Investigation and inquest
On 10 and 11 March 2026, I heard the inquest in the death of Mr Darren Robert Dickson, aged 35 years, at the time of his death on 6 February 2025. The investigation concluded at the end of the inquest, where I returned a narrative conclusion, and found the cause of death to be 1(a) Toxic effects of alcohol and benzodiazepine II Ischaemic heart disease and possible hypertrophic cardiomyopathy.
Circumstances of the death
I found that Darren Robert Dixon resided at 35 Gote Road, Cockermouth, Cumbria. Darren was employed as a mental health adviser at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.
Mr Dickson had been experiencing a period of mental ill health following witnessing an extremely traumatic incident at his place of work. Mr Dickson had sought medical treatment for this mental health condition. Independent to this, Mr Dickson had started to take benzodiazepine to assist his condition. Mr Dickson had sought assistance from his employer, his GP and Recovery Steps in relation to his mental health condition and use of benzodiazepine.
It is not possible on the balance of probabilities to determine the exact extent of the advice provided to Mr Dickson in relation to the ongoing use of benzodiazepine after 24 January 2025.
Having last been seen at approximately 9pm on 5 February 2025, Mr Dickson was found unresponsive at 35 Gote Road. Mr Dickson was taken to West Cumberland Hospital where, despite treatment, he died on 6 February 2025. Toxicology analysis showed the presence of benzodiazepine and alcohol in Mr Dickson’s body, at levels that, on the balance of probabilities, led to his death.
Coroner’s concerns
I had evidence that Mr Dickson’s supervision records were being overwritten and the full nature of those records could not accurately be ascertained. Following Mr Dickson’s death, those supervision records were destroyed and were not available to me at the inquest.
I heard evidence, and was provided with an updated policy, addressing the issues concerning overwriting of supervision records. I was therefore satisfied that the issues concerning overwriting of records has been addressed.
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 about destruction of records. I was therefore given insufficient reassurance that this specific concern is being addressed.