Lee Hughes

Coroner's concerns

AI summary

There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities for escalation and appropriate care were missed.

View full coroner's concerns

- That the GP who increased Mr Hughes's methadone on 20th December 2021, did this by applying guidelines without full consideration of evidence from others, for example his COWS score of 2 the previous day after methadone, that Mr Hua hes had slent, that the nurse who knew him felt he was not exoeriencina withdrawal. Further, the assessment that this GP made relied largely upon subjective symptoms rather than objective signs to form a COWS score of 7 and

Responses

2 respondents

NHS England NHS / Health Body

4 Mar 2024 PDF

Action Planned

NHS England will use the learning from this case to strengthen the service specification, and all reports received are discussed by the Regulation 28 Working Group to share learnings and identify emerging trends. (AI summary)

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Dear Professor Wilcox Re: Regulation 28 Report to Prevent Future Deaths – Mr Lee Martin Hughes (also known as Martin Lee Hughes) who died on 25 December 2021

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4 March 2024 concerning the death of Lee Martin Hughes on 25 December 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Martin’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Martin’s care have been listened to and reflected upon.

I respond to each of the matters of concern raised in your Report below.

1. Too heavy reliance by clinicians on patients sharing symptoms rather than seeking evidence (physical signs) of withdrawal. Use of the Clinical Opiate Withdrawal Scale (COWS), which may be subjective, rather than Objective Signs of Withdrawal Assessments (OWS) to determine whether methadone should be prescribed.

NHS England commissioned services use national clinical guidelines and the tools described in these to assess patients for opioid, or other withdrawal from dependence forming medicines. For opioid and benzodiazepines withdrawal this guidance is Drug misuse and dependence: UK guidelines on clinical management
- GOV.UK (www.gov.uk) along with guidance issued by the National Institute for Health and Care Excellence (NICE) which is found at Recommendations | Drug misuse in over 16s: opioid detoxification | Guidance | NICE.

NHS England does not specify use of a particular assessment tool unless this is advised within national standards and guidelines. The choice of assessment tool is made on a case-by-case basis and is a clinical judgement made by the clinician.

Skills associated with assessment are vital when providing drug treatment and clinicians are required to meet competencies set out in relevant professional and other appropriate standards.

2. That prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners who should be more experienced in when, whether and how much to prescribe. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

19 April 2024

Any clinician assessing and prescribing for substance misuse is expected to have the appropriate competencies to make and action clinical decisions independently. These decisions are made using the clinical system, information and evidence available to the clinician, to consider holistic health considerations. Referral to a colleague seeking advice or support is only necessary where a clinician is uncertain about what actions to take.

Responsibility for ensuring competencies is met lies with the clinician’s employer, most often the healthcare provider. This also applies to assuring training compliance.

3. That guidelines are followed without sufficient consider to whether they apply to the individual.

National clinical guidelines are developed by NICE: (https://www.nice.org.uk/guidance) and professional clinical organisations using the best available evidence, to assist practitioners and clinicians with decisions about appropriate health care for patients in specific circumstances. They are designed to support decision making processes but the responsibility for the decision lies with the clinician and their professional judgement, which is based on several factors.

Any training needs are addressed by the employer, who is also responsible for assuring the clinicians competency.

4. That practitioners, when prescribing consider whether time spent in custody before remand, may have reduced an individual’s tolerance to opiates; this is especially when methadone is to be prescribed with a synergistic agent such as benzodiazepines.

5. That methadone should be withheld and/or reduced if the individual is showing signs of sedation.

Consideration to time spent in custody before remand and whether this may have reduced an individual’s tolerance to opiates forms part of the assessment as described in national guidance: Drug misuse and dependence: UK guidelines on clinical management - GOV.UK (www.gov.uk) and police custody guidance (Detainees with substance use disorders in police custody: Guidelines for clinical management (5th edition) - FFLM . This also informs the dose prescribing, which is titrated against symptoms after each does. This also applies to withholding or reducing methadone if there are signs of sedation.

