Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0699, written 20 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Dec 2024 |
|---|---|
| Reference | 2024-0699 |
| Deceased | Oliver Winson |
| Coroner | Samantha Goward |
| Coroner area | Norfolk |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: NHS England By Email 1 CORONER I am Samantha GOWARD, Area Coroner for the coroner area of Norfolk 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 On 20 June 2024 I commenced an investigation into the death of Oliver James WINSON aged 33. The investigation concluded at the end of the inquest on 19 December 2024. The medical cause of death was: 1a) Cocaine Toxicity The conclusion of the inquest was: Drug related 4 CIRCUMSTANCES OF THE DEATH Oliver Winson was a 33 year old man who had a history of drug misuse and he was under the care off substance misuse services since December 2013. He had previously been diagnosed with a mixed anxiety and depressive disorder for which he was prescribed medication. In 2017 he was referred to the adult ADHD (attention deficit hyperactivity disorder) service as his GP was concerned that his attention span was limited, and he had become quite hyperactive. In a response to a request for further information, his GP confirmed that Mr Winson had been concerned for many years about his low attention span and found it difficult to concentrate and there were concerns that this might point to hyperactivity and drug related behaviour. He had a history of impulsive behaviour, and this led to a risk of him becoming aggressive and a risk of going back to significant drug abusing behaviour. The GP felt that he was at quite a high risk of significant harm to himself in the long run if he was not diagnosed and managed appropriately. As Mr Winson was under the care of the drug and alcohol service it was felt that someone in that team could see him so the referral was not accepted at that time. However, the service misuse team referred Mr Winson back to the mental health Trust on 19th June 2020 for an adult ADHD undiagnosed assessment. They confirmed that he had been abstinent from drugs for four to five years and was on daily methadone. The adult ADHD service said they would accept the referral on to the undiagnosed wait list but indicated he should remain abstinent from drugs to benefit from the service. At that time, it was indicated that the waiting list was likely to be in the region of two years. The substance misuse service regularly sought updates on the waiting list and were advised Regulation 28 – After Inquest Document Template Updated 30/07/2021 that this was very lengthy due to unprecedented referrals and that the COVID pandemic had also impacted on this. By May 2023 when seeking an update, the service raised the concern that it had taken five years and a lot of hard work for Mr Winson to get to the point that he was at and that they were concerned that his historic drug use was chaotic, and he was at risk of death by overdose. Sadly, Mr Winston did relapse into drug use and on 10th June 2024 police were called to his home address where he was found deceased and toxicology evidence confirmed drug use prior to death and that death was as a result of cocaine toxicity. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provided details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time, as at the time of his death Mr Winson had been waiting for four years. I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country. It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment, their condition is not monitored and there is a risk as with Mr Winson, that their condition may deterioration or lead to risk or harmful behaviour and death. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by February 13, 2025. 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: Mother of Oliver Winson Norfolk and Suffolk NHS Foundation Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. Regulation 28 – After Inquest Document Template Updated 30/07/2021 I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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. 9 Dated: 20/12/2024 Samantha GOWARD Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Ms Samantha Goward
Area Coroner
Norfolk Coroner’s Service
County Hall
Martineau Lane
Norwich
NR1 2DH
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
27 February 2025
Re: Regulation 28 Report to Prevent Future Deaths – Oliver James Winson who
died on 10 June 2024
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20
December 2024 concerning the death of Oliver James Winson on 10 June 2024. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Oliver’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Oliver’s care
have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise
for any anguish this delay may have caused Oliver’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I
appreciate this will have been an incredibly difficult time for them.
Your Report notes that, despite local and national efforts, the scale of demand for adult
ADHD services is a system wide issue across the country. You raised the concern that
patients who have been identified specifically of being at risk as a result of
undiagnosed and/or untreated ADHD remain on significantly lengthy waiting lists,
during which time they are not receiving treatment, their condition is not monitored and
there is a risk that their condition may deteriorate or lead to risk or harmful behaviour
and death.
NHS England are aware that there are extensive waits for ADHD services nationally,
including for assessment of ADHD. The number of people requesting assessments for
attention deficit hyperactivity disorder (ADHD) has grown exponentially in recent
years, with the number of adults waiting for a first appointment doubling each year
since 20181.
We recognise that those awaiting support for ADHD might have other conditions which
may be impacted by their ADHD symptoms, and that those with ADHD are at higher
risk of a range of adverse outcomes, including substance abuse disorder, suicide and
accidental death compared with those without ADHD.
1 Darzi Report
ADHD services are a complex landscape. They are commissioned locally by
Integrated Care Boards (ICBs) with significant national variation existing in pathways
and provision, including independent sector providers operating under the Right to
Choose framework.
