Lee Hughes
4 Mar 2024 · Coroner Fiona Wilcox · Inner West London
The coroner's concerns
1. overreliance on patient-reported symptoms leading to inadequate withdrawal assessment
“clinicians, wishing to believe their patients, are relying too heavily on what patients tell them (symptoms) rather than looking for evidence (physical signs) of withdrawal”
2. inappropriate prescribing by non-specialist clinicians
“prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners”
3. generic guideline application ignoring patient-specific factors
“guidelines are followed without sufficient consideration as to whether they apply to the individual patient”
4. reduced opioid tolerance due to custodial abstinence
“time spent in custody prior to remand may have reduced an individual's tolerance to opiates”
5. continued methadone administration despite sedation risk
“methadone should be withheld and or reduced if the patient/inmate is showing signs of sedation”
6. absence of rapid drug testing limiting clinical assessment
“tests available for illicit drugs for near patient testing to allow a clinician to better assess a patient showing signs of intoxication”