6. There should be tests available for illicit drugs for near patient testing to allow clinicians to better assess a patient showing signs of intoxication.

Urine testing is carried out to inform clinical reviews and assessments for informing clinical decisions about substance misuse prescribing.

I am pleased to see from your Report that processes and procedures have been changed within HMP Wandsworth to address learning identified in this case and meet expectations in terms of prescribing and supplying sedating medicines safely.

Nationally, NHS England is in the process of updating the service specification and will use this learning to strengthen this.

I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Oxleas NHS Foundation Trust NHS / Health Body

4 Mar 2024 PDF

Action Taken

Oxleas NHS Foundation Trust has revised its substance misuse operational policy to include consideration of time spent in custody when prescribing methadone, and mandates withholding sedating medication from patients showing signs of intoxication until a urine drug screen and clinical review are completed. HMP Wandsworth now stocks and mandates the use of near-patient urine tests for drugs for patients presenting with sedation of unknown cause. (AI summary)

View full response

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.

Report sections

Investigation and inquest

Between 26th February 2024 and 29th February 2024, evidence was heard before a jury touching the death of Mr Lee Martin Hughes, also known as Martin Lee Hughes. He had died on the 25th December 2021, aged 50 years whilst remanded in HMP Wandsworth. Medical Cause of Death 1 a Methadone and Benzodiazepine intoxication How, when, where and in what circumstances the deceased came by his death: Lee Martin Hughes was remanded to HMP Wandsworth on 18th December 2021. He was found deceased in his cell in HMP Wandsworth on 25th December 2021 at approx. 0500. On arrival, the nurse gave him a COWS score of 12 and a CIWA score of 12-13. He was familiar to the nurse based on previous visits and she noted him looking healthier than previously.
• Mr Hughes reported drug use of heroin /day; cocaine; diazepam tablets; cannabis. He also reported alcohol/week. We consider this report to be unreliable based on other evidence we heard.
• His urine test was positive for: opiates (not specifically heroin); cocaine; diazepam; cannabis. His urine was negative for methadone.
• He was prescribed diazepam twice daily, administered on 18th , 19th , and 20th ; and methadone on the 18th ; and 19th and 20th -

