Darren Dickson

Recovery Steps Cumbria  
Stocklund House 
Castle Street 
Carlisle 
CA3 8SY 

HM Coroner’s Office 
Allerdale House 
Workington 
Cumbria 
CA14 3JY 

8 May 2026 

Dear Mr Cousins 

Re: Waythrough's response in regard to the Regulation 28, following the Inquest into the late Darren 
Robert Dickson 

I  write  in  response  to  your  Regulation  28  Report  to  Prevent  Future  Deaths  dated  16  March  2026 
concerning the death of Darren Robert Dickson on 6 February 2025. I respond on behalf of Waythrough, 
which operates Recovery Steps Cumbria ("RSC"). 

Waythrough has carefully considered each of the matters of concern set out in your report. We wish to 
express  our  sincere  condolences  to  Mr  Dickson's  family  and  friends  for  their  loss.  The  death  of  any 
individual  known  to  our  services  is  treated  with  the  utmost  seriousness,  and  we  have  given  detailed 
consideration to the concerns you have raised. 

It is stated within your findings that: 

1.  At the appointment on 27 January 2025, it could not be ascertained from the records what 
information regarding signposting to other services was provided to Mr Dickson; and 

2.  There was scope for confusion between the GP's advice regarding benzodiazepine use and the 

instruction to keep a drugs diary. 

Context of Service 

Before addressing the specific concerns, it may assist the Court to understand the context of the 
service provided by RSC. 

RSC is a specialist drug and alcohol recovery service for adults over the age of 18 who have an alcohol 
or drug need and who reside in Cumbria. The service is wholly funded by the local authority through 

Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. 
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity 
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713) 

                                                                          
 
 
 
 
 
          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 public health teams. RSC is delivered by Waythrough and operates a person-centred, recovery-
oriented model underpinned by trauma-informed practice, delivering inclusive support pathways 
tailored to individuals' specific needs and varied goals. 

RSC operates three primary treatment pathways: an opioid pathway, an alcohol pathway, and a non-
opioid and non-dependent alcohol pathway. Mr Dickson presented seeking support with illicit 
benzodiazepine use and would have been supported on the non-opioid pathway. Under this pathway, 
the prescribed intervention follows a structured programme of approximately 12 sessions, progressing 
through engagement and building motivation for change, to addressing triggers, high-risk situations and 
coping skills, and then to lapse/relapse prevention and forward planning. Harm reduction information 
and psychosocial interventions, delivered with a trauma-informed approach, are provided throughout 
the treatment journey. 

The Purpose of an Initial Assessment 

The appointment on 27 January 2025 was Mr Dickson's first contact with RSC. He had self-referred on 
24 January 2025 following a hospital admission. He had not previously accessed a structured drug and 
alcohol service. 

Within Waythrough's delivery model, the treatment journey follows a staged pathway: from initial 
assessment, through engagement and building motivation, into structured treatment, and onward to 
sustained recovery. The initial assessment sits at the very beginning of this journey. Its primary function 
is information gathering - establishing the individual's circumstances, substance use, physical and 
mental health, and broader social context - whilst beginning to discuss treatment options and goals. It 
is the gateway into structured support, not a comprehensive treatment intervention. 

Had Mr Dickson attended his follow-up appointment on 17 February 2025, the next steps would have 
included a review of his drugs diary, further assessment of his mental health, and once sufficient 
information had been gathered, an appointment would be made with RSC’s clinical team to develop a 
tailored reduction plan. The initial assessment was the first step in an ongoing process, not its 
conclusion. 

It is within this context, of a first contact at the earliest stage of the treatment pathway, that both 
matters of concern should be understood. 

The Support Provided to Mr Dickson 

To provide context for the Coroner's concerns, it is relevant to set out the nature and extent of RSC's 
involvement with Mr Dickson. 

