Help service and trust to change after drug death

A coroner has raised concerns over how a trust and drugs recovery programme handled records leading up to a man's death.

Darren Dickson, from Cockermouth, who worked at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) died after drinking alcohol and taking benzodiazepine on 6 February 2025.

Coroner Andrew Cousins found that his supervision records were destroyed by the trust, and the information Recovery Steps Cumbria gave him about drug doses was confusing.

CNTW said it was reviewing its processes and the recovery service said it worked to "prevent tragedies" and would provide a "thorough response" to the report.

The coroner's report said the 35-year-old was going through a period of mental ill health after witnessing a traumatic event at his work as a mental health advisor.

He had sought help from his employer, GP and Recovery Steps and was using benzodiazepine.

He was found unresponsive at his home on 5 February 2025 and died in hospital the following day.

The report said it did not know if he had been signposted to other services.

"I was concerned that the records did not allow a full and verifiable understanding of the information and assistance provided to Mr Dickson," the coroner said.

The report said he was told by his GP that if he took benzodiazepine, it should be a lower dose.

"I was concerned that there was scope for confusion as to the information being given to Mr Dickson, and the level of communication that Recovery Steps has with the GP services on ongoing use and doses of drugs," he said.

The coroner also said supervision records were not available at the inquest because they had been destroyed.

"I was not provided with sufficient evidence to allay my concern about the retention and the non-destruction of records and considered that the trust's policy did not address the issue," he said.

"I was given insufficient reassurance that this specific concern is being addressed."

The coroner ordered the trust and the recovery service to take action.

Executive director of CNTW Lynne Shaw, said it took concerns "very seriously".

She said: "We are undertaking a review into our processes to address the concerns highlighted by the coroner."

Amy Levy, of charity Waythrough, which runs Recovery Steps Cumbria, said drug-related deaths had a "devastating effect on the people and communities left behind".

She said the group sent its "deepest sympathies" to the family and it was "committed to providing a full and thorough response" to the report.

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