Based on a COWS score of 2 found on 19th December 2021 we understand that
• this medication was sufficient to control his signs of withdrawal. On 20th December 2021, the Doctor increased his methadone prescription to to be titrated up over the following days. Our understanding is this was reasonable and appropriate based on a COWs score of 7 and BNF guidance. We believe this increase in methadone did contribute to his death, but does not
• equate to a failure in care. He was declined an increase in methadone on 23rd December 2021. Our
• understanding is this was appropriate. He showed signs of intoxication on 23rd December 2021 (nodding off) .
• We believe based on the evidence in hindsight ii would have been appropriate
• to omit a dose of methadone on 23rd December 2021, despite confounding factors. We found evidence of multiple events where Mr Hughes was unrousable on
• 24/12/2021, in order to administer diazepam. Based on the evidence, we do not believe this was appropriately managed by
• healthcare. We have seen insufficient evidence to believe he was seen awake or vaping on
• 24th December 2021 at 2100. Based on the evidence, we understand his consciousness to have been
• impaired when he was visited by the nurse at c. 2110 on 24th December 2021. Medical help should have been sought:
• Code Blue should have been called at 2110 .
• Medical escalation to the HOTEL nurse when the medication could not be
• administered by the Pharm Tech at 18:10. Based on this evidence, we believe there a really serious (gross) failure to
• care for Mr Hughes, encompassing the behaviour of the nurse who entered the call at 21:10. Had care been sought, we believe Mr Hughes would have survived at this
• time. We believe this was a lost opportunity .
• We find the medical cause of death to be methadone and Benzodiazepine
• Intoxication. As a footnote, we believe Mr Hughes's knowledge of the system (drug
• seeking behaviours) contributed to his death. We note the lack of communication between disciplines in HMP
• Wandsworth was a contributing factor to Mr Hughes's death, specifically Pharmacy techs not adequately escalating the reason that Mr Hughes could
• not be medicated, including the lack of real time and accessible written notes. The delay in trying to medicate Mr Hughes between the pharmacy techs
• alerting the day nurses for a second time at 18: 10 and the night nurse first visiting Mr Hughes at 20:42. Conclusion of the Jury as to the death: Drug-related Misadventure contributed to by Neglect. Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report in addition to the findings of the jury above, which I do not repeat: The independent expert instructed by the court in this case in this case raised multiple concerns:
- That the GP who increased Mr Hughes's methadone on 20th December 2021, did this by applying guidelines without full consideration of evidence from others, for example his COWS score of 2 the previous day after methadone, that Mr Hua hes had slent, that the nurse who knew him felt he was not exoeriencina withdrawal. Further, the assessment that this GP made relied largely upon subjective symptoms rather than objective signs to form a COWS score of 7 and increase the methadone to a level that proved ultimately fatal with the concurrent administration of benzodiazepines, rather than leaving Mr Hughes at the same dose and reviewing him. That no dose of methadone was omitted on 23rd December 2023 despite Mr Hughes nodding off in the consultation. That Mr Hughes would have been highly likely to have survived even if emergency help was requested at the last interaction at 21 :10, and naloxone and other supportive care had been given. That tolerance to opiates can fall away completely within 3 to 4 days of lack of opiate use, increasing risks of death if for example methadone is started. That due the long half life of methadone that it takes 5 days of same dose prescribing before the level in the blood stream stabilises. That most deaths from methadone occur in the first two weeks of starting the drug. Mr Hughes died on day 7. There was at that time, no reliable drug testing for illicit drugs, especially SPICE, available for near patient testing. That one reason for prescribing cited by the doctors was to mitigate the drive for the inmate to use illicit drugs, which have their own dangers. Evidence was taken that illicit drugs are widely available in HMP Wandsworth, however the toxicology findings were consistent with him having died solely from methadone and diazepam as prescribed. Other evidence was that the pharmacy technicians had no training in consciousness assessment and did not record their interactions on the medical records ( System One). Since Mr Hughes's death an SI was undertaken and many lessons were learned and procedures changed within Wandsworth, including the following matters: Pharmacy technicians have been trained as to how to assess consciousness and the risks of sedative drugs especially when given in combination. That emergency medical assistance should be sought when an inmate shows signs of impaired consciousness. That pharmacy technicians should record their patient/inmate interactions on System One. That this case has raised awareness across the prison estate of dangers of methadone, especially when prescribed alongside benzodiazepines or other sedatives, prescribed or illicit drugs. That all prescribing for those inmates that require pharmaceutical intervention for withdrawal is undertaken by the Substance Misuse Team. That the use of objective assessment to assess withdrawal signs is emphasised. That on commencing methadone consideration is given to the time spent in custody before remand in prison as to how much methadone should be prescribed in view of the risks of decreasing tolerance to cardiorespiratory effects that may have taken place whilst in custody when prescribing methadone. That especial consideration should be given when methadone is prescribed in combination with other sedative drugs. That policies reiterate that methadone should be withheld if patient/inmate is showing signs of intoxication. That there is better availability of near patient testing for illicit drugs, including SPICE. Much of this is clearly good practice and there would be benefits if these changes and imorovements in oractice were adooted across the orison estate. 6

Action should be taken

It is for each addressee to respond to matters relevant to them.

Copies sent to

Governor, HMP Wandsworth, Heathfield Road, Wandsworth, London. Sw18 3HU. , Investigator, PPO, Third Floor, 10, South Colonnade, Canary Wharf, London. E14 4PU

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