Cornwall and Isles of Scilly

CORNWALL AND ISLES OF SCILLY

DRUG AND ALCOHOL ACTION TEAM

First Draft for attention of the Cornwall & Isles of Scilly Drug Related Deaths Review Group

(Tuesday 18th December 2012)

DRUG RELATED DEATHS

REPORT CONCERNNG MONITORING AND CONFIDENTIAL INQUIRIES INTO DRUG RELATED DEATHS WITHIN CORNWALL & ISLES OF SCILLY

1st January 2012 – to – 31st December 2012

CONTENTS

Executive SummaryPage 3

IntroductionPage 7

Update to 2011 ReportPage 8

Drug Related Deaths 2012Page 9

Brief Circumstances/Case Studies 2012Page 11

Synopsis Drug Related Deaths 2012Page 15

New Measures/Initiatives 2012Page 16

Other and Alcohol DeathsPage 21

ConclusionPage 21

Appendices

Appendix A – Year on Year chart of drugPage 23

related deaths 1999-2012

Appendix B – National Treatment Agency ReportPage 25

Appendix C – DAAT Confidential Inquiry FormPage 27

Appendix D – Ambulance Attendance DataPage 32

Appendix E - Alcohol DeathsPage 42

Appendix F - ‘Cornwall Model’Page 44

Appendix G – ‘How safe are you’ toilet stickerPage 47

Executive Summary

From 2004 all Drug and Alcohol Action Teams are required by the Department of Health and Home Office to have in place a system of monitoring and surveillance of all drug related deaths within their area of responsibility.

All Drug and Alcohol Action Teams, Police and Department of Health work to the standard definition of a drug related death ‘deaths where theunderlying cause is poisoning, drug abuse or drug dependence and where any of the substances listed in the Misuse of Drugs Act 1971, as amended, were involved’.

In 2009 a new database was set up to routinely record all drug related deaths throughout Devon and Cornwall. This database is maintained by Devon and Cornwall Police with researchers appointed to trawl daily occurrence logs and input suspected drug related deaths. Cornwall & IOS DAAT has access to this database and has also back recorded onto the database all Cornwall & IOS drug related deaths since 2004. The database was updated during 2011 to ease search facilities and continues to be an effective monitoring tool.

The system of monitoring and surveillance of drug related deaths introduced by Cornwall & IOS DAAT and known as ‘The Cornwall Model’ continues to be effective and is acknowledged and recommended by the National Treatment Agency (NTA)as good practice. This model was subject of a national review by the NTA in July 2009 and a report on its findings is included at Appendix B. A further review conducted by the NTA in 2011 has declared the Cornwall DAAT process as ‘gold standard’. A copy of the model which outlines the respective roles and responsibilities is included at Appendix F.

This report is prepared in draft for consideration by the Cornwall Drug Related Deaths Review Panel on 18th December 2012 and to be included in the planning process for the 2013-2014 DAAT annual plan.

The following table shows all deaths reported in 2012:

2012 / 2011 / 2010 / 2009
Total suspected drug related deaths reported / 27 / 21 / 24 / 21
Confirmed / suspected non drug related deaths / 6 / 9 / 6 / 6
Heroin / Morphine / 8* / 8 / 9 / 8
Methadone / 11* / 2 / 7 / 5
Other controlled drug / 2*
Mephedrone
Cocaine / 2 MDMA +other / 2 x cocaine / 0
RTA/Suicide (+ CD as included above) / 1 x RTA
5 x sus. suicide as above* / 2
Phenobarbitone / 1 (Heroin) / 2 (traces cannabis )
Total drug related deaths / 21 / 12 / 18 / 13
% Increase or Reduction / 75 % Increase from 2011 / Reduction 38%
from 2010 / Increase 38%
from 2009 / Reduction 27% from 2008

The new Devon and Cornwall database assists in screening out most non-relevant deaths that do not involve controlled drugs. Of those reported throughout 2012 as suspected to be drug related 6 are now confirmed as not drug related deaths.

Deaths from illicit Heroin alone have decreased slightly from 8 in 2011 to 5 during 2012 which represents a reduction of 37% this slightly better than the national average reduction in Heroin related deaths of 25% . One of the Cornwall recorded Heroin deaths is suspected to involve suicide. There has also been three Morphine deaths, these are unprecedented for the purposes of this report and are now outlined within the following paragraph.

Unexplained deaths from Morphine, (this being the pharmaceutical preparation), have not previously come to light for the purposes of this report however during 2012 there were 3 deaths involving a significant overdose of Morphine, in two cases the Morphine was not prescribed to the deceased. All three of the Morphine deaths are suspected to be suicides however this will be a matter for HM Coroner for Cornwall to direct and no inferences should be drawn until HM Coroner’s Inquisition is completed.

