Form  6.2

Response

SHERIFFDOM OF CENTRAL, TAYSIDE AND FIFE AT PERTH                                                    

Court ref: PER B17-20

RESPONSE

to the

DETERMINATION OF SHERIFF W M WOOD

UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC. (SCOTLAND) ACT 2016

IN THE

INQUIRY INTO THE DEATH OF SCOTT ANDREW ROSS (born 17 October 1980)

To: the Scottish Courts and Tribunals Service

1.

Tayside Health Board, being a participant in the inquiry and being an organisation to whom a recommendation under section 26(1)(b) was addressed, do respond to the Court’s six recommendations as follows.

Recommendation

Response

1.        

There should be a co-ordinated approach between the hospital and the prison systems in the management of a prisoner’s drug withdrawal.

Prison Healthcare

Prior to any patient being admitted to hospital, the prison clinician speaks to Consultant Connect in the hospital to discuss treatment plans.

Emergency Department

Prison Healthcare staff have direct access to a Senior Emergency Medicine Clinician 24hrs a day / 7 days per week for emergency clinical advice through NHS Tayside Flow Navigation Centre via Consultant Connect.  All calls are recorded for governance purposes.

Acute Medicine

There is an agreement in place that prisoners transferred to hospital for acute care should be accompanied by a photocopy of their drug prescription Kardex on admission. If this is not available at the point of admission, the ward clinical pharmacist will contact the prison to request a copy. 

2.

Those managing benzodiazapine withdrawal should consider carefully the proper dosage required for safe discontinuation. Under-prescription in respect of benzodiazapine discontinuation may cause seizures, which can cause brain damage and death; the expert evidence was that overprescription was less harmful than underprescription.

Prison Healthcare

Within prison, a standard detox is given to all. This is a standard detox prescribed across prisons in Scotland and is safe and effective in the majority of patients when treated in the prison setting. Should the patient require the detoxification to be optimised based on inadequate clinical response this will be done with advice from addiction specialists and/or medical consultants. Transfer to a medical ward will be facilitated if this is necessary for safe treatment to be delivered.

Emergency Department

Within the Emergency Department, a patient with seizures due to withdrawal would be treated acutely based on their individual clinical emergency needs.  Acute benzodiazepine withdrawal symptoms (without seizure) would be dealt with based on their individual clinical needs and admitted for inpatient management.

Outlined in Royal College of Emergency Medicine Best Practice Guideline, Drug Misuse and the Emergency Department: 

7. Drug detoxification should not be undertaken by the ED, but clinicians should know how to treat acute intoxication or withdrawal.

Acute Medicine

A protocol for benzodiazapine withdrawal standardises treatment and reduces the risk of under prescription, however individual patients’ clinical condition requires to be a reviewed with regard to withdrawal symptoms and dose adjusted accordingly.

Currently, a comprehensive history is sought at the point of admission to an acute hospital. This can be difficult if patients are still intoxicated and the history of drug doses may not be reliable.  This allows an individualised risk/benefit assessment in the context of the patient’s clinical presentation.  

NHS Tayside staff both in prison and in hospitals should consider the existing protocols relating to drug withdrawal. The protocols should be fit for purpose and, where appropriate, tailored to fit the needs of individual prisoners. The requirements for safe opiate withdrawal and safe benzodiazapine withdrawal are unlikely to be the same.

Prison Healthcare

Within Prison Healthcare, there are standard withdrawal protocols as per Recommendation 2.  There are different detox regimes for opiate and benzodiazepine withdrawal.

Emergency Department

Within the Emergency Department a patient with seizures due to acute withdrawal (benzodiazepine or opiate) would be treated acutely based on their individual clinical emergency needs. Acute benzodiazepine or opiate withdrawal symptoms (without seizure) would be dealt with based on their individual clinical needs and admitted for inpatient management.

