Concerns raised 4 Lack of a mechanism to remedy failed delivery View source Lack of an effective mechanism for immediate detection of failed delivery View source Failure to witness or confirm delivery View source Reliance upon delivery of a physical prescription document View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Agree contingency plans for failed deliveries and escalate unresolved issues to the Area Manager and Clinical Lead.
View source
Action
Require failed delivery attempts to be reported immediately by telephone to a nominated on-site manager using prearranged contact details.
View source
Action
Record failed prescription deliveries in the incident system, notify relevant staff, review incidents and identify learning to prevent recurrence.
View source
Action
Provide Saturday morning service availability to remedy unresolved Friday prescription deliveries and maintain weekend provision.
View source
Action
Require prescription deliveries to pharmacies to be made directly to staff, with recipient details, signature, returned paperwork and management-system records.
View source
Action
Escalate the lack of electronic FP10 MDA prescription functionality through relevant national and professional networks.
View source See 3 more actions
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AI-generated summary
Claire COPELAND · 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
Claire Copeland had a break in the continuity of her drug addiction treatment after a physical prescription was delivered unsuccessfully, leaving her unable to obtain medication for the weekend. The inquest concluded that she subsequently consumed drugs, including heroin, and that her death was drug-related. The report identified concerns that the prescription delivery arrangements lacked confirmation, prompt detection of failed delivery, and a fail-safe mechanism to remedy it, creating a risk of discontinuity of important medical treatment.
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 Waythrough; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to remedy failed delivery
Wider context from the report “Arrangements to which you are a party:
• rely upon delivery of a physical prescription document;
• allow that delivery be neither witnessed nor confirmed;
• lack effective mechanism immediately to detect failed delivery; and
• lack mechanism to remedy failed delivery ; and thereby
presents danger to life in that it is capable of causing discontinuity of important medical treatment.
” 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 Waythrough; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective mechanism for immediate detection of failed delivery
Wider context from the report “Arrangements to which you are a party:
• rely upon delivery of a physical prescription document;
• allow that delivery be neither witnessed nor confirmed;
• lack effective mechanism immediately to detect failed delivery ; and
• lack mechanism to remedy failed delivery; and thereby
presents danger to life in that it is capable of causing discontinuity of important medical treatment.
” 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 Waythrough; that does not assign responsibility.
PFD Monitor interpretation Failure to witness or confirm delivery
Wider context from the report “Arrangements to which you are a party:
• rely upon delivery of a physical prescription document;
• allow that delivery be neither witnessed nor confirmed ;
• lack effective mechanism immediately to detect failed delivery; and
• lack mechanism to remedy failed delivery; and thereby
presents danger to life in that it is capable of causing discontinuity of important medical treatment.
” 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 Waythrough; that does not assign responsibility.
PFD Monitor interpretation Reliance upon delivery of a physical prescription document
Wider context from the report “Arrangements to which you are a party:
• rely upon delivery of a physical prescription document ;
• allow that delivery be neither witnessed nor confirmed;
• lack effective mechanism immediately to detect failed delivery; and
• lack mechanism to remedy failed delivery; and thereby
presents danger to life in that it is capable of causing discontinuity of important medical treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree contingency plans for failed deliveries and escalate unresolved issues to the Area Manager and Clinical Lead.
Verbatim wording from the response “During the telephone contact between the team member attempting to deliver the prescription and nominated manager a contingency plan will be agreed. This plan will take into account the individual circumstances of the delivery including known pharmacy availability and the timescale requirement of dispensing from the prescription. Continuity of care for the service user and safe prescription management will be equally paramount in agreeing a course of action. If an effective contingency plan cannot be immediately agreed, the issue will be escalated to the service Area Manager and Clinical Lead for further guidance and resolution.” Source location Response from HumanKind
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require failed delivery attempts to be reported immediately by telephone to a nominated on-site manager using prearranged contact details.
Verbatim wording from the response “The service’s prescription delivery standard operating procedure states that should it not be possible to directly deliver and confirm delivery of a prescription, the team member should return to their vehicle and make telephone contact with a nominated manager who is on-site within the service base.” Source location Response from HumanKind
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record failed prescription deliveries in the incident system, notify relevant staff, review incidents and identify learning to prevent recurrence.