Considering the challenges being reported about ADHD services, NHS England
undertook a rapid review in December 2023. This identified several key areas of work
in relation to ADHD which are now underway, including improving available data,
developing resources to support commissioners in improving the quality and
consistency of ADHD services nationally, and facilitating the sharing of information,
innovation and good practice. NHS England has also convened the independent
to understand more about
ADHD Taskforce, which works cross-sector
the issues impacting
families, and how service
provision can be better joined up to meet people’s needs, including access to early
support. It is increasingly recognised that ADHD is not solely a health concern, and
that a cross-sector approach is needed to effect change.
those with ADHD and
their
NHS England is committed to working with system partners, including commissioners
and providers of ADHD support, to improve health-related experience and outcomes
for those with ADHD, including exploring opportunities to:
• Revise information on ADHD available to patients, families and carers via the
nhs.uk website, the NHS’s primary patient information resource (led by NHS
England, anticipated February 2025).
• Standardise pathways to improve consistency and transparency for those with
ADHD, their families and carers.
• Expand the scope of existing care pathways to offer greater support for those
with ADHD, their families and carers. This may include pre-diagnostic or ‘waiting
well’ support, which focuses on what can be done to support the individual ahead
of assessment and/or diagnosis.
• Move to a needs-based approach, which focuses on understanding the specific
challenges an individual is facing, ensuring they receive the most appropriate
support for those challenges. This might include support outside of health
services, such as at school or in the workplace.
Your Report also referred to there being a shortage of medication for those patients
who have been diagnosed with ADHD. NHS England works closely with the
Department of Health and Social Care (DHSC), who are responsible for medication
supplies in England. NHS England has developed specific guidance for systems,
shared via the Specialist Pharmacy Service, to support the system response to the
medication shortages. At this time, the availability of most medicines used to treat
ADHD has been restored, though there remains some disruption to supplies of
methylphenidate prolonged-release capsules and tablets2.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
2 Prescribing available medicines to treat ADHD – SPS - Specialist Pharmacy Service – The first stop for
professional medicines advice
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 events, such as the sad death of Oliver,
are shared across the NHS at both a national and regional level and helps us to 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
Samantha Goward Area Coroner for the coroner area of Norfolk Ref: 2024-0699 By email: 24th February 2025 Dear Ms Samantha Goward, RE: Regulation 28 Prevention of Future Death Report for Mr Oliver James Winson, deceased. We are writing to you regarding the report into the death of Mr Oliver James Winson dated 20th December 2024. We would like to express our sincere condolences to the family of Mr Winson. The Royal Pharmaceutical Society (RPS) is the professional leadership body for pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. Our role is to lead and support development of the pharmacy profession including the advancement of science, practice, education and knowledge in pharmacy. We transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 2010 and they now regulate pharmacy and pharmacy professionals in Great Britain. The RPS has taken the opportunity to write to you regarding this Prevention of Future Death report (PFD), as we believe that any PFD reports published involving pharmacy and the pharmacy profession should be responded to, to allow any learning to be shared more widely and help to prevent future deaths. The RPS in November 2024 published a report entitled Medicines Shortages: Solutions for Empty Shelves, which articulates some of the concerns raised in your report (in relation to the national shortage of ADHD medicines), and through the implementation of some of the recommendations for collaborative action, may help to address them. The Report is a culmination of extensive engagement and collaboration with patients, the pharmacy profession, wider healthcare professionals and the key local, regional and national stakeholders integral to ensure the continuity of medicines supply. The RPS Report and its recommendations have been presented to UK Government bodies during November and December 2024. There is growing concern about the impact of medicines shortages on patient care in the UK. All medicines shortages have the potential to raise concerns for patient safety. Through the engagement and research phase of the RPS Medicines Shortages project, together with feedback from our members, we know this is having a significant and distressing impact on patients and professionally frustrating for pharmacists who want to see patients get the best care they can. Patient safety concerns are multifactorial with medicines shortages. These issues are explored in detail in our Medicines Shortages Report following a comprehensive assessment of what is causing medicines shortages, their impact on patients, pharmacists and healthcare professionals and what more can be done to mitigate and manage medicines shortages. Thank you for highlighting your concerns in this prevention of future death report. We will consider how we can continue to raise awareness of these important issues through our future communications and engagement with the wider pharmacy sector. We will also raise these issues with our colleagues at the professional and representative bodies for pharmacy as they also play an important role in providing advice and support to the pharmacy professions. Should you require any further information on the RPS Medicines Shortages Report please contact Alwyn Fortune, Policy Lead for the Medicines Shortages work, via email Alwyn.Fortune@rpharms.com Yours sincerely, Policy and Engagement Lead - Wales Royal Pharmaceutical Society Patient Safety Manager Royal Pharmaceutical Society
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