Oxleas NHS Foundation Trust
NHS Trust
Action Taken
AI-generated response summary
• HMP Wandsworth healthcare delivered a case-based learning event for prescribers, focusing on objective signs of withdrawal. • The policy for pharmacological treatment of drug and alcohol withdrawal has been reviewed, revised, and disseminated, with a full-time substance misuse practitioner employed. • Revised operational policies mandate considering prior time in custody for opiate tolerance and withholding sedating medication from intoxicated patients; near-patient urine tests for a wider variety of drugs are now stocked and mandated.
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Dear Madam,
Prevent Future Deaths Report – Inquest touching the death of Mr Lee Hughes
Thank you for your regulation 28 report to prevent future deaths dated 4th March 2024 following the inquest into the death of Mr Lee Hughes which concluded on 29th February 2024.
In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Mr Hughes’ family and loved ones. Oxleas NHS Trust is keen to assure the family and the coroner that the concerns raised about Mr Hughes’ care have been listened to and acted upon. I appreciate that responses to Coroner Reports may constitute an important part of process through which family and friends come to terms with the passing of their loved one, and that this will have been an incredibly difficult time for them.
In your paragraph 7 letter you raised concerns in relation to the care provided to Mr Hughes whilst at HMP Wandsworth, namely:
1. That clinicians are relying too heavily on subjective signs of withdrawal and that OWS should be used to determine whether methadone should be prescribed rather than COWS.
2. That prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners.
3. That guidelines are followed without sufficient consideration of whether they apply to the individual patient.
4. That practitioners should consider whether time spent in custody prior to remand may have reduced opiate tolerance when prescribing opiates, especially when methadone is prescribed with a synergistic agent such as benzodiazepine.
5. That methadone should be withheld and or reduced if the patient is showing signs of sedation.
6. That tests should be available for illicit drugs for near patient testing to allow a clinician to better assess a patient showing signs of intoxication.
Following the inquest senior leaders from Oxleas NHS Foundation Trust have considered these helpful observations and have responded to each of your concerns as follows: 23rd April 2024
Private & Confidential Fiona J Wilcox HM Senior Coroner Inner West London
25 Bagley’s Lane Fulham London SW6 2QA Oxleas NHS Foundation Trust Pinewood House Pinewood Place Dartford Kent DA2 7WG
1. The replacement of COWS with an Opiate Withdrawal Scale which excludes subjective reported symptoms would provide a more objective measure of opiate withdrawal and has great merit. Oxleas NHS Foundation Trust would require any deviation from current standards to be ratified at a national level and across the entire prison estate before it could be recommended as standard care. This has been raised with commissioners and we will follow up the direction from NHSE in relation to the use of a new withdrawal scale, and will fully support implementation of any revision to national guidance. In the interim I do recognise and recommend that clinicians should focus more on objective signs of withdrawal than subjective ones. As a result, HMP Wandsworth healthcare has already delivered a case-based learning event for all its prescribers, focussing on the risks of over relying on reported symptoms over verifiable clinical signs.
2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day reviews. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently. She is also responsible for quality assurance, audit and supervision and professional development of the wider substance misuse team, including the learning event referred to above.
3. This case has provoked a great deal of reflection on the balance of risks and benefits of methadone, especially in the first days of drug accumulation, and when prescribed alongside benzodiazepines or other sedatives. The findings and recommendations of Mr Hughes’ inquest have been shared with all prescribers. His case has already been discussed within a reflective practice forum for prescribers, focussing on the judicious interpretation of the individual patient’s history, clinical signs and investigations (such as urine drug screens), to prioritise safety with a ‘start low and go slow’ approach, even when this is unpopular with the patient.
4. The revised substance misuse operational policy includes instructions that prescribers should consider time spent in custody prior to arrival to prison as a factor in reducing opiate tolerance. A lower tolerance reduces the ceiling of safe methadone dosing, especially when co-prescribed with other sedative medications such as benzodiazepines. This policy was revised in July 2023 and has been shared with all clinical staff at Clinical Governance meetings following publication.
5. The revised operational policy mandates that sedating medication is withheld from patients showing signs of intoxication or over sedation, until they have had a urine drugs screen and a thorough clinical review by a member for the substance misuse team. This revised policy has been shared with all clinical staff in Clinical Governance meetings following publication.
6. HMP Wandsworth has investigated the commercially available near patient urine tests for drugs, including psychoactive substances (‘spice’). HMP Wandsworth now stock a test which detects a wider variety of prescribed and illicit drugs. These tests are now mandated for patients who present with sedation of unknown cause. The limitations of these tests, particularly false negatives, are well known to substance misuse practitioners. However, they are a useful aid to the management of patients whose urine test suggests continuing illicit drug use on a prison wing. These tests are currently being used and are available to all clinicians.