Mr Dickson was referred to RSC seeking support with illicit benzodiazepine use. At the initial 
assessment on 27 January 2025, five evidence-based screening tools were conducted: 

•  AUDIT (Alcohol Use Disorder Identification Test) — scored 2, indicating low risk; 
•  GAD-7 (Generalised Anxiety Disorder assessment) — scored 17, indicating severe anxiety; 
•  PHQ-9 (Patient Health Questionnaire 9) — scored 15, indicating moderately severe depression; 
•  SAD-Q (Severity of Alcohol Dependence Questionnaire) — scored 0, indicating no alcohol 

dependence; and 

Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. 
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity 
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713) 

                                                                          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Blue Light Questionnaire (Activity Factor) — indicating no immediate safety concerns requiring 

emergency contact. 

An initial Recovery Plan and risk assessment were also completed. The risk assessment confirmed no 
suicidal ideation, and it is documented that Mr Dickson was made aware he could contact emergency 
services, his GP, the CRISIS Team, and the Samaritans if he required support. 

A drugs diary was also provided, as Mr Dickson was unable to provide a precise account of his 
benzodiazepine use at the initial assessment. As set out further below, this is standard practice in 
specialist substance use services where an individual's pattern of use is not yet established. 

Response to Concern 1: Record-Keeping and Signposting to Other Services 

The Coroner's concern is that it could not be ascertained from the records what information regarding 
signposting to other services was provided to Mr Dickson, and that the records did not allow a full and 
verifiable understanding of the information and assistance provided at the appointment. 

We have reflected carefully on this concern. The records from Mr Dickson’s initial assessment do 
document specific signposting. In particular, the risk assessment records that Mr Dickson was made 
aware he could contact emergency services, his GP, the CRISIS Team, and the Samaritans if he 
required support. An initial Recovery Plan was also completed, setting out Mr Dickson’s personal goals 
and the next steps in his treatment. A follow-up appointment was arranged and confirmed via text 
message. Signposting and referral is a core component of RSC’s assessment process under 
Waythrough’s delivery model. 

The information captured and documentation generated at this appointment, as set out above, reflects 
the scope and purpose of a first contact with a new service user. RSC's operating procedures provide 
for documentation to develop and deepen as the individual progresses through the treatment pathway. 
The Recovery Coordinator followed the established process for initial appointments, which includes 
completing the initial contact template, undertaking a risk assessment, producing a Recovery Plan, and 
booking the next appointment.  

We are satisfied that the approach taken was consistent with RSC's operating procedures, 
Waythrough's delivery model, and national treatment guidelines (Drug Misuse and Dependence: UK 
Guidelines on Clinical Management). Having reflected on the concern raised, we are confident that the 
initial assessment processes are robust and we remain committed to reviewing our practices regularly 
in line with our principles of ongoing and continuous improvement.  

Response to Concern 2: The Drugs Diary and Potential for Confusion with GP Advice 

The Drugs Diary 

The Coroner's concern is that Mr Dickson had been told by his GP to take less benzodiazepine, and that 
there was scope for confusion between this advice and the instruction to keep a drugs diary, as well as 
the level of communication between RSC and GP services. 

We have given careful thought to this concern and welcome the opportunity to explain the clinical 
rationale for the approach taken.  

Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. 
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity 
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713) 

                                                                          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The drugs diary is not an instruction to take drugs. It is an established, evidence-based clinical 
recording tool, supported by Waythrough’s Benzodiazepines (including Z-Drugs) Prescribing Policy and 
consistent with national clinical guidelines. Its purpose is to enable the individual to document their 
existing pattern of use so that the service can understand its nature, frequency, and quantity. This is a 
prerequisite to any safe reduction plan. Without an accurate baseline of what an individual is actually 
using, it is not possible to formulate safe treatment options. This is particularly important in the context 
of illicit benzodiazepines, where content, potency, and effects are often unclear, and the risks 
associated with unsupervised benzodiazepine withdrawal, including seizures, can be serious.  

Under Waythrough's Benzodiazepines Prescribing Policy, before any prescribing or reduction 
intervention can be considered, benzodiazepine dependency must first be established (as opposed to 
binge use) through a comprehensive assessment of the person's history and clinical record. This 
includes at least two consecutive positive benzodiazepine screens in the preceding six weeks. The 
drugs diary forms part of this broader assessment process, alongside drug screening and validated 
clinical tools. 

