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Peter Thomas

3 Sept 2025 · Coroner Rachel Knight · South Wales Central
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The coroner's concerns

  1. 1. use of CIWA protocol in elderly delirious patients

    “I am concerned that the CIWA protocol is something of a blunt instrument, not at all nuanced to take account of for example, advancing age and different metabolic rate, delirium and confusion and lack of collateral evidence”

  2. 2. over-sedation from unguided CIWA use

    “Clinicians without further guidance on its use, will continue to be at risk of implementing the CIWA protocol and prescribing sedatives at significant dose and frequency when it is not required, which presents risks of over-sedation and its consequences, particularly in the elderly and potentially delirious cohort, based upon pattern recognition rather than reliable evidence”

  3. 3. lack of guidance for alcohol withdrawal delirium

    “the NICE guidelines on the management of alcohol withdrawal do not explicitly deal with the situation here, which could well recur and lead to future deaths”

Responses

2025-0450-Response-from-National-Institution-for-Health-and-Care-Excellence.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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