6 December 2022

Before Rosamund Rhodes-Kemp Coroner
Winchester Coroner’s Court, The Castle, Castle Hill, Winchester, SO23 8UL
Heard 18-21 July 2022
Concluded 24 November 2022

Daniel John Varndell, 30, died on 11 May 2020 as a result of mixed drug intoxication, days after his release from HMP Lewes in East Sussex.

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 the Approved Premises, Dickinson House. His release was subject to detailed planning and oversight under multi-agency public protection arrangements (MAPPA).

On 11 May, Daniel left Dickson House 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 Dickson House 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 Bramble, has set out her frustration at mental health services to whom Daniel was referred while he was in prison: Mental health services refused to accept Dan as a patient even though he had long-standing and complex needs. He spent a long time on the Segregation Unit in prison immediately before his release - even on constant watch – which the coroner said was unusual.

I am grateful for the efforts that Dickson House staff made with Dan before his death. But I cannot understand the actions of mental health services and the gaps in the licence conditions policy. I hope steps are taken so no other family has to suffer in this way.

Aimee Jones of Harding Evans solicitors, who represented the family, said: “Daniel was a very vulnerable man who required appropriate support following his release from prison. The purpose of MAPPA was to consider and plan to manage those risks. The removal of a Licence Condition that would have required Daniel to engage with Mental Health Services was wholly inappropriate, particularly given the extensive planning that had gone into Daniel’s safe release. We welcome the Coroner’s Report for the Prevention of Future Deaths and await the response.”



For more information and a photo of Daniel contact Lucy McKay on [email protected]

The family was represented by INQUEST Lawyers Group members Aimee Jones of Harding Evans Solicitors and Cian Murphy of Doughty Street Chambers.