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John Pace

13 Nov 2023 · Coroner Jeane Mellani · Essex
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The coroner's concerns

  1. 1. lack of documented discharge pathway for methadone detoxification

    “One of the material issues in evidence was about changes in the discharge pathway for prisoners on methadone detoxification as well as those who decided to stop the detoxification programme before completion. CRG identified the need for this change in their Root Cause Analysis review and their live witnesses provided evidence that this new process is now being followed. Forward Trust provided evidence that this is the new process now embedded in their operating procedure. However, no documentary”

Responses

2023-0447-Response-from-the-Forward-Trust.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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John Pace · Recurance