Prevention of Future Deaths reports · 2024

Lee Hughes

Regulation 28 report to prevent future deaths, reference 2024-0120, written 4 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Mar 2024
Reference2024-0120
DeceasedLee Hughes
CoronerFiona Wilcox
Coroner areaLondon Inner (West)
CategoryAlcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO  PREVENT FUTURE DEATHS 

THIS REPORT  IS  BEING SENT TO: 

Chief Executive 
Oxleas NHS Trust via emial 

Chief Executive, 
NHS England- via email 

CORONER 

I am Professor Fiona J Wilcox,  HM  Senior Coroner,  for the Coroner Area of Inner West 
London 

2 

CORONER'S LEGAL POWERS 

I make this  report under paragraph 7,  Schedule 5,  of the Coroners and Justice Act 2009 
and  regulations 28 and 29 of the Coroners' (Investigations) Regulations 2013. 

3 

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 
We consider this report to be unreliable based on  other evidence we heard. 

 alcohol/week. 

•  His  urine test was positive for:  opiates (not specifically heroin); cocaine; 

diazepam; cannabis.  His urine was negative for methadone. 

•  He was prescribed 

20th ;  and  methadone 

 diazepam twice daily,  administered on  18th 
 on  the 18th ;  and 

 19th  and 20th 
-

,  19th 

,  and 

 
 
 
 • 

• 

• 

• 
• 

• 

• 

• 

• 

• 

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. 

4 

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. 

 To this end,  this  report has also  been  sent to  NHS  England,  so that the lessons learned 
from this death may  be applied to  all  prison  health care services. 

5 

Matters of Concern 

1.  That 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,  As such,  given the  particular difficulties of 
prescribing to  prisoners,  that objective signs of withdrawal assessments 
(OWS) should  be  used to determine whether methadone should  be 
prescribed rather than the COWS score which  contains many subjective 
factors and  may be more easily  manipulated by  an  inmate to appear as  if 
that inmate is  experiencing withdrawal from  drugs necessitating an  increase 
in  methadone. 

2.  That prescribing of drug treatments for withdrawal should only be 

undertaken  by substance misuse practitioners,  who should therefore be 
more experienced as  to when, whether and  how much  to  prescribe. 

3.  That guidelines are followed  without sufficient consideration  as to whether 

they apply to the individual patient. 

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

5.  That methadone should  be withheld  and  or reduced  if the patient/inmate is 

showing signs of sedation. 

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

6 

ACTION  SHOULD BE TAKEN 

In  my  opinion action should  be taken to prevent future  deaths and  I believe you 
[AND/OR your organisation] have the  power to take such action.  It is  for each addressee 
to  respond  to matters relevant to them. 

7 

YOUR RESPONSE 

You  are under a duty to respond to this  report within  56  days of the  date of this report.  I, 
the coroner,  may extend the period. 

Your response  must contain details of action taken  or proposed to  be taken,  setting out 
the timetable for action.  Otherwise,  you  must explain why  no action  is  proposed. 

8 

COPIES and  PUBLICATION 

I have sent a copy of my  report to the Chief Coroner and to the following  Interested 
Persons: 

 Sister of Mr Hughes : 

Governor, 
HMP Wandsworth, 
Heathfield Road, 
Wandsworth, 
London. 
Sw18 3HU. 

, 

Investigator, 
PPO, 
Third Floor, 
10,  South Colonnade, 
Canary Wharf, 
London. 
E14 4PU. 

I am also under a duty to  send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary 
form.  He may send a copy of this  report to any person who he believes may find  it useful 
or of interest.  You  may make representations to me,  the coroner,  at the time of your 
response,  about the release or the publication of your response  by  the Chief Coroner. 

g 

4th  March 2024. 

Professor Fiona J Wilcox 

HM  Senior Coroner Inner West London 

Westminster Coroner's Court 
65, Horseferry Road 
London 
SW1P 2ED 

Inner West London Coroner's Court, 
33, Tachbrook Street, 
London. 
SW1V2JR 
Telephone:0207 641  8789.

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from NHS England (PDF)
Fiona Wilcox 
Westminster Coroner’s Court 
65 Horseferry Road  
London  
SW1P 2ED 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

19 April 2024 

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. 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 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. 

clinical 

guidelines 

National 
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.  

developed 

are 

by 

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.   

Yours sincerely 

National Medical Director
Response from Oxleas NHS Foundation Trust (PDF)
23rd April 2024 

Private & Confidential 
Fiona J Wilcox 
HM Senior Coroner Inner West London 

25 Bagley’s Lane 
Fulham 
London SW6 2QA 

Dear Madam, 

Oxleas NHS Foundation Trust 
Pinewood House 
Pinewood Place 
Dartford 
Kent 
DA2 7WG 

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: 

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 
such  as 
benzodiazepines.  This  policy  was  revised  in  July  2023  and  has  been  shared  with  all 
clinical staff at Clinical Governance meetings following publication. 

sedative  medications 

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. 

Yours sincerely 

Chief Executive Officer 

On behalf of 

, Director of Offender and Healthcare Services 

CC: 

, Director of Nursing 

, Service Director

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