“Itwas stated by a nurse that he had, while dispensing medication to Mr Devlin and other…”
Dated 22 Jul 2014, from the coroner for County Durham and Darlington. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 16 Sep 2014. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated22 Jul 2014
- Deadline16 Sep 2014
- Published on judiciary.uk22 Jul 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| National Offender Management Service | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Sep 2014. A reply may have been sent and not yet published. |
| Care UK | Response publishedPublished on judiciary.uk in July 2014. |
| HMP Durham | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Sep 2014. A reply may have been sent and not yet published. |
| Tees, Esk and Wear Valleys NHS Foundation TrustNamed in the report as “Tees Esk Wear Valley NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Sep 2014. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) Itwas stated by a nurse that he had, while dispensing medication to Mr Devlin and other patients on F Wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient. (2) He claimed this was his own common practice and was also common practice ‘amongst nursing staff on F Wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodei (8) If this were the case, no one would know whether a patient is taking the medication intended for him. (4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed. (5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him. (6) The concomitant concem with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery. (7) Further, no one would know whether somebody else was appropriating that patient's medication. (8) Depending on the type of medication, this may be traded within the establishment raising security concerns. (9) The drugs could be stockpiled with a view to creating a potentially lethal overdose. ‘ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2014-0335
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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