The agreed plan was for Mr Dickson to complete the drugs diary for review at his next session, enabling 
an accurate pattern of use to be established. The next steps would then have been to arrange an 
appointment with RSC’s clinical team to develop a tailored reduction plan.  

Importantly, there is no contradiction between the drugs diary and Mr Dickson's GP's advice to reduce 
his benzodiazepine intake. Both are directed toward the same objective: the safe reduction of Mr 
Dickson's benzodiazepine use. The GP's advice addressed the direction of travel, that Mr Dickson 
should reduce his intake. The drugs diary addressed the clinical means by which that reduction could 
be achieved safely, by first establishing an accurate baseline, which is a prerequisite to any evidence-
based reduction plan. The diary does not invite continued use; it asks the individual to record what they 
are actually using so that clinical decisions can be properly informed. This approach is standard 
practice across specialist substance use services nationally.  

In addition to providing the drugs diary, harm reduction advice and safety information were provided to 
Mr Dickson at the initial assessment, including advice around the risks of purchasing substances from 
unregulated sources.  

The drugs diary is an established, evidence-based clinical tool, supported by Waythrough's 
Benzodiazepines Prescribing Policy and consistent with national clinical guidelines and we are 
satisfied that its use in Mr Dickson's case was appropriate. We recognise, however, the importance of 
ensuring that individuals understand the purpose of the diary at the point it is provided, and how it sits 
alongside any other advice they may have received. In line with our commitment to ongoing and 
continuous improvement, we will continue to reflect on how we communicate this in practice. 

Communication with Primary Care Services 

In relation to communication with GP services, RSC works collaboratively with primary care. When an 
individual is reviewed by a clinician (as distinct from the Recovery Coordinator who conducts the initial 
assessment), a summary letter is sent to their GP detailing the clinical review, any findings and 
recommendations, and confirming the initiation or continuation of prescribing by RSC where 

Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. 
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity 
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713) 

                                                                          
 
 
 
 
 
 
 
 
 
 
 
 
 applicable. At the stage of Mr Dickson's initial assessment, no clinical review had yet taken place. 
Communication with Mr Dickson's GP would have followed as the treatment pathway progressed.  

In addition, within North Cumbria, the North East and North Cumbria Integrated Care Board (NENC 
ICB) launched the North Cumbria Health Pathways tool in 2022. This is a web-based clinical resource 
designed for use by GPs during primary care consultations, providing clear and concise guidance on 
assessing and managing patients with particular conditions and on making referrals to local specialist 
services. The content is developed collaboratively between general practitioners, hospital clinicians, 
and other health professionals. RSC contributed to a number of specialist pathways within the tool, 
including the pathway on Benzodiazepine Use and Dependence. This means that Mr Dickson's GP 
practice had access to a clear referral pathway and guidance on the specialist support available 
through RSC at the time of Mr Dickson's engagement with the service. RSC is committed to continuing 
to work with primary care partners to enhance mutual awareness of specialist services and 
communication pathways, particularly at the point of referral. 

Conclusion 

I hope that the above provides reassurance in respect of how Waythrough has considered the issues 
raised. The protocols in place at the time of Mr Dickson's initial assessment were appropriate, 
evidence-based, and followed correctly, consistent with our operating procedures and national 
guidelines. 

Tragically, Mr Dickson passed away on 6 February 2025, before his scheduled follow-up appointment 
on 17 February. The service did not have the opportunity to progress beyond the initial assessment 
stage. 

Reducing drug and alcohol related deaths within the country is a priority for Waythrough, and we are 
committed to working collaboratively with all partner agencies to learn from, and reduce, the number 
of such deaths in the area.  

On behalf of all staff at RSC, I would like to pass our sincere condolences to Mr Dickson's family and 
friends. 

Yours sincerely, 

Area Manager  

Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. 
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity 
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)