Verbatim wording from the response “Any failed delivery attempt of a prescription is recorded as an incident within Humankind’s incident management system. This system notifies all relevant managers and team members of the incident, creates a review process and supports identification of learning to prevent further occurrences.” Source location Response from HumanKind
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Saturday morning service availability to remedy unresolved Friday prescription deliveries and maintain weekend provision.
Verbatim wording from the response “For any failed deliveries on a Friday that cannot be resolved on that day, the service is available on a Saturday morning, enabling an opportunity to remedy delivery and ensure provision for the weekend.” Source location Response from HumanKind
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require prescription deliveries to pharmacies to be made directly to staff, with recipient details, signature, returned paperwork and management-system records.
Verbatim wording from the response “A comprehensive standard operating procedure for all team members delivering prescriptions to pharmacies has been implemented. This includes the mandatory requirement for prescriptions to be handed directly to a member of the pharmacy staff team, obtaining details of the person taking receipt and a signature from that person to confirm delivery. Completed paperwork is returned to the service base and stored for reference and also included within the service’s management information system.” Source location Response from HumanKind
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate the lack of electronic FP10 MDA prescription functionality through relevant national and professional networks.
Verbatim wording from the response “Further to this, at this time there is no functionality for the electronic transfer of FP10 MDA blue instalment prescriptions. This is a national issue and not specific to Humankind/Spectrum/County Durham Drug and Alcohol Recovery Service. Humankind have continued to escalate this issue, for example with Controlled Drugs Local Intelligence Networks and the Office of Health Inequalities and Disparities, especially during the COVID-19 pandemic where the ongoing need for this to be resolved became especially pertinent.” Source location Response from HumanKind
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic transfer of controlled-drug instalment prescriptions is unavailable nationally, so physical prescriptions remain unavoidable until functionality is developed.
Verbatim wording from the response “Unfortunately, the County Durham Drug and Alcohol Recovery Service, along with all other community drug and alcohol services, must rely on paper prescriptions as pharmacies cannot legally use faxed copies of prescriptions to dispense from for controlled drugs, including buprenorphine.” Source location Response from HumanKind
Open published response
Concerns raised 2 Failure to test drug and alcohol service clients for drug use View source Failure to provide in-person assessment and support for drug and alcohol service clients View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Maintain at least 12-weekly drug testing and face-to-face reviews for service users.
View source
Action
Review all service users through face-to-face appointments.
View source
Action
Drug-test service users who have not received testing within the previous 12 weeks using urinalysis.
View source
×
AI-generated summary
Darrell Lee DEVLIN · 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
Darrell Lee Devlin died at home on 23 February 2021 after being unwell with a chest infection and while receiving methadone treatment. The inquest record reported active bronchopneumonia and an extremely high level of Flubromazolin in his bloodstream. Concerns focused on reliance on telephone contacts, the absence of in-person assessment and drug testing, and the resulting difficulty in assessing and supporting him while receiving treatment.
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 Waythrough; that does not assign responsibility.
PFD Monitor interpretation Failure to test drug and alcohol service clients for drug use
Wider context from the report “(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.
” 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 Waythrough; that does not assign responsibility.
PFD Monitor interpretation Failure to provide in-person assessment and support for drug and alcohol service clients
Wider context from the report “(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.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain at least 12-weekly drug testing and face-to-face reviews for service users.
Verbatim wording from the response “Humankind follows best practice as stated in NICE guidelines and The Drug Misuse and Dependence guidelines on clinical management (Orange Book), in respect of ensuring that the following takes place every 12 weeks as a minimum:” Source location 2021-0397-Response-from-Humankinds_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all service users through face-to-face appointments.
Verbatim wording from the response “As noted in your findings, it was highlighted that Mr Develin had not been seen face to face nor was a drug screen provided in his last treatment episode with Unity. Humankind’s mobilisation strategy for Cumbria, which reflects the national Humankind approach, concentrates on the following:” Source location 2021-0397-Response-from-Humankinds_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Drug-test service users who have not received testing within the previous 12 weeks using urinalysis.
Verbatim wording from the response “As noted in your findings, it was highlighted that Mr Develin had not been seen face to face nor was a drug screen provided in his last treatment episode with Unity. Humankind’s mobilisation strategy for Cumbria, which reflects the national Humankind approach, concentrates on the following:” Source location 2021-0397-Response-from-Humankinds_Published
Open published response
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Request correction
Addressed to Humankind, now represented here by Waythrough.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations