Richard Philip WHITE · Prevention of Future Deaths report

On 14 June 2013 I commenced an investigation into the death of Richard Philip WHITE. The investigation concluded at the end of the inquest on 5th February 2014. The conclusion of the inquest was findings were that Mr White died at Darlington Memorial Hospital on 9th June 2013, having previously taken an overdose of cyclizine at 700 Club, Hope House, Darlington (“Hope House”) and the conclusion of the Inquest was that he had died as a result of misadventure.

a. Richard White became a resident at Hope House on or about 15th or 16th May 2013. 700 Club is a charity which provides at Hope House, and St George’s Hall, supported hostel accommodation and support for vulnerable people with substance misuse issues or alcohol issues. On the 17th May Richard received a prescription for 21 cyclizine 50 mg tablets at Neasham Road Surgery, Darlington. On 6th June 2013 he received a prescription for 84 cyclizine 50 mg tablets plus 10 zopiclone 7.5 mg tablets at the same surgery. The zopiclone is a “sleeping pill” and the cyclizine was prescribed in relation to nausea. Richard had a history of previous attempts at self-harm, including one shortly before being admitted to Hope House, of which the staff there were aware at time the prescriptions were obtained.

b. At the appointment on 6th June 2013 with ████████ Mr White attended with his mother, ████████ and his Support Worker from 700 Club, ████████. During the Inquest ████████ gave evidence that she believed all of the medication she prescribed, cyclizine and zopiclone, would be kept securely by Hope House staff and that she known that this was not the case she would probably not have prescribed as much of the cyclizine as she did. ████████ gave evidence that he was concerned only about the “sleeping pills” (zopiclone) being looked after by Hope House staff. ████████ gave evidence that she, like ████████ had the impression that the medication would be kept secure by Hope House. ████████ manager of Hope House, gave evidence that the policy of 700 Club is that medication is self-administered by the residents and only secured upon the request of the residents themselves and retained with their consent. She stated that she did not known where this policy was written down or kept.

c. After the appointment Mr White, his mother and ████████ attended the pharmacy where the medication was collected. ████████ took the zopiclone and placed it in the office of Hope House for Richard subsequently to access it. Mr White took possession of the cyclizine, from the outset. On 9th June 2013 Richard White presented to staff at Hope House and announced that he had taken 104 cyclizine tablets and 7 or 8 zopiclone tablets. In spite of the best endeavours of the staff and paramedics, he subsequently died as a result of cyclizine toxicity.

1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions;

2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████

3) That no such protocol or policy statement was available.