Missed opportunity before Daniel Varndell’s death days after release from prison

A coroner has concluded that there was a missed opportunity before the death of Daniel Varndell days after his release from HMP Lewes. The Coroner will also make a Prevention of Future Deaths Report in respect of alterations to licence conditions after their agreement by the MAPPA process.

Daniel John Varndell, 30, died on 11 May 2020 as a result of mixed drug intoxication. The inquest into his death concluded on 24 November with Coroner Rosamund Rhodes-Kemp finding that there was a missed opportunity in the response to an incident at Dickson House Approved Premises prior to Daniel’s death.

Daniel’s mother remembers his good sense of humour, quick wit, and cheeky grin. Even as a child he was loving, adventurous, and great with children, adults, and animals alike.

He had a history of mental ill health, which included a diagnosis of schizophrenia and more recently personality disorder.

After being released from HMP Lewes on 7 May 2020, Daniel initially seemed to be reasonably settled at Dickson House. His release had been subject to detailed planning and oversight under multi-agency public protection arrangements (MAPPA).

On 11 May, Daniel left the premises after an altercation with another resident. The coroner found that there was a discrepancy in timings and a gap of about ten minutes from when staff said they had activated their personal alarm and when notification was received by the alarm company. There was a missed opportunity because of that delay.

Police, who had responded promptly as soon as they were alerted, were unable to locate Daniel. He was later found dead at an address not previously associated with him.

The coroner had heard evidence that Daniel was a risk to himself because of his drug use and his mental health conditions. This, along with other risks, had led to extensive planning for Daniel’s release. However, a licence condition in relation to engagement with mental health services was deleted shortly before his release.

In giving her conclusions, the coroner said “I do think it is inappropriate for a person to unilaterally remove a Licence Condition agreed by a multi professional MAPPA meeting particularly without discussion with anyone more senior involved in the MAPPA process”.

There was no policy in place on such licence amendments. As a result of her concern, the coroner made a Prevention of Future Deaths Report in relation to this amendment. A response is required within 56 days.  

Daniel’s mother, Paula, was represented by Cian Murphy, instructed by Aimee Jones of Harding Evans Solicitors.

Read the full press release on the INQUEST website here.