“There is no specific protocol or policy in place to ensure that patients are warned of…”
Dated 4 Jun 2024, from the coroner for County Durham and Darlington. Sent to 2 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 30 Jul 2024. 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 dated4 Jun 2024
- Deadline30 Jul 2024
- Published on judiciary.uk30 Jul 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| County Durham and Darlington NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Tees, Esk and Wear Valleys NHS Foundation Trust | Response publishedPublished on judiciary.uk in July 2024. |
The coroner’s concerns
– (1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug , should they drink alcohol or misuse drugs. (2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other’s records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge. (3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends, which may have provided an essential safety net in the absence of accessible professional support. The TEWV Trust are candid that work in relation to this issue is a work in progress and remains incomplete. (4) Although both Trusts indicated that they are in the process of addressing the concerns raised in this Inquest, I consider that at the time of the conclusion of this Inquest that there remains a risk that future deaths could arise.
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, 2024-0367
- 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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