"predecessor-version":[{"id":5743,"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/pages\/5633\/revisions\/5743"}],"up":[{"embeddable":true,"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/pages\/3084"}],"wp:attachment":[{"href":"https:\/\/www.devon.gov.uk\/public-health\/wp-json\/wp\/v2\/media?parent=5633"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}