“Darrell first came into contact with Unity (the drug and alcohol service that your trust…”

The coroner’s concerns

(1) Darrell first came into contact with Unity (the drug and alcohol service that your trust was contracted to provide for Cumbria) in 2015. and his final episode of care began on 30th January 2020 when he self referred to ask for treatment for daily heroin use. At the time of his death he was receiving a daily dose of Methadone supplied every week. Evidence heard at the inquest covered the final 7 months of this treatment episode, during this period I heard of 6 telephone contacts, the last just 18 days before Darrell died, however he was never seen in person and never tested for drug use. (2) Apart from admitting to a single bag of heroin on 1 occasion Darrell consistently told his drug workers that he was abstinent from illicit drugs or alcohol and was well maintained on his daily dose of methadone. The forensic toxicology report (of which I attach a copy for your information) however indicates he was almost certainly not truthful. I am concerned that reliance on remote contacts and lack of testing make it very difficult for drug workers to accurately assess and support their clients, and put the clients at risk of harm or death due to excessive dosage or polydrug exposure on top of their regular medication, as in this case. I am aware that face to face appointments were avoided where possible due to the Covid pandemic but feel this case highlights a need for more effective supervision than that given to Darrell. (3) Despite the presence of bronchopneumonia, a natural illness, it is my view that the drug combination -particularly the use of -was the major factor in Darrell's death. (4) I note that since Darrell's death the contract to provide drug and alcohol services in Cumbria has transferred to Humankind, and thus I am addressing the report to them as well while acknowledging that they played no part in Darrell's care.

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, 2021-0397

Added to Minute Book

8 Oct 2026

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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