Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0450, written 3 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Sep 2025 |
|---|---|
| Reference | 2025-0450 |
| Deceased | Peter Thomas |
| Coroner | Rachel Knight |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES HIS MAJESTY’S SENIOR CORONER SOUTH WALES CENTRAL CORONER AREA ANNEX A CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive National Institute for Health & Care Excellence (NICE) CORONER I am Rachel Knight H M Coroner, for the coroner area of South Wales Central. 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. INVESTIGATION and INQUEST On 3 February 2022 I commenced an investigation into the death of Peter Malcolm THOMAS . The investigation concluded at the end of the inquest 02/09/2025 . The conclusion of the inquest was the following narrative: Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW 1 2 3 Peter Malcolm Thomas was aged 78 and had developed peripheral vascular disease which led to necrotic and subsequently gangrenous toes. This became osteomyelitis of the foot, and a wider spread, more significant infection. On 15th January 2022, Peter collapsed and was taken into the Royal Glamorgan Hospital, Llantrisant, where he was treated with antibiotics and fluids. Sadly, his condition deteriorated significantly, and his infection became a systemic sepsis until he became unconscious and sadly died on 19th January. Although Peter was given diazepam as a sedative, a treatment he did not require, on balance it did not contribute more than minimally to the development of bronchopneumonia, from which he ultimately died. His cause of death was found to be: 1a Bilateral Bronchopneumonia 1b Osteomyelitis of the Foot 1c Peripheral Vascular Disease II CIRCUMSTANCES OF THE DEATH It was identified early upon admission that Peter was likely suffering from a serious infection as well as delirium. A clinician undertaking an examination took an account from Peter which led him to instruct the CIWA protocol to be used, due to information provided by Peter and some concerning signs and symptoms. In fact, CIWA was a red herring, as Peter was not in alcohol withdrawal, he was confused and delirious and gave an erroneous account of having been drinking. The signs and symptoms he exhibited were more likely due to the serious infection taking hold of him and leading to shaking, sweating, agitation and anxiety. His false account was likely due to confusion or delirium. 4 No collateral information was sought from medical records, nor from capacitous family (who would have been available by phone very easily) and when Peter’s symptoms scored against the CIWA protocol, he was given 80mg of diazepam over 6 hours. He did not require this drug and at 78 with serious comorbidities and a developing sepsis, his metabolism of it was likely hindered. 2 doses of the antidote were subsequently given but Peter did not regain consciousness. He went on to die from pneumonia. The Inquest focused upon:- a. The use of CIWA with Peter at all b. The dosing suggested within CIWA c. The effect of the diazepam and its contribution to Peter’s death CORONER’S CONCERNS 5 Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) 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) 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) 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 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th October 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. COPIES and PUBLICATION I have sent a copy of my report to family who may find it useful or of interest. Also, a copy will be sent to the Chief Executive of Cwm Taf Morgannwg Health Board and Cardiff & the Vale Health Board for their information and consideration. Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW 6 7 8 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. 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 3 September 2025 SIGNED: 9 Rachel Knight H M Coroner for South Wales Central Coroner Area Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
1 response 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.
k l l f C N a t i° n a l Institute for Health and Care Excellence 2nd Floor 2 Redman Place London E20 1JQ United Kingdom 29 October 2025 Rachel Knight HM Coroner Coroner’s Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Dear Ms Knight, Re: Regulation 28 Prevention of Future Deaths Report in respect of Peter Malcolm Thomas I write in response to your report of 3 September 2025, regarding the very sad death of Peter Malcolm Thomas. I would like to express my sincere condolences to Mr Thomas’s family. The patient safety leads at NICE have carefully considered the content of your report and the matters raised, and any action that we should take as a result. Response to the matters of concern I note that your matters of concern relate to the NICE guideline entitled Alcohol-use disorders: diagnosis and management of physical complications (reference CG100), and the recommendations within the guideline. The guideline includes the following recommendations: 1.1.2 Assessment and monitoring 1.1.2.1 Healthcare professionals who care for people in acute alcohol withdrawal should be skilled in the assessment and monitoring of withdrawal symptoms and signs. [2010]; and 1.1.2.3 People in acute alcohol withdrawal should be assessed immediately on admission to hospital by a healthcare professional skilled in the management of alcohol withdrawal. Our opinion is that these recommendations adequately convey the need for professional skill in the assessment and monitoring of patients and in the application of our recommendations. NICE www.nice.org.uk | nice@nice.org.uk Based on the limited information available to us, we cannot see that the clinicians caring for Mr Thomas confirmed a diagnosis of alcohol withdrawal, and so cannot conclude that these recommendations were followed. A further recommendation in the same guideline, which you have referred to, states: 1.1.2.2 Follow locally specified protocols to assess and monitor patients in acute alcohol withdrawal. Consider using a tool (such as the Clinical Institute Withdrawal Assessment - Alcohol, revised [CIWA-Ar] scale) as an adjunct to clinical judgement. [2010] The CIWA-Ar protocol is a validated 10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome, and to monitor and medicate patients throughout withdrawal. This recommendation suggests the CIWA-Ar as a possible option, in addition to the clinical judgment of the healthcare professionals who have responsibility for caring for their patient. Status of NICE guidelines As background regarding the status of NICE guidelines, it is important to note that the recommendations in our guidelines represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals and practitioners are expected to take NICE guidelines fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory for the NHS to apply the recommendations, and the guideline does not override the responsibility for clinicians to make decisions appropriate to the circumstances of the individual, in consultation with them (and their families and carers or guardian where appropriate). Responsibility for decisions on the most appropriate treatment stays with individual clinicians. NICE guidelines are a practical tool to be used in conjunction with and not as a substitute for clinical judgement. Action to be taken In the case of the CIWA-Ar scale, this protocol was not produced by NICE, and so we are unable to amend it, but it is appropriate for us to consider whether it is still relevant for NICE to recommend its use as an assessment and monitoring tool in our guidance. Decisions as to whether NICE will update existing guidance are overseen by an integrated, cross-organisational prioritisation board, chaired by NICE’S chief medical officer. The prioritisation board has previously considered the topic of alcohol withdrawal, and considering the volume of new evidence in this area, and the time since our guidance on this topic area was originally published, the board concluded that an update should be considered. This topic will therefore be looked at again by the prioritisation board in approximately February-March 2026, to determine what changes, if any, are needed to the guideline. This will include consideration of pharmacological treatment for acute alcohol withdrawal to optimise treatment options for patients. Page | 2 The decisions taken as a result will be published on our website at www.nice.orq.uk following the prioritisation board’s meeting, and if any changes are made to the guidance, this will also be published so that it is freely available to all. I hope that the information above is helpful and would like to reiterate my sincere condolences to Mr Thomas’s family. Yours sincerely, Chief Executive Page | 3
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