Methadone related deaths have increased considerably on all previous years and are the highest since DAAT records commenced in 1999. Methadone related deaths total 11 for 2012 compared to just 2 deaths in 2011, this represents a 450% increase. Of these deaths 6 involve ‘displaced’ Methadone which has been supplied unlawfully. One death is yet another suspected suicide involving Methadone prescribed to the deceased and four other deaths also involve Methadone prescribed to the deceased.

It is unfortunately not possible to identify reasons for the continuing decrease in Heroin related deaths and equally, despite continuing close scrutiny and urgent reviews of these deaths with the permission of HM Coroner it has not been possible to identify any trends or patterns that would account for such a large increase in the deaths involving Methadone.

All of the deaths reported to DAAT and suspected to be drug related are subject of immediate investigation to determine the circumstances and to ensure effective measures are introduced to prevent similar fatalities.

The number of recorded drug related deaths shows a considerable increase of 75% from 2011 (21 compared with 12 in 2011). Toxicology reports kindly provided by HM Coroner for Cornwall indicate cases where controlled drugs confirm such deaths to be ‘drug related’ in accordance with Department of Heath directives, toxicology results have been received for all but one of the 27 suspected drug related deaths during 2012, the outstanding report is suspected to identify concentrations of illicit Methadone as an empty Methadone bottle was located at the scene.

The following tables offer a brief synopsis of the recorded 2012 deaths:

Male

2012 / 2011 / 2010 / 2009
Total Drug Related Deaths / 21 / 12 / 18 / 13
Males / 14 66% / 11 91% / 15 88% / 9 69%
Mean age / 42.9 / 35.8 / 40.3 / 27.09
Oldest / 63 ( 6 x o/40 yrs) / 53 (5x o/40 yrs) / 64 (5 x o/40yrs) / 39
Youngest / 27 / 24 / 29 / 27
Males – Heroin/alcohol/benzos / 4 / 8 / 9 / 7
Males –Methadone / 9 / 1 / 5 / 2
Males – other controlled drug / 1 / 2 / 2 (cocaine) / 2 (traces cannabis)
Males in Treatment / 6 / 5 / 5 (incl 1x ref/assessed) / 4 + 1 referred not seen

Female

2012 / 2011 / 2010 / 2009
Total Drug Related Deaths / 21 / 12 / 17 / 13
Females / 7 33% / 1 9% / 2 12% / 4 31%
Mean age / 37 / 24 / 27.5 / 29.75
Oldest / 59 / 24 / 31 / 49
Youngest / 17 / 24 / 24 / 17
Females –Heroin/alcohol/benzos + Morphine / 4 / 0 / 0 / 2
F/males-Methadone / 2 / 1 / 2 / 2
Females - other c/drug / 1 / 0 / 0 / 0
Females in Treatment / 1 / 0 / 2 / 3 + 1 referred not seen

England & Wales

From the ONS Drug Death Reports 2011,2010, 2009 and 2008. The 2012 ONS report will not be available until late August 2013. The table below shows the ONS ‘drug misuse deaths’, this covers all illicit and pharmaceutical drugs.

2011 / 2010 / 2009 / 2008
Total Drug Related Deaths / 1605 / 1784 / 1876 / 1939
Male / 1192 / 1382 / 1512 / 1506
Female / 413 / 402 / 364 / 433

Heroin & Methadone Deaths England & Wales 2010 / 2011 ONS Statistics

2011 / 2010 / +/-
Heroin / 596 / 791 / -195 (25%)
Methadone / 486 / 355 / +131 (36%)

Heroin & Methadone Deaths England & Wales 2010 / 2011 NpSAD Statistics

2011 / 2010 / +/-
Heroin / 820 / 1061 / -241 (22%)
Methadone / 765 / 503 / +262 (52%)

Heroin & Methadone Deaths Scotland. General Register Office Statistics

Here for the first time in the UK deaths from Methadone have overtaken Heroin related deaths.

2011 / 2010 / +/-
Heroin / 206 / 254 / -48 (18%)
Methadone / 275 / 174 / +101 (58%)

15. DAAT has introduced or been involved in a number of new initiatives throughout 2012 aimed at preventing and reducing drug related deaths these are outlined within section 6 of the main report.

All DAAT areas are required to prepare an annual report identifying the process of recording and inquiry into drug related deaths together with any preventative measures introduced. This is the report prepared by the Cornwall and IOS Drug and Alcohol Action Team.

INTRODUCTION

1.1This is the ninth annual report concerning drug related deaths prepared by the Cornwall and Isles of Scilly Drug and Alcohol Action Team (DAAT). The report follows a requirement by the Department of Health and Home Office for all Drug and Alcohol Action Teams to have in place a system of recording and conducting confidential inquiries into all drug related deaths within their specific areas.

