Darrell Devlin

PRIVATE & CONFIDENTIAL 

Dr Nicholas Shaw 
HM Assistant Coroner for Cumbria Area 
Fairfield 
Station Road 
Cockermouth 
Cumbria  
CA13 9PT 

20 January 2022 

Dear Dr Shaw 

 Trust Management Offices 
First Floor, The Curve 
Bury New Road 
Prestwich 
Manchester 
M25 3BL 

Web: www.gmmh.nhs.uk 

Re:  Darrell Devlin (deceased) Regulation 28 Preventing Future Deaths Response 

Thank  you  for  highlighting  your  concerns  during  Mr  Devlin’s  Inquest  which  concluded  on  18 
November 2021.  

On behalf of the Trust can I apologise that you have had to bring these matters of concern to 
the Trust’s attention. We would like to extend our sincere condolences to Mr Devlin’s family and 
friends at this very sad time. 
I hope the response below demonstrates to you and Mr Devlin’s family that GMMH have taken 
the concerns you have raised seriously and will learn from this.  

Please  see  the  Trust’s  response  in  relation  to  the  concerns  you  have  raised,  and  the  actions 
taken by the Trust: 

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.

As highlighted at the inquest, Mr Devlin passed away during the Covid-19 pandemic
when health and social care services continued to be affected by associated restrictions.
Cumbria’s Community Addiction Services were known as Unity and delivered by GMMH
until 30th September 2021.

Unity remained open throughout the pandemic period and continued to operate to
protect those most vulnerable and reduce the burden on other healthcare services.

 
 However, face to face contact was advised to be kept to a minimum by Public Health 
England and the Department of Health - (see guidance applicable at the time)  

([Withdrawn] COVID-19: guidance for commissioners and providers of services for 
people who use drugs or alcohol - GOV.UK (www.gov.uk). 

In line with this, the multi-disciplinary Senior Leadership Team (SLT) for the GMMH 
Addictions Division, reviewed service delivery and made adaptations to support changes 
where required and GMMH developed Trust guidance for staff that supported the Multi-
Disciplinary Team to review each service user in terms of their risk factors, stability on 
their prescribed medication and their engagement with services.   

GMMH Community Addiction Services recognise that face to face contact is the 
preferred method of communication and, from mid-2021, services began planning for the 
re-introduction of these in response to the easing of Covid-19 restrictions.   

For high-risk service users face to face reviews were always maintained, however, for 
the remaining service users, action plans were put in place to re-introduce face-to-face 
appointments for all other service users. The service issued guidance to all staff-advising 
all first appointments should to be face to face and specific guidance in ensuring 
everybody had been drug tested within a 12-month period.  Service User contact 
information is closely monitored by the Senior Leadership Team monthly and by local 
managers on a weekly basis.  

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  suppor1 
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. 

Mr Devlin had been reviewed considering national and local guidance with his risk 
management plan updated to reflect this on 21st April 2020. His prescription was 
changed from a daily supervised dispense of methadone to a weekly collection. This 
clinical decision was made due to Mr Devlin remaining mostly illicit drug free and 
positively engaging with Unity services. The decision reduced the risks of contracting 
Covid-19 and supported government requirement to limit social contacts, deemed as 
paramount due to the respiratory health problems experienced by Mr Devlin.  

 
 
 
 
 
 
 
 
 
 
 
 
 There were continual checks to ascertain Mr Devlin had access to naloxone (a life-
saving opiate antagonist emergency medication) and a discussion is recorded where Mr 
Devlin was encouraged to be honest with staff surrounding any illicit drug use.   

Unity services allocated service users to pathways, based on risk, and presenting need. 
Mr Devlin was allocated to the pathway known as “Recovery Journey” which provided 
contact every 4-6 weeks and, during the Covid-19 restriction this was via a telephone 
review.  In the year prior to his death, Mr Devlin is described in each telephone contact 
as stable on his prescription and reporting no illicit use (except for 21st October 2020 
where he reported he shared one bag of heroin with his partner). There were no 
telephone contacts during which Mr Devlin sounded drowsy, intoxicated, incoherent or 
exhibited any behaviour indicative of illicit drug use.   

If Mr Devlin had exhibited any signs of illicit drug use during his telephone appointments, 
his Recovery Coordinator would have invited him in for a face-to-face appointment and 
undertaken a clinical assessment and review, to consider past and current substance 
use and the need for a standard oral drug screen. Mr Devlin did not exhibit any signs of 
illicit use during his telephone contacts; therefore, he was not seen in person up to the 
time of his death. This practice was in line with the national and local guidance in place 
at that time.  

