Background: Liverpool John Moores University is commissioned by local authorities to deliver a model of reviewing drug-related deaths across the North West of England and the Midlands. The Integrated Monitoring System (IMS) has been operational now for a decade in some areas, and supports the focus of the UK government’s ambition to reduce drug-related deaths over coming years.

Methods: While the system examines figures and trends from aggregated data which feeds into the model, the review panels which form part of this process use information submitted by any service which had previous contact with an individual prior to their death to look at individual cases and what the learnings are not just for specific organisations but at a systemic level.

Results: Recurring themes which come out of the panel discussions are often related to social justice and inequalities for people who use drugs (PWUD), such as the barriers in accessing support for mental health, the impact of social isolation, stigma within hospital settings and the impact of children being removed from care.

Implications: The findings from the panels highlight the challenges in accessing appropriate care, services or support for PWUD at multiple points within the various organisations they come into contact with. While the learnings are focussed on what may have potentially prevented the person’s death, they have implications for the wider population of PWUD.