1.2The 2012 report follows a similar format to that of 2011, 2010 and 2009 these varied from previous years and now include more statistical analysis, more case studies together with findings and recommendations. There is more emphasis on the pro-active measures that Cornwall & IOS DAAT has introduced throughout the year to prevent and reduce drug related deaths.

1.3Reports prior to 2009 have detailed the robust system of monitoring and recording drug related deaths throughout Cornwall and the Isles of Scilly. This model of recording has been regarded as best practice and presented at many regional and national conferences. The Cornwall & IOS DAAT is frequently requested to forward details of the Cornwall recording process together with any recent annual report to other DAAT areas or interested parties. The Cornwall ‘model’ of recording and monitoring drug related deaths will not be described again within this report except to confirm that the system remains most effective and has proven to be sustainable. Some reference will however be made to the Cornwall DAAT system of recording as recognised by reports commissioned by the National Treatment Agency into the drug death review processes throughout the country and following certain requests the Cornwall ‘model’ itself will be included for reference purposes at Appendix F.

1.4Confusion unfortunately still continues amongst the media and interested parties regarding the actual number of annual drug related deaths. This arises from the many varying criteria for recording drug related deaths within respective annual reports. The Home Office, all 43 Police Forces within England and Wales, all Drug and Alcohol Action Teams, all Health Authority areas and the Department of Health operate specifically within the nationally agreed definition of ‘deaths where the underlying cause ispoisoning, drug abuse or drug dependence and where any of the substances listed in the Misuse of Drugs Act 1971, as amended, are involved’.

1.5On 29th August 2012 the Office of National Statistics (ONS) released their annual report concerning drug related deaths throughout England and Wales for 2011. All drug related deaths are recorded however this is also filtered to include deaths within the above definition involving drug misuse. There is some criticism of the ONS report as, through necessity it reports mainly on deaths during 2010. Deaths during the latter part of 2011 are not routinely included owing to the time delay in collecting this data hence parts of the report could relate to matters almost two years previously.

1.6ONS reported that the total ‘drug misuse deaths’ for England and Wales during 2011 was 1192 for males which represents a reduction of 14% from 2010. However over the same period the number of female deaths rose slightly by 3% to 413. 596 of the deaths that related to drug poisoning involved Heroin or Morphine but this was a reduction of 25% from the 791 deaths in 2010. Deaths associated with Methadone however increased from 355 deaths in 2010 to 486 in 2011, a significant increase of 36.9%

1.7The National Programme for Substance Misuse Deaths (NpSAD) produced a report for the year 2010 on 7th November 2012. Funding for this programme actually ceased in July 2011 however the team involved in collecting the data have remained and a little funding was obtained for the publication of the 2010 figures.

The data collected by this programme relies upon the completion of NpSAD forms by HM Coroners following inquests into drug related deaths. HM Coroners continue to routinely forward these forms and the data is still being collected by the prime author of the NpSAD report John Corkery. Cornwall DAAT has been in contact with Mr Corkery and obtained details of the number of NpSAD recorded deaths for England and Wales involving Heroin and Methadone . This indicates, along with the ONS findings and the emerging pattern within Cornwall that Heroin deaths are decreasing. There were 820 Heroin related deaths in 2011 compared with 1061 in 2010, a reduction of 241 which represents a decrease of 22%. Methadone deaths however increased significantly from 503 in 2010 to 765 in 2011 an increase of 262 which represents a rise of 52%.

1.8Figures released by the General Register Office for Scotland on 12th August 2012 reported a similar reduction in Heroin related deaths of 18% ( 206 compared with 254 in 2010) but quite alarmingly for the first time within the UK deaths from Methadone overdose have overtaken Heroin deaths and represent a significant increase of 58% (275 compared with 174 in 2010). Deaths in Scotland from drug misuse rose by 99 deaths, Methadone deaths alone rose by 101 deaths.

1.9The figures concerning drug related deaths published by the Cornwall & IOS DAAT are suggested to be consistently accurate. DAAT works closely with other agencies and the Suicide Audit Group to ensure there is no double counting and that high standards of monitoring and recording are maintained. A database for recording and monitoring drug related deaths was introduced in 2009 which ensures all Peninsula DAATs and the Devon and Cornwall Constabulary work to a common format. The database will be described later within this report.

UPDATE TO 2011 REPORT

2.1The Cornwall & IOS DAAT report into Drug Related Deaths for 2011 was published on 20th December 2011. Early publication was completed to allow appropriate review and inclusion within the consultation process for the 2012/13 DAAT Annual Plan and this has been the practice for the past four years. It has normally been necessary to amend the previous year’s report as certain other deaths came to notice following the publication of the report. However for 2011 there is just one amendment which involves the death of a 53 years old male that occurred on 30th December 2011. This male was in treatment with the Cornwall Drug and Alcohol team (CDAT) for drug dependency and died following an overdose of illicit Heroin. Records for 2011 have been amended and included in the year on year chart at Appendix A.

