Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0050, written 14 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Feb 2019 |
|---|---|
| Reference | 2019-0050 |
| Deceased | Matthew Hamilton |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HMP Durham CORONER tam Jeremy Chipperfield, senior coroner for the coroner area of Country Durham and Darlington CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Requlations 2013. INVESTIGATION and INQUEST On the 6th of July 2018 I commenced an investigation, and on the 13th of February 2018 I heard the inquest concerning the death of Matthew David Hamilton. He died as a result of 1(a) toxicity of morphine and his metabolites, and I concluded that his was a drug related death. 4 | CIRCUMSTANCES OF THE DEATH Whilst in custody at HMP Durham, Matthew Hamilton, a known heroin user, arranged to procure drugs from the wife of a fellow prisoner immediately upon his release. He made that acquisition on the evening of the day of his release; on the following morning he was taken to the emergency department of Darlington Memorial Hospital, suffering from the toxic effects of morphine, and later he died of the same. The deceased had not been provided with the release pack created by the Drug and Alcohol Recovery Team (DART), which includes information on tolerance reduction and the risks of overdose following post-release drugs taking; that document is not provided to known drugs users upon their release unless they have elected to engage with DART services whilst in custody- the deceased had not so engaged. He was not otherwise advised as to the effects of abstinence induced tolerance reduction. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you The MATTERS OF CONCERN are as follows. On being released from custody, some users of heroin (and/or other drugs) are unaware of: (1) the fact or extent to which abstinence during imprisonment is likely to have reduced their tolerance to heroin (and/or other substances): and/or (ii) that consumption of those substances, at levels which may have been normal for them prior to their period in custody, may prove immediately fatal afterwards. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 12" April 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - Family of deceased Tam 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. 14 February 2019 IS Gupta JEREMY CHIPPERFIELD
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Prison Reform. HMP Durham Old Elvet Durham DH1 3HU 2 April 2019 Jeremy Chipperfield Senior Coroner HM Coroners office Bishop Auckland Durham DL14 4FY Dear Sir Re: Regulation 28 Report — Matthew David Hamilton deceased | refer to your report dated 14 February 2019 concerning the death of Mr Hamilton who died as a result of toxicity of morphine and his metabolites. You concluded that his was a drug related death. | thank you for bringing to my attention the Matters of Concern arising from the inquest as follows: On being released from custody, some heroin users (and/or other drugs) are unaware of: (i) the fact or extent to which abstinence during imprisonment is likely to have reduced their tolerance to heroin (and/or other substances): and/or (ii) that consumption of those substances, at levels which may have been normal for them prior to their period in custody, may prove immediately fatal afterwards. | take note that in your opinion action should be taken by me and my organisation to prevent future deaths. | would like to bring to your attention the steps | have now taken to satisfy the Matters of Concern: e The Drug and Alcohol Reduction Team (DART) have updated their guidance pack, which in future will be offered to all prisoners on their discharge from HMP Durham and not just to those who had elected to engage with DART while in custody. The guidance pack is also offered to those with the potential of release from court. | will be happy to supply a copy of the guidance pack should you wish to receive it. e As part of a pilot scheme, prisoners who are identified as being at risk of an opiate overdose can be offered Naloxone* upon release. e The DART team have a trained prisoner (DART Mentor) to offer additional harm reduction advice to prisoners at the point of release. This includes information on community based support services, as well drug specific, harm reduction information. | am confident that these additional improvements to our processes will reduce the risk of drug related deaths following release and | submit them for your considerations Yours etc pucony HM Prison & Tees & Wear Probation Service | Prisons Group. Prison Reform. *Naloxone is a drug which temporarily reverses the effects of opioids such as heroin, methadone and morphine. For many years, naloxone has been used within emergency medical settings to reverse the effects of opioid overdose and to prevent death. UK Guidelines on Clinical Management of Drug Misuse fully endorses the use of naloxone in overdose management and prevention. a HM Prison & Probation Service Tees & Wear Prisons Group Prison Reform.
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