Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0307, written 11 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Dec 2013 |
|---|---|
| Reference | 2013-0307 |
| Deceased | Damion Stanley Joseph Henson |
| Coroner | Ian Smith |
| Coroner area | Cumbria (South & East) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Over Manager, Riverview, 62 Lound Road, Kendal. Manager, 1 CORONER I am, Ian Smith, senior coroner, for the coroner area of South & East Cumbria 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 9th July, 2013 I commenced an investigation into the death of Damion Stanley Joseph Henson, aged 42 yrs. The investigation concluded at the end of the inquest on 9th December, 2013. The conclusion of the inquest was that the deceased died from abuse of drugs and the cause of death was Methadone Toxicity with Bronchopneumonia. 4 CIRCUMSTANCES OF THE DEATH The deceased was found dead in his own flat on 4th July, 2013, having overdosed principally on methadone but having taken other drugs as well. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – I am concerned that this is the second or third death at these premises and it seems to me that the death occurred, at least in part, because the property was not supervised 24 hours a day. I understand that the residence is for homeless people but by default some drug users have been placed there and unfortunately on occasions these drug users introduce other drug users into the property out of hours with risks to all those who are present. The address is not a drug rehabilitation unit but is a homeless unit but in the present way that it is being used, it appears to me that 24 hours supervision would be preferable. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th February, 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out 1 the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, (mother). I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 DATE 11th December, 2013 [SIGNED BY CORONER] 2
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