GMMH work in partnership with local community pharmacies via sub-contracting 
arrangements, meaning they have a responsibility to assess service users’ presentations 
when collecting their prescriptions and to alert GMMH Community Addiction Services 
when someone appears intoxicated and there were no concerns raised nor calls made 
to Unity regarding Mr Devlin’s weekly presentation. However, his partner frequently 
collected his medication for him due to his respiratory problems and the risks associated 
with Covid-19. We acknowledge that given his partner was collecting his medication, to 
minimise other risks, one of our usual safeguards was not in place. 

GMMH Addictions Division have a comprehensive risk assessment training package, 
which requires mandatory completion by all clinical staff.  Considering Covid-19 and 
implications to care and treatment, this training material will be revised and updated, to 
include a case study reflecting some of the issues raised in Mr Devlin’s death. This will 
be completed by end February 2022.  

3.  Despite the presence of bronchopneumonia, a natural illness, it is my view that the 
drug combination -particularly the use of Flubromazolam -was the major factor in 
Darrell's death. 

Unity used two oral drug screening tests. The main standard oral screen allowed staff to 
select one or more of a range of substances such as opiates, 6-monoacetylmorphine (6-
MAM), methadone, buprenorphine, and benzodiazepines (although the particular type of 
benzodiazepine was not specified in the result of this test). For those prescribed OST, 
ordinarily the only test requested would be for opiates, 6-MAM and, if the patient was not 
on supervised consumption, the prescribed medication (methadone or buprenorphine).  
Prior to the Covid-19 pandemic, Unity would have completed the standard oral screen 

 
 
 
 
 
 
 
 
 
 
 
 every three months for those prescribed OST and on the pathway applicable to Mr 
Devlin.  

Due to the restrictions related to Covid-19, Unity had not been completing routine drug 
screens on the usual basis. Instead, the use of the drug screens was determined by 
clinical risk and need.  

Mr Devlin was prescribed clonazepam by his GP to treat his epilepsy, meaning any drug 
test for benzodiazepines would be expected to show as positive. Furthermore, Unity had 
no suspicion that Mr Devlin was using illicit benzodiazepines and, as flubromazolam is a 
novel benzodiazepine, none of the drug testing technologies afforded to Unity used 
would have been able to detect it. The Verum screen which became available after the 
onset of the Covid-19 pandemic (July 2020) and can detect up to 50 substances, could 
allow the identification of a wider range of benzodiazepines but based on Mr Devlin’s 
history, Unity would not have considered this was clinically indicated throughout his 
treatment. 

We note the high blood concentration of flubromazolam in his toxicology report but given 
his long-term prescription of clonazepam it would be likely that Mr Devlin would have a 
high degree of tolerance to benzodiazepines. We feel it would be likely that the 
contribution of the prescribed sedating drugs (such as pregabalin, dihydrocodeine and 
clonazepam) might have contributed to his death as well as the flubromazolam, 
methadone and the bronchopneumonia.  

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. 

In review of the concerns raised in your report, GMMH met with Humankind, the new 
service provider in the county since 1st October 2021. Both organisations would like to 
offer assurances to the coroner, surrounding the transfer process. GMMH commenced 
the decommissioning process approximately ten months prior to the official handover, 
having made an organisational decision not to bid for the new contract.  
The decommissioning process included regular internal (GMMH) and external 
(Humankind) meetings, agreement of information governance arrangements to enable a 
safe transfer of clinical data, the development of guidance in the management of 
incidents, investigations and inquests, post transfer and the sharing of clinical pathways, 
local procedures and complex case reviews completed by both organisation’s medical 
leads.  

From our meeting we understand Humankind are developing their own response to the 
issues raised in your report and how they will take these forward within their 
organisation. 

Under the circumstances, GMMH would like to offer an opportunity to meet with coroner Ms 
Cheema to discuss the transfer of addiction services to a new provider and the ongoing 
response of services during the COVID-19 pandemic. However, we do appreciate that, given 
the Trust are no longer the provider of Community Addiction Services in Cumbria, this offer 
may be more appropriately directed to Humankind, or indeed a three-way meeting may be 
considered.  

