Alexi Susiluoto

I am R Brittain, Assistant Coroner for Inner London North.

INVESTIGATIONS and INQUESTS Mr Alexi Susiluoto died on 22/5/24. An investigation into his death was opened on 5/6/24. The inquest was part-head on 27/9/24 and concluded on 31/1/25. I reached the conclusion that Mr Susiluoto died from an alcohol-related death.

Mr Susiluoto was born in Finland on 16/9/92. He had lived in the UK for several years and had a significant medical history of mental health disorders, substance  misuse and epilepsy (following a head injury). At the time of his death, Mr Susiluoto was homeless but being  housed  by  Camden  Council  in  various  hotels  across  London,  depending  on availability. He continued to suffer from alcohol misuse and had periods of binge drinking. He was under the care of Turning Point for this issue and had previously been reviewed by multiple mental health trusts, depending on his location at the particular time of referral/review. Mr Susiluoto was found deceased in a hotel room on 22/5/24. The cause of his death was alcohol misuse disorder resulting in acute ethanol toxicity. Contributing factors were epilepsy and Olanzepine and Levetiracetam use (prescribed medication).

During the course of this inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN following the inquest into Mr Susiluoto’s death were as follows:

1. I heard evidence that the Office for Health Improvement and Disparities is  currently undertaking a review of how patients with dual diagnoses (substance  misuse and mental health disorders) are treated. I was concerned by two related issues:

a.   That substance misuse and mental health treatment is routinely provided by different organisations, despite close interplay between these conditions and that this can result in significant complexities for agencies caring for the  same patient. I understand that this aspect is part of the current review; b.   However, I also heard that the review is not taking into consideration the additional issues that arise when a patient with dual diagnoses is also  homeless. Evidence presented at the inquest set out that this already  complex situation is often compounded by homelessness, since individuals  are often moved between temporary accommodation and therefore between different mental health trust and substance misuse providers. In Mr  Susiluoto’s case, this resulted in significant confusion as to who was  providing his care and which local authority would fund potential substance  misuse treatment.

ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees have the power to take such action.