On 09 September 2015 commenced an investigation into the death of Daniel James Paylor aged 39. His Inquest was opened on the 16th November 2015 following the receipt from the Pathologist of a cause of death being attributable to opiate overdose_ concluded investigation at a final Inquest hearing on Wednesday 29lh June 2016_ The conclusion of the Inquest was that Daniel, known to his family as Dan; had died as a result of an opiate overdose_ My formal conclusion on the Record of Inquest as to his death was Misadventure" . was not satisfied to either of the two standards of proof that Dan intended to take his own life_

Dan had for a number of years been employed as a Paramedic with the South Western Ambulance Service. He was registered as a Paramedic with the Health & Care Professions Council 'HCPA"). He had been diagnosed with Bi-polar disorder back in 2010 and had suffered with intermittent depression predominately since 2006_ He had first sought help insofar as an addiction to Codeine it appears following an accidental overdose in August 2014 That resulted in a referral to the Mental Health professionals but he was discharged from their care in February 2015. It appears that he relapsed insofar as his addiction to Codeine in 2015 at which stage he sought advice drugs advisory body called Turning Point: offered to provide support and assistance to Dan on the basis that he had to disclose to his employer that he had an addiction to Codeine. He made this disclosure in August 2015 but_as_his_duties_would not involve_him_coming_into_contact _with_opiate_based_drugs_he_was the from July They allowed to continue work with their support and the knowledge that he was in receipt of from Turning Point No disclosure was made to the HCPA At Inquest it appears that despite positive obligation on an employee to disclose secondary work to his employer (South Western Ambulance Service) Dan had never disclosed that for a number of years he had been providing paramedic services privately to local motor cross events: It appears that his registration as a paramedic enabled him to privately acquire and store in safe variety of drugs including morphine based drugs such as Oramorph. heard evidence from one of his work colleagues and a good friend, that the list of available drugs that can be acquired in this way is prescribed by the Medicine and Health Care Products Regulatory Agency and that the control of those drugs in terms of their keeping is overseen by the Home Office_ Whilst guidance is given as regards the keeping of the drugs, health care professionals it appears have to devise their own paperwork to all intents and purposes to record the administering of drugs from time to time and the replacement of drugs that have gone, say, past their use by date was told by (that the Home Office have a power to make random checks but he himself has not been subject to one having been actively involved in these events for some 7 years_ Having heard the evidence found that more likely than not at the end of a shift on the morning of the 1st September 2015 Dan returned to his brother's home where he was staying and at some point after that opened the safe more likely than not at a time of relapse and consumed a 10Oml bottle of Oramorph His unresponsive body was discovered by his brother lying on the bed on the afternoon of the September 2015 and the post mortem examination revealed that Dan had died from an opiate overdose (1303 micrograms per litre of blood free morphine).

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action to address the concern highlighted above.