Dayle Bates: Prevention of future deaths report

Alcohol, drug and medication related deaths

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Date of report: 08/02/2024

Ref: 2024-0070

Deceased name: Dayle Bates

Coroner name: Robert Cohen

Coroner Area: Cumbria

Category: Alcohol, drug and medication related deaths

This report is being sent to: Recovery Steps Cumbria

Recovery Steps Cumbria
I am Robert Cohen HM Assistant Coroner for Cumbria
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.
On 8 September 2023 I commenced an investigation into the death of Dayle BATES. The investigation concluded at the end of the inquest . The conclusion of the inquest was
Drug related death.
1a       Drug Intoxication
Dayle Bates was 39 years old. He lived in Workington, Cumbria. Mr Bates had a past medical history of drug misuse. On 31st August 2023 Mr Bates’ body was discovered at his home. Ambulance staff were unable to revive Mr Bates and his death was confirmed at 11:50. A post mortem examination has confirmed that his death was caused by the combined effect of heroin, bromazolam, protonitazene, xylazine and alcohol.
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.
Mr Bates had a prescription for methadone issued by Recovery Steps. He was required to collect a dose each day from a named pharmacy. On 14th July 2023 Mr Bates stopped collecting methadone. The pharmacy explained that they sought to inform Recovery Steps of this development shortly after 14th but did not have any contact details other than a general number which is not always answered and a direct line for one key worker. They attempted to raise their concerns with that key worker, but the message appears not to have been relayed. Recovery Steps did not become aware that Mr Bate was not collecting methadone until 30th August 2023.
In answer to question from the Court, the pharmacy have also indicated that although it is there practice to inform Recovery Steps of any other concerns they might have about a person prescribed with methadone, this is a voluntary decision on their part and not a matter that arises from any obligation.
I am concerned that this situation gives rise to a risk of future death. It appears that there is no direct means by which a pharmacy can report to Recovery Steps that a service user has stopped collecting methadone. There is also no apparent obligation on pharmacies to report wider concerns for service users’ welfare to Recovery Steps. In each case this may mean that Recovery Steps are unaware that vulnerable service users require additional support.
In my opinion action should be taken to prevent future deaths and I believe you Recovery Steps Cumbria have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 5th April 2024. 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Mr Bates.
I have also sent it to of J H Sandham Chemists, who may find it useful or of interest.
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.
98 February 2024
Robert Cohen HM Assistant Coroner for