I hope that this letter reassures you that Oxleas has been highly attentive to the findings of your investigation, and that concerted remedial action has been taken on all the areas you identified to prevent any similar future deaths.
Please do not hesitate to contact me if any clarification or further assurance is required.
Prevent Future Deaths Report – Inquest touching the death of Mr Lee Hughes
Thank you for your regulation 28 report to prevent future deaths dated 4th March 2024 following the inquest into the death of Mr Lee Hughes which concluded on 29th February 2024.
In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Mr Hughes’ family and loved ones. Oxleas NHS Trust is keen to assure the family and the coroner that the concerns raised about Mr Hughes’ care have been listened to and acted upon. I appreciate that responses to Coroner Reports may constitute an important part of process through which family and friends come to terms with the passing of their loved one, and that this will have been an incredibly difficult time for them.
In your paragraph 7 letter you raised concerns in relation to the care provided to Mr Hughes whilst at HMP Wandsworth, namely:
1. That clinicians are relying too heavily on subjective signs of withdrawal and that OWS should be used to determine whether methadone should be prescribed rather than COWS.
2. That prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners.
3. That guidelines are followed without sufficient consideration of whether they apply to the individual patient.
4. That practitioners should consider whether time spent in custody prior to remand may have reduced opiate tolerance when prescribing opiates, especially when methadone is prescribed with a synergistic agent such as benzodiazepine.
5. That methadone should be withheld and or reduced if the patient is showing signs of sedation.
6. That tests should be available for illicit drugs for near patient testing to allow a clinician to better assess a patient showing signs of intoxication.
Following the inquest senior leaders from Oxleas NHS Foundation Trust have considered these helpful observations and have responded to each of your concerns as follows: 23rd April 2024
Private & Confidential Fiona J Wilcox HM Senior Coroner Inner West London
25 Bagley’s Lane Fulham London SW6 2QA Oxleas NHS Foundation Trust Pinewood House Pinewood Place Dartford Kent DA2 7WG
1. The replacement of COWS with an Opiate Withdrawal Scale which excludes subjective reported symptoms would provide a more objective measure of opiate withdrawal and has great merit. Oxleas NHS Foundation Trust would require any deviation from current standards to be ratified at a national level and across the entire prison estate before it could be recommended as standard care. This has been raised with commissioners and we will follow up the direction from NHSE in relation to the use of a new withdrawal scale, and will fully support implementation of any revision to national guidance. In the interim I do recognise and recommend that clinicians should focus more on objective signs of withdrawal than subjective ones. As a result, HMP Wandsworth healthcare has already delivered a case-based learning event for all its prescribers, focussing on the risks of over relying on reported symptoms over verifiable clinical signs.
2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day reviews. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently. She is also responsible for quality assurance, audit and supervision and professional development of the wider substance misuse team, including the learning event referred to above.
3. This case has provoked a great deal of reflection on the balance of risks and benefits of methadone, especially in the first days of drug accumulation, and when prescribed alongside benzodiazepines or other sedatives. The findings and recommendations of Mr Hughes’ inquest have been shared with all prescribers. His case has already been discussed within a reflective practice forum for prescribers, focussing on the judicious interpretation of the individual patient’s history, clinical signs and investigations (such as urine drug screens), to prioritise safety with a ‘start low and go slow’ approach, even when this is unpopular with the patient.
4. The revised substance misuse operational policy includes instructions that prescribers should consider time spent in custody prior to arrival to prison as a factor in reducing opiate tolerance. A lower tolerance reduces the ceiling of safe methadone dosing, especially when co-prescribed with other sedative medications such as benzodiazepines. This policy was revised in July 2023 and has been shared with all clinical staff at Clinical Governance meetings following publication.
5. The revised operational policy mandates that sedating medication is withheld from patients showing signs of intoxication or over sedation, until they have had a urine drugs screen and a thorough clinical review by a member for the substance misuse team. This revised policy has been shared with all clinical staff in Clinical Governance meetings following publication.
6. HMP Wandsworth has investigated the commercially available near patient urine tests for drugs, including psychoactive substances (‘spice’). HMP Wandsworth now stock a test which detects a wider variety of prescribed and illicit drugs. These tests are now mandated for patients who present with sedation of unknown cause. The limitations of these tests, particularly false negatives, are well known to substance misuse practitioners. However, they are a useful aid to the management of patients whose urine test suggests continuing illicit drug use on a prison wing. These tests are currently being used and are available to all clinicians.
I hope that this letter reassures you that Oxleas has been highly attentive to the findings of your investigation, and that concerted remedial action has been taken on all the areas you identified to prevent any similar future deaths.
Please do not hesitate to contact me if any clarification or further assurance is required.