 
 
 
 
 
 
 
 
 
 
 
 Dr  Shaw,  on  behalf  of  the  Trust  can  I  thank  you  for  bringing  these  matters  of  concern  to  the 
Trust’s attention. I hope this response demonstrates to you and Mr Lawrence’s family that GMMH 
have taken the concerns you have raised seriously. If you have any further questions in relation 
to the Trust’s response, please do let me know. 

Yours Sincerely, 

Dr 
Medical Director

Recovery Steps Cumbria 
Stocklund House 
Castle Street 
Carlisle 
CA3 8SY 

Coroner’s Office 
Fairfield 
Station Road 
Cockermouth 
CA13 9PT 

11th January 2022 

Re: Humankinds response in regard to the Regulation 28, following the Inquest into 
the late Darrell Lee Devlin 

Following on from your letter dated 23rd November 2021, which outlined the matters of 
concern identified during the coronial process, as the incoming provider of Addictions 
Services within Cumbria from October 1st 2021, I would like to detail Humankind’s approach 
to the delivery of addictions services, including our focus on reducing drug related deaths 
across the County.   

During the transfer of services from Greater Manchester Mental Health NHS Foundation 
Trust, Humankind worked collaboratively with Unity to ensure that the change of provider 
and subsequent service was safe, seamless, and effective. The focus was to ensure 
continuity of care for service users, to enable this to happen the following took place: 

• Weekly provider meetings
• Clinical handover for high-risk cases, led by Unity’s Consultant in Addictions

Psychiatry, and involved Humankind’s Executive Medical Director, Director of
Pharmacy and Director of Nursing

• Signed information governance procedures to allow sharing of relevant real time

information between organisations

• Site visits from Humankind
• Sharing of treatment and recovery pathways
• Data transfer of all active service user’s relevant information, which included, service
users notes, risk assessments, care plans and prescribing arrangements, which lead
by the data, quality and performance teams from each organisation

• Engagement with external providers to ensure continuity of care
• GMMH produced 8 weeks of bridging prescriptions for all those in prescribed 

treatment
Joint communication was sent out to all service users, via letter

•

Humankind understands and appreciates the significant impact the pandemic has had on 
services, this includes the way in which treatment services had to adapt processes and 
procedures to align with national guidance. Humankind has had a national role in working 

 Recovery  Steps Cumbria  is a service  led  by Humankind.   Humankind  is a company  registered  in England.   Registered  Company  No1820492  and a 
Registered  Charity  No. 515755.  VAT No 334676343.Registered  Social  Landlord  (RSL) 4713Registered  Office:  Inspiration House, Unit 22 Bowburn North 
Industrial Estate DH6 5PF 

     
 
 with The Office for Health Improvements and Disparities, formally Public Health England, to 
set standards of best practice, including being part of creating the sectors response to the 
pandemic.  

As noted in your findings, it was highlighted that Mr Develin had not been seen face to face 
nor was a drug screen provided in his last treatment episode with Unity. Humankind’s 
mobilisation strategy for Cumbria, which reflects the national Humankind approach, 
concentrates on the following: 

•  The training of staff teams and embedding new pathways and procedures 
•  Reviewing all service users at a face-to-face appointment 
•  Medically reviewing all service users in prescribed treatment 
•  Drug testing all service users via uranalysis, that haven’t been tested in the last 12 

weeks 

•  A comprehensive audit on high-risk prescribing  

Humankind follows best practice as stated in NICE guidelines and The Drug Misuse and 
Dependence guidelines on clinical management (Orange Book), in respect of ensuring that 
the following takes place every 12 weeks as a minimum:  

•  Recovery plans 
•  Risk assessments 
•  TOPS 
•  Medical reviews 
•  Drug testing 
•  Face to face reviews 

I hope that the above offers reassurance in respect of expected minimum standards for the 
service and the focus on ensuring that we see service users face to face. It is prudent to 
acknowledge the challenges that addictions services are facing, which includes staffing 
shortages and reduced community pharmacy provision particularly for those in receipt of 
opiate substitute medication. Humankind is committed to working collaboratively with all 
partner agencies to overcome these challenges. 

Humankind looks forward to working together with yourselves in Cumbria to learn from and 
reduce the number of drug related deaths in the area.  

Yours faithfully   

Area Manager  

    Recovery  Steps Cumbria  is a service  led  by Humankind.   Humankind  is a company  registered  in England.   Registered  Company  No1820492  and a 
Registered  Charity  No. 515755.  VAT No 334676343.Registered  Social  Landlord  (RSL) 4713Registered  Office:  Inspiration House, Unit 22 Bowburn North 
Industrial Estate DH6 5PF