Darrell Lee DEVLIN · Prevention of Future Deaths report

On 26 February 2021 I commenced an investigation into the death of Darrell Lee DEVLIN aged 33. The investigation concluded at an inquest on 18th November 2021 . The short form conclusion of the inquest was that of a Drug Related Death. The medical cause of death being given as: 1a Bronchopneumonia and drug use (████████)

The record of inquest read as follows: Darrell Lee Devlin died at his home ████████ on 23rd February 2021. He had been unwell for a few weeks with a chest infection and was also under the care of the local drug and alcohol service provider receiving a methadone prescription. Postmortem examination revealed active bronchopneumonia and an extremely high level of Flubromazolin in his bloodstream. The combination of these two factors caused his death.

[BRIEF SUMMARY OF MATTERS OF CONCERN]

(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.