Outlined in Royal College of Emergency Medicine Best Practice Guideline, Drug Misuse and the Emergency Department: 

7. Drug detoxification should not be undertaken by the ED, but clinicians should know how to treat acute intoxication or withdrawal.

Acute Medicine

NHS Tayside has an agreed protocol for the planned withdrawal of benzodiazepine.  This is contained within the Guidelines on Medical Treatments for Substance Use, developed by NHS Tayside Substance Use Services and is available to clinicians on NHS Tayside intranet (copy of June 2023 guidelines attached to response for reference). 

Clinicians assess and prescribe appropriate withdrawal medication based on clinical judgement taking into account reported drug use, Prison Kardex, clinical assessment and consideration of concurrent diagnoses and medication.  The prescribed dose can be increased beyond the protocol as required to minimise the risk of under-prescribing.

4.

All NHS staff should be supported in their care of prisoners withdrawing from illicit substances by being able to seek expert support and advice.

Prison Healthcare

Prison Healthcare staff have access to a Substance Use Specialist GP and Psychiatrist, when on site.  They have access to support and advice out with these times through Consultant Connect.

Emergency Department

NHS Tayside Emergency Medicine has senior medical cover available 24hrs a day / 7 days per week for emergency clinical advice.

Acute Medicine

NHS Tayside Acute Medicine has senior clinical decision makers on acute medical receiving 24hrs a day / 7 days per week. In working hours there is close contact with clinical pharmacists for complex cases when drug interaction is considered, or further information required from the Prison.

The in hours period would be considered as 9am to 5pm. Out of hours, prescribing would be based on the clinician's judgement and the assessment of the patient's condition at the time. Senior medical input is available during the out of hours period.

5.

A patient’s reported use of illicit drugs ought to be taken into account and not ignored or disbelieved - particularly where there is evidence of such abuse (such as urine samples) and observed withdrawal seizures.

Prison Healthcare

The patient reported use will be taken into account when confirmed by evidence such as urine samples and observed withdrawal seizures.

Emergency Department

Patients attending the Emergency Department with presentations that might possibly be related to drug use, or may be a marker for drug use, are asked about this as part of their clinical assessment.

Acute Medicine

Currently, a comprehensive history is sought at the point of admission to an acute hospital. This can be difficult if patients are still intoxicated and the history of drug doses may not be reliable.  The information conveyed by the patient regarding their drug use is taken into consideration to avoid under prescription of withdrawal treatment.  This allows an individualised risk/benefit assessment in the context of the patient’s clinical presentation and reported drug use.  

6.

More generally, there must be a co-ordinated approach between NHS staff in prison and those working in hospitals in relation to the timely and expeditious passage of clinical information in respect of a patient moving from one facility to another.

Prison Healthcare

All patients are transferred following a conversation with a hospital doctor.  The patient kardex will accompany them to hospital or if this is not available at the point of admission, the ward clinical pharmacist will contact the prison to request a copy.

Details of any medication prescribed and administered to the patient will be discussed and a copy of the kardex may be sent to the hospital if appropriate

Emergency Department

Prison Healthcare staff have direct access to a Senior Emergency Medicine Clinician 24hrs a day / 7 days per week for emergency clinical advice through NHS Tayside Flow Navigation Centre via Consultant Connect.  All calls are recorded for governance purposes.

In wider collaborative interface, Emergency Department staff have been supported in visiting HMP Perth to gain a better understanding of the Prison Healthcare interface and wider prison structure.

Acute Medicine

NHS Tayside now has fully electronic notes and discharge systems. All inpatient notes are immediately available to health care professionals in NHS Tayside (including primary care and prison service) via 'clinical portal' and electronic discharge scripts are available same day on the electronic system. 

Electronic documentation will contain information about any plans for current drug regimes eg. the duration of treatment and any titration regime should be clearly documented. There may be recommendations or suggestions about future treatments but these will not necessarily be prescribed.

Digital advances since this event have improved communication between the healthcare services, including Prison Healthcare.