South Western Ambulance Service NHS Foundation Trust
NHS / Health Body
Action Planned
The ambulance service will issue further guidance for clinicians on methadone overdose, highlighting the characteristics of methadone and the need for hospital transfer even after initial treatment. They are also working with other agencies and have presented a case study to the Controlled Local Intelligence Network. (AI summary)
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Dear Dr Earland, Clare Louise BAIN Deceased DOD 05/10.2012 Inquest: August 2014 at County Hall;, Topsham Road, Exeter Coroner's Rule 28 Report Thank you for your letter regarding the above inquest under Schedule 15 to the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. set out the Trust's response below: Recommended Action Your Regulation 28 Report recommends that we:
1) review the training of paramedics in giving opiate antagonists; and
2) consider a more robust protocol for dealing with respiratory depressant effects of opiates to include mandatory admission to hospital until the effects have passed and drugs metabolised Response
1) Review training _in relation to opiate antagonists On the 1st October; the Trust will be issuing further guidance for clinicians to raise awareness of methadone overdose and how it should be treated: The guideline will highlight: Way
the particular characteristics of methadone including the extent to which it acts slowly, meaning that overdose can initially be asymptomatic, and its potential to in the system for a long time the difference in the elimination half life of methadone 15-40 hours) and naloxone (1-1.5 hours) and the need to convey the patient to hospital for further observation; even where they have responded well to initial treatment_ Action to take if a patient refuses to be transported to hospital. have enclosed a copy of the Clinical Notice in its current draft form for your information with a final version to follow by the end of October 2014.
2) Consider a more robust protocol for dealing with respiratory _depressant effects of opiates to include mandatory admission to_hospital Our aim in releasing the methadone overdose Clinical Notice is to ensure that all our clinicians are fully aware of the most appropriate treatment options for methadone overdose. This includes the importance of transporting the patient to hospital. Particular issues arise in respect of methadone overdose patients who refuse to be conveyed to hospital, despite the risks being fully explained and emphasised to them . It is our experience that; because they do not feel unweli, some patients who have taken an overdose do not accept that require close monitoring in hospital or that are likely to need further treatment_ As you will be aware, our clinicians can only transport a patient to hospital without hislher consent if helshe is assessed as lacking capacity to make their own decision regarding their medical treatment under provisions of the Mental Capacity Act 2007 . However; in methadone overdose cases patient who does not feel unwell will often have sufficient capacity and awareness to make decisions regarding their treatment_ To assist clinicians in the effective and robust assessment of patient capacity we have recently issued a new and detailed mental health guideline, which provides clear and detailed guidance regarding capacity assessments. have enclosed a copy for your reference_ In addition, the Trust has now started to trial an electronic patient record system which be rolled out more widely going forward. The system has been configured to allow clinicians to run through a structured assessment which complies with the Mental Capacity Act and best practice guidelines The methadone overdose Clinical Notice sets the steps clinicians should take in respect of a methadone overdose patient with capacity who refuses transport to hospital including: Ensuring that the patient is left with a responsible adult who can monitor the patient over the next 8 hours; Giving comprehensive and well-documented advice on steps to take if the patient's condition worsens; Notifying the Clinical Supervisors in the Trust's control centre that the situation may deteriorate rapidly and notifying other out of hours service providers as appropriate. stay they they the will out
More generally, the Trust is also working with other agencies to address some of the particular challenges that methadone overdose presents_ Our Accountable Officer; along with one of our senior clinicians, presented a similar case study at the Controlled Local Intelligence Network (Bristol, North Somerset and South Gloucestershire) Annual Learning Meeting in July this year: This meeting is attended by the Police and other healthcare agencies including those concerned with substance misuse and harm reduction. The Police commented that even if transported the patient to hospital, there was currently not a mechanism to detain the patient against their wishes. A consultation has been carried out by the Medicines and Healthcare Products Regulatory Agency regarding their proposal to allow wider access to naloxone for use in emergencies_ (https IIwWW gov UklgovernmentIconsultationslproposal-to-allow-wider-access-to naloxone-for-use-in-emergencies) . Supplying naloxone to clients receiving methadone, and providing both them and their friends and family with appropriate education and training; could lead to the provision of an additional safeguard in the future hope the information contained within this letter provides you with assurance that the Trust is committed to reviewing its own practices and working alongside our colleagues in the wider health community to provide effective care to methadone overdose patients. If / can provide any further information, please do not hesitate to contact me
1) review the training of paramedics in giving opiate antagonists; and
2) consider a more robust protocol for dealing with respiratory depressant effects of opiates to include mandatory admission to hospital until the effects have passed and drugs metabolised Response
1) Review training _in relation to opiate antagonists On the 1st October; the Trust will be issuing further guidance for clinicians to raise awareness of methadone overdose and how it should be treated: The guideline will highlight: Way
the particular characteristics of methadone including the extent to which it acts slowly, meaning that overdose can initially be asymptomatic, and its potential to in the system for a long time the difference in the elimination half life of methadone 15-40 hours) and naloxone (1-1.5 hours) and the need to convey the patient to hospital for further observation; even where they have responded well to initial treatment_ Action to take if a patient refuses to be transported to hospital. have enclosed a copy of the Clinical Notice in its current draft form for your information with a final version to follow by the end of October 2014.
