Learning lessons from drug and alcohol-related deaths

Alcohol Change UK believes that learning from deaths and serious incidents is essential to improving systems and preventing further harm. We have led multi partner work to develop alcohol death review models and to strengthen local approaches to Drug and Alcohol Related Death reviews.

In September 2024 the government published guidance to help local partnerships to set up and review their processes for drug and alcohol related deaths (DARDs) and near fatal overdoses.

Alcohol Change UK has long argued that meaningful learning from deaths and serious incidents is essential to preventing future harm. We have led and supported multi-agency work on alcohol and drug death reviews for over two decades, helping local systems move beyond counting deaths towards understanding why systems failed and what needs to change.

This work is led by senior consultants with national expertise in alcohol, safeguarding, mental capacity and system failure, including extensive experience of designing, running and reviewing DARD processes, authoring national guidance, and supporting statutory partnerships.

Our service

We can support local areas to:

  • Design and implement Drug and Alcohol Related Death review systems
  • Develop Non Fatal Overdose review processes
  • Review and strengthen existing systems through independent desk based analysis and stakeholder consultation
  • Provide expert input to live review panels
  • Deliver training on setting up, running and participating in review systems, including applying Root Cause Analysis


Our focus is not simply on compliance, but on meaningful learning. We help partnerships identify where systems can improve, strengthen collaboration across agencies, and translate recommendations into practical change to prevent future deaths.

Contact us

For more information about this service please contact our Consultancy and Training team on [email protected] who will be able to provide you with further information and answer any questions you may have