Recipient

Recovery Steps Cumbria

First report 8 Feb 2024•Latest report 16 Mar 2026

Recipient record

Reports, concerns and published responses

Health and care · Independent healthcare provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Recovery Steps Cumbria linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 Mar2026
Cumbria
Concerns raised2
1. Failure to maintain records providing a full and verifiable account of information and assistance provided
2. Failure to ensure clear communication with GP services about ongoing drug use and doses
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

DARREN ROBERT DICKSON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Darren Robert Dickson was found unresponsive at home after last being seen on 5 February 2025 and died in hospital on 6 February 2025. Toxicology found benzodiazepine and alcohol, and concerns were raised about incomplete records of information and signposting provided by Recovery Steps, and possible confusion or insufficient communication between Recovery Steps and GP services about benzodiazepine use and doses.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recovery Steps Cumbria; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain records providing a full and verifiable account of information and assistance provided
Wider context from the report
“(1) At the appointment on 27 January 2025, Mr Dickson was seen by a Recovery Co-Ordinator in relation to his use of benzodiazepine. It could not be ascertained from the records what information regarding signposting to other services that could have assisted Mr Dickson with treatment, was provided to him. I was concerned that the records did not allow a full and verifiable understanding of the information and assistance provided to Mr Dickson at this appointment. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recovery Steps Cumbria; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure clear communication with GP services about ongoing drug use and doses
Wider context from the report
“(2) At the appointment on 27 January 2025, Mr Dickson was given advice to prepare a ‘drugs diary’. This was required so that, at his follow up appointment, it could be ascertained what his usage of benzodiazepine he was, so that a better-informed treatment plan could be prepared. I was conscious of the need your staff have for accurate information as to the extent of the drug use so that a well informed and coherent plan could be put in place. The concern I had was that Mr Dickson had seen his GP prior to the appointment on 27 January 2025 and had been told that if he was to take any benzodiazepine, it should be less than what he had previously taken. 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 in relation to the issue of ongoing use and doses of drugs. ”
Open source report
11 Mar2026
Cumbria
Concerns raised1
1. Inadequate information-sharing procedures for service users regardless of treatment-pathway acceptance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

CHARLOTTE LOUISE JONES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Charlotte Louise Jones was found deceased at her home on 10 February 2025, with her death attributed to fatal levels of alcohol and bromazolam. She had a history of self-harm and substance use, and had multiple attendances at A&E following overdose and self-harm before her death. The principal concern was that CNTW and Recovery Steps did not have an adequate procedure for exchanging information about service users, including those not accepted onto a particular treatment pathway.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recovery Steps Cumbria; that does not assign responsibility.
PFD Monitor interpretation
Inadequate information-sharing procedures for service users regardless of treatment-pathway acceptance
Wider context from the report
“Whilst CNTW and Recovery Steps have procedures by which information about service users is shared, those procedures are not yet appropriate to ensure adequate exchange of information about service users whether or not the service user has been accepted onto a particular treatment pathway. ”
Open source report
8 Feb2024
Cumbria
Concerns raised2
1. Lack of a direct pharmacy-to-provider means for reporting stopped methadone collection
2. Lack of an obligation on pharmacies to report wider service-user welfare concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Dayle BATES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Dayle Bates, aged 39, was found dead at his home on 31 August 2023 after ambulance staff were unable to revive him. A post-mortem examination attributed his death to the combined effect of heroin, bromazolam, protonitazene, xylazine and alcohol. The report raises concerns that Recovery Steps were not promptly informed when he stopped collecting methadone, and that pharmacies lacked a direct reporting route and were not obliged to report wider welfare concerns.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recovery Steps Cumbria; that does not assign responsibility.
PFD Monitor interpretation
Lack of a direct pharmacy-to-provider means for reporting stopped methadone collection
Wider context from the report
“(1) Mr Bates had a prescription for methadone issued by Recovery Steps. He was required to collect a dose each day from a named pharmacy. On 14th July 2023 Mr Bates stopped collecting methadone. The pharmacy explained that they sought to inform Recovery Steps of this development shortly after 14th but did not have any contact details other than a general number which is not always answered and a direct line for one key worker. They attempted to raise their concerns with that key worker, but the message appears not to have been relayed, Recovery Steps did not become aware that Mr Bate was not collecting methadone until 30th August 2023. In answer to question from the Court, the pharmacy have also indicated that although it is there practice to inform Recovery Steps of any other concerns they might have about a person prescribed with Methadone, this is a voluntary decision on their part and not a matter that arises from any obligation. I am concerned that this situation gives rise to a risk of future death. It appears that there is no direct means by which a pharmacy can report to Recovery Steps that a service user has stopped collecting methadone. There is also no apparent obligation on pharmacies to report wider concerns for services users' welfare to Recovery Steps. In each case this may mean that Recovery Steps are unaware that vulnerable service users require additional support. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recovery Steps Cumbria; that does not assign responsibility.
PFD Monitor interpretation
Lack of an obligation on pharmacies to report wider service-user welfare concerns
Wider context from the report
“(1) Mr Bates had a prescription for methadone issued by Recovery Steps. He was required to collect a dose each day from a named pharmacy. On 14th July 2023 Mr Bates stopped collecting methadone. The pharmacy explained that they sought to inform Recovery Steps of this development shortly after 14th but did not have any contact details other than a general number which is not always answered and a direct line for one key worker. They attempted to raise their concerns with that key worker, but the message appears not to have been relayed, Recovery Steps did not become aware that Mr Bate was not collecting methadone until 30th August 2023. In answer to question from the Court, the pharmacy have also indicated that although it is there practice to inform Recovery Steps of any other concerns they might have about a person prescribed with Methadone, this is a voluntary decision on their part and not a matter that arises from any obligation. I am concerned that this situation gives rise to a risk of future death. It appears that there is no direct means by which a pharmacy can report to Recovery Steps that a service user has stopped collecting methadone. There is also no apparent obligation on pharmacies to report wider concerns for services users' welfare to Recovery Steps. In each case this may mean that Recovery Steps are unaware that vulnerable service users require additional support. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to maintain records providing a full and verifiable account of information and assistance provided

Failure to ensure clear communication with GP services about ongoing drug use and doses

Concerns raised1

Inadequate information-sharing procedures for service users regardless of treatment-pathway acceptance

Concerns raised2

Lack of a direct pharmacy-to-provider means for reporting stopped methadone collection

Lack of an obligation on pharmacies to report wider service-user welfare concerns