Source · Prevention of Future Deaths

Darren Dickson

Ref: 2026-0150 Date: 16 Mar 2026 Coroner: Andrew Cousins Area: Cumbria Responses identified: 1 / 1 View PDF

Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record retention.

Date 16 Mar 2026
56-day deadline 11 May 2026
Responses identified 1 of 1
Alcohol, drug and medication related deaths

Coroner's concerns

AI summary
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record retention.
View full coroner's concerns
The MATTER OF CONCERN is as follows. I heard evidence that Mr Dickson’s supervision records were being over written 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.

Responses

1 respondent
Cumbria Northumberland Tyne Wear NHS Foundation Trust NHS / Health Body
5 May 2026 PDF
Action Taken

• The matter has been discussed with the staff member involved to ensure that there is clear understanding of expectations in the future. • The Trust has taken steps to further strengthen the relevant section of the Clinical Supervision Policy. • A Trust- wide Policy Alert, via email on 27th April (AI summary)

View full response
Dear Mr Cousins, Inquest into the death of Darren Robert Dickson Response to Regulation 28 Report; Prevent Future Deaths Response This response has been prepared by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (“The Trust”) and addresses the concern highlighted by HM Coroner in the Regulation 28 Report dated 16 March 2026 following the investigation into the death of Darren Dickson. This response addresses the concern set out by HM Coroner in relation to the retention and non-destruction of records and sets out the work that has been undertaken to strengthen and communicate the guidance provided to staff regarding the retention of clinical supervision records. Coroners Concern HM Coroner remained concerned, following the inquest, about the retention and the non-destruction of records and considered that the Trust’s policy did not suitably address this. Trust Response As was heard in evidence at the inquest, the disposal/destruction of supervision records in this case occurred out-with expected policy guidance, which stated that comprehensive records of clinical supervision (originals and copies) should be kept for a minimum of three years, The matter has been discussed with the staff member involved to ensure that there is clear understanding of expectations in the future. In addition, in response to HM Coroner's concern, the Trust has taken steps to further strengthen the relevant section of the Clinical Supervision Policy (enclosed). Section Safer Care St Nicholas Hospital Jubilee Road Gosforth Tyne and Wear NE3 3XT

2
11.2 of this policy now explicitly states that Clinical Supervision records should never be disposed of or destroyed before the minimum 3 year retention period has passed. A link to the national Records Management Code of Practice has also been embedded in this section of the policy for ease of reference. To bring this update to the attention of all staff, the Trust have also issued a Trust- wide Policy Alert, via email on 27th April 26, also enclosed. This alert summarised HM Coroner's concern from this case and highlighted the policy amendment. We hope that the information provided offers the necessary assurances that the Trust has acted in light of the concerns raised in this case.

Report sections

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.
Copies sent to
Castlegate & Derwent SurgeryDAC Beachcroft

Similar PFD reports

Shared signals

Report details

Reference
2026-0150
Date of report
16 March 2026
Coroner
Andrew Cousins
Coroner area
Cumbria

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 May 2026.

Sent to

Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust

Part of a series

2 reports
2026-0151 All responses identified

Source links