Northamptonshire Healthcare Foundation Trust
NHS / Health Body
Action Taken
The trust has reminded prescribing clinicians of expectations for assessing and managing cumulative sedative burden, and has re-emphasized documentation standards. They have also introduced a new harm minimisation advice leaflet for patients. (AI summary)
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Dear Mr Milburn
Regulation 28 Report Concerning Fallon Leanne Adams
Thank you for your Report to Prevent Future Deaths (‘Report’) dated 29 December 2025 concerning the death of Fallon Leanne Adams between 8 and 9 February 2023. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Ms Adams’ family and loved ones.
The matters of concern in your Report centre on the safeguards in place when prescribing medication in the prison setting. You highlighted the risk of interactions between prescribed and other medications, the warning or advice given by prescribers about such interactions, and that a specific warning in relation to the risks of oversedation has not yet been implemented.
You have asked me either to provide details of action taken, or proposed to be taken, or to explain why no action is proposed. Accordingly, please find below my response to your concerns detailing the actions we will take to prevent future deaths.
Advising patients on the risk of medication interactions The safe and effective use of medications within the secure environment is high priority for NHFT. We welcome the opportunity to learn from the circumstances surrounding Ms Fallon’s death to strengthen our approach.
Cont’d/… Ref: PFD Fallon Adams Date: 23rd February 2026
Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Tel: 0300 027 1717
We agree it is important that a patient is informed about the risk(s) of any medication(s) our clinicians prescribe, including those that may arise from interactions with other medications they may be taking, whatever the source.
In line with guidelines from the National Institute for Health and Care Excellence (NICE), we expect our prescribers to discuss a prescription with their patient. This will include advice on: the purpose of the prescribed medicine and what the patient can expect; how, when, and for how long to take the medicine; the risks, potential side effects, and when/how to seek help; interactions with other medicines or lifestyle factors; and monitoring or follow-up requirements.
We expect our clinicians to take contemporaneous notes of their consultation(s) with patients, which would include a record of the advice they have provided alongside information on the prescription.
We have taken the opportunity to remind prescribing clinicians working within the secure environment of our expectations concerning their discussions with patients and record keeping.
Mitigating the risk of oversedation Requests for night sedation are frequent within the secure environment, particularly from patients with substance misuse problems, because those withdrawing from illicit drugs including cannabis, opiates, alcohol and benzodiazepines commonly experience insomnia.
It is well known that insomnia may increase the risk of self-harm and suicide by negatively affecting mood, thoughts and behaviour, independently of other risk factors impacting on mental health. Whilst a non-pharmacological approach to the management of insomnia is recommended as the first line treatment, patients may require a prescription of hypnotic medication.
Considering that it is also common for patients within the secure environment to be prescribed multiple medications, it is particularly important that our clinicians are equipped to assess, manage, and communicate the risks of over-sedation with their patient(s).
Cont’d/…
Interim Chair: Faisal Hussain
Chief Executive: Angela Hillery
Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Tel: 0300 027 1717
In response to your Report, we have reminded our prescribing clinicians of our expectations concerning the assessment and management of cumulative sedative burden, recognition of over-sedation, and the need for proactive escalation where concerns are identified.
We have re-emphasised our expectations on documentation standards to ensure consistent and contemporaneous recording of clinical observations, including withdrawal assessments, blood pressure readings, and explicit confirmation where no signs of over-sedation are present. Staff have been reminded of the importance of repeating observations where results are unexpected and clearly documenting clinical judgement and escalation decisions.
We have also introduced a new harm minimisation advice leaflet, which is now routinely provided to patients. This leaflet clearly outlines key risks, including polypharmacy, the use of illicit drugs alongside prescribed medication, the dangers of using substances alone in cells (particularly overnight), reduced tolerance following periods of abstinence, and the increased risk associated with medication initiation and titration periods.
I hope the content of this letter fully addresses the concerns you raised in your Report and provides assurance on the steps we will take to prevent future deaths. Please contact me if you have any questions about this letter or require further information.
Regulation 28 Report Concerning Fallon Leanne Adams
Thank you for your Report to Prevent Future Deaths (‘Report’) dated 29 December 2025 concerning the death of Fallon Leanne Adams between 8 and 9 February 2023. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Ms Adams’ family and loved ones.
The matters of concern in your Report centre on the safeguards in place when prescribing medication in the prison setting. You highlighted the risk of interactions between prescribed and other medications, the warning or advice given by prescribers about such interactions, and that a specific warning in relation to the risks of oversedation has not yet been implemented.
You have asked me either to provide details of action taken, or proposed to be taken, or to explain why no action is proposed. Accordingly, please find below my response to your concerns detailing the actions we will take to prevent future deaths.
Advising patients on the risk of medication interactions The safe and effective use of medications within the secure environment is high priority for NHFT. We welcome the opportunity to learn from the circumstances surrounding Ms Fallon’s death to strengthen our approach.
Cont’d/… Ref: PFD Fallon Adams Date: 23rd February 2026
Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Tel: 0300 027 1717
We agree it is important that a patient is informed about the risk(s) of any medication(s) our clinicians prescribe, including those that may arise from interactions with other medications they may be taking, whatever the source.
In line with guidelines from the National Institute for Health and Care Excellence (NICE), we expect our prescribers to discuss a prescription with their patient. This will include advice on: the purpose of the prescribed medicine and what the patient can expect; how, when, and for how long to take the medicine; the risks, potential side effects, and when/how to seek help; interactions with other medicines or lifestyle factors; and monitoring or follow-up requirements.
We expect our clinicians to take contemporaneous notes of their consultation(s) with patients, which would include a record of the advice they have provided alongside information on the prescription.
We have taken the opportunity to remind prescribing clinicians working within the secure environment of our expectations concerning their discussions with patients and record keeping.
Mitigating the risk of oversedation Requests for night sedation are frequent within the secure environment, particularly from patients with substance misuse problems, because those withdrawing from illicit drugs including cannabis, opiates, alcohol and benzodiazepines commonly experience insomnia.
It is well known that insomnia may increase the risk of self-harm and suicide by negatively affecting mood, thoughts and behaviour, independently of other risk factors impacting on mental health. Whilst a non-pharmacological approach to the management of insomnia is recommended as the first line treatment, patients may require a prescription of hypnotic medication.
Considering that it is also common for patients within the secure environment to be prescribed multiple medications, it is particularly important that our clinicians are equipped to assess, manage, and communicate the risks of over-sedation with their patient(s).
Cont’d/…
Interim Chair: Faisal Hussain
Chief Executive: Angela Hillery
Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Tel: 0300 027 1717
In response to your Report, we have reminded our prescribing clinicians of our expectations concerning the assessment and management of cumulative sedative burden, recognition of over-sedation, and the need for proactive escalation where concerns are identified.
We have re-emphasised our expectations on documentation standards to ensure consistent and contemporaneous recording of clinical observations, including withdrawal assessments, blood pressure readings, and explicit confirmation where no signs of over-sedation are present. Staff have been reminded of the importance of repeating observations where results are unexpected and clearly documenting clinical judgement and escalation decisions.
We have also introduced a new harm minimisation advice leaflet, which is now routinely provided to patients. This leaflet clearly outlines key risks, including polypharmacy, the use of illicit drugs alongside prescribed medication, the dangers of using substances alone in cells (particularly overnight), reduced tolerance following periods of abstinence, and the increased risk associated with medication initiation and titration periods.
I hope the content of this letter fully addresses the concerns you raised in your Report and provides assurance on the steps we will take to prevent future deaths. Please contact me if you have any questions about this letter or require further information.