2) Consider a more robust protocol for dealing with respiratory _depressant effects of opiates to include mandatory admission to_hospital Our aim in releasing the methadone overdose Clinical Notice is to ensure that all our clinicians are fully aware of the most appropriate treatment options for methadone overdose. This includes the importance of transporting the patient to hospital. Particular issues arise in respect of methadone overdose patients who refuse to be conveyed to hospital, despite the risks being fully explained and emphasised to them . It is our experience that; because they do not feel unweli, some patients who have taken an overdose do not accept that require close monitoring in hospital or that are likely to need further treatment_ As you will be aware, our clinicians can only transport a patient to hospital without hislher consent if helshe is assessed as lacking capacity to make their own decision regarding their medical treatment under provisions of the Mental Capacity Act 2007 . However; in methadone overdose cases patient who does not feel unwell will often have sufficient capacity and awareness to make decisions regarding their treatment_ To assist clinicians in the effective and robust assessment of patient capacity we have recently issued a new and detailed mental health guideline, which provides clear and detailed guidance regarding capacity assessments. have enclosed a copy for your reference_ In addition, the Trust has now started to trial an electronic patient record system which be rolled out more widely going forward. The system has been configured to allow clinicians to run through a structured assessment which complies with the Mental Capacity Act and best practice guidelines The methadone overdose Clinical Notice sets the steps clinicians should take in respect of a methadone overdose patient with capacity who refuses transport to hospital including: Ensuring that the patient is left with a responsible adult who can monitor the patient over the next 8 hours; Giving comprehensive and well-documented advice on steps to take if the patient's condition worsens; Notifying the Clinical Supervisors in the Trust's control centre that the situation may deteriorate rapidly and notifying other out of hours service providers as appropriate. stay they they the will out
More generally, the Trust is also working with other agencies to address some of the particular challenges that methadone overdose presents_ Our Accountable Officer; along with one of our senior clinicians, presented a similar case study at the Controlled Local Intelligence Network (Bristol, North Somerset and South Gloucestershire) Annual Learning Meeting in July this year: This meeting is attended by the Police and other healthcare agencies including those concerned with substance misuse and harm reduction. The Police commented that even if transported the patient to hospital, there was currently not a mechanism to detain the patient against their wishes. A consultation has been carried out by the Medicines and Healthcare Products Regulatory Agency regarding their proposal to allow wider access to naloxone for use in emergencies_ (https IIwWW gov UklgovernmentIconsultationslproposal-to-allow-wider-access-to naloxone-for-use-in-emergencies) . Supplying naloxone to clients receiving methadone, and providing both them and their friends and family with appropriate education and training; could lead to the provision of an additional safeguard in the future hope the information contained within this letter provides you with assurance that the Trust is committed to reviewing its own practices and working alongside our colleagues in the wider health community to provide effective care to methadone overdose patients. If / can provide any further information, please do not hesitate to contact me