2.2The total number of drug related deaths recorded at 20th December 2011 was 11 this has now risen to 12 and included within all charts and tables hereafter.

2.3The following table shows an amended comparison for the years 2011/2010/2009/2008:

2011 / 2010 / 2009 / 2008
Total suspected drug related deaths reported / 21 / 24 / 21 / 25
Confirmed Not drug related deaths / 9 / 6 / 6 / 7
Heroin / and methadone / 8 / 9 / 8 / 11
Methadone only / 2 / 7 / 5 / 6
Other controlled drug / 2 / 2 cocaine / 0 / 1 x amphetamine.
RTA/Suicide +CD / 0 / 1 / 2 (traces cannabis ) / 0
Total drug related deaths / 12 / 18 / 13 / 18
+ /- % / -33% / + 38% / -27%

RECORDED DRUG RELATED DEATHS –Cornwall & IOS 2011

3.1This current report now incorporates all reported suspected drug related deaths throughout Cornwall & IOS for 2012 and has been prepared for the information of the Cornwall & IOS Drug Related Deaths Review Group sitting on 18h December 2011; this is the steering and monitoring group for all drug related deaths matters. The report will also be forwarded for the approval of the DAAT Board and thereafter copies to H.M Coroner, DAAT partners and the Peninsula Drug Related Deaths Review Groups next meeting on 15th March 2013.

3.2The following table shows the total number of suspected drug related deaths reported to Cornwall & IOS DAAT throughout 2012 together with a breakdown of the commodities involved. Comparative (and now amended) figures for 2011, 2010 and 2009 are shown alongside:

2012 / 2011 / 2010 / (2009)
Total suspected drug related deaths reported / 27 / 21 / 24 / 21
Confirmed / suspected non drug related deaths / 6 / 9 / 6 / 6
Heroin / and methadone / 8 / 8 / 9 / 8
Methadone only / 11 / 2 / 7 / 5
Other controlled drug / 2 / 2 MDMA + other / 2 x cocaine / 0
RTA/Suicide + CD / 1 RTA
5 x susp. suicide / 2 (Phenobarbitone) / 1 (heroin) / 2 (traces cannabis )
Total drug related deaths / 21 / 12 / 18 / 13
% Increase or Reduction / Increase 75% / Reduction 38%
From 2010 / Increase 38%
from 2009 / Reduction 27% from 2008

3.3Early indications show the database system introduced in 2009 filters out many of the non-relevant deaths that do not involve controlled drugs hence 6 of the reported deaths are either confirmed or suspected to be non drug related. DAAT also monitors deaths where Tramodol features as a contributory factor, Tramodol is not a controlled drug and therefore is not part of the DAAT recording process however DAAT and HM Coroner are particularly concerned regarding this drug and the frequency with which it features in Cornwall deaths. Deaths involving Tramodol will be outlined at the end of Section 4 of this report.

3.4Deaths from Heroin toxicity have actually decreased by three such deaths from 8 to 5. This represents a decrease of 37% and is more than the national average of 25% (ONS 2010/2011) and 22.7% (Np-SAD 2011)). One of the Heroin deaths involved suspected suicide by hanging. Two of the Heroin deaths were initially thought to have involved a ‘bad batch’ of Heroin which was believed to be particularly strong however subsequent police analysis revealed this was not so and the purity of the Heroin concerned was just 6%.. Tramodol has previously been present in Cornwall Heroin deaths however it did not feature within any Heroin related death during 2012. From the commencement of Cornwall DAAT records in 1999 deaths from Heroin overdose have fluctuated between 6 -13 annually as may be seen in the year on year comparison chart at Appendix A.

3.5Deaths from overdose of Methadone which fell sharply during 2011 from 7 to just 2 have risen significantly during 2012 from the 2 in 2011 to now 11 in 2012. Six of these deaths involve displaced Methadone supplied unlawfully, of the remaining five all were all prescribed Methadone, one of which also involves a suspected suicide.

3.6Unfortunately it is not possible to identify either the reason for the reduction of Heroin related deaths or the considerable increase in Methadone related deaths. Concerted efforts to engage people with treatment providers together with overdose awareness initiatives and harm reduction programmes may have contributed to some of the reductions but street purity issues surrounding Heroin may have encouraged some users to seek out illicit Methadone, not prescribed to them. Purity levels of street Heroin as ascertained from Police seizures during 2012 have ranged from 6% to 16% purity, this is very low when compared with previous years when on occasions it has been as high as 69%.