A hospital's failure to tell a chronic alcoholic that he could not drink after being given medication "contributed more than minimally" to his death on a Durham City side street. 

Andrew Naylor, 37, was found dead in Drury Lane, Durham, on October 11, 2022, a day after he had been discharged from University Hospital of North Durham for an overdose. 

Whilst in hospital, he had been administered medications for alcohol withdrawal and a drug overdose - but the cocktail of medications and alcohol had a depressant effect on Mr Naylor's organs. It caused him to go into acute cardiorespiratory failure out on the street. 

A recent inquest into Mr Naylor's death concluded that an array of errors by healthcare staff could have led to his death and assistant coroner Janine Richards criticised the health trusts involved. 

In a Prevention of Future Deaths Report, Ms Richards outlined the lack of protocol to warn patients of the acute risk of respiratory depression and death following the administration of the medication if they drink alcohol or misuse substances. 

She also slammed the "lack of joined-up processes" between acute clinicians, alcohol and drug treatment teams, and mental health teams from both County Durham and Darlington Foundation Trust (CDDFT) and Tees, Esk and Wear Valleys Mental Health Trust (TEWV). 

In the lead-up to Mr Naylor's tragic death, he had been evicted from his supported accommodation - but this was not communicated between the mental health team and the medical team.

Healthcare staff could have delayed his discharge until a safe place was identified, or contacted his family or friends to provide "an essential safety net in the absence of professional support", but Mr Naylor fell through the cracks. 

The coroner wrote: "Poor communication between the various agencies involved led to a failure to ensure a robust safety plan was in place.

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"These cumulative failures contributed more than minimally to the death."

"Although both TEWV and CDDFT indicated that they are in the process of addressing the concerns raised in this Inquest, I consider that at the time of the conclusion of this Inquest, there remains a risk that future deaths could arise."

Both healthcare trusts must now respond to the report, outlining how they are tackling issues to ensure the same mistakes are not repeated.