Protocol:Suspected Drug Related Death Review Protocol

Protocol:Suspected Drug Related Death Review Protocol

Date: Review date: May 2010

Accountability: Adult Commissioning Group, Safe Newcastle Drug Support Unit

This protocol details Safe Newcastle’s critical incident review procedure for suspected drug related deaths for all commissioned drug treatment services.

Information contained in this report is provided for management, quality assurance and briefing purposes only. It should not be released into the public domain.

NB: This process has been agreed and signed off by the Adult Commissioning Group. This protocol will be reviewed over the next six months with submission to the Performance Management and Resources Group and Safe Newcastle Board in December 2010

Document specification

Contents

1. Questionnaire

1. Confidentiality Statement

1. Copy of Outcomes and Recommendations form used in review panel

Safe Newcastle Suspected Drug Related Death Review Protocol

1.Background

1.1Safe Newcastle Drug Related Death Group will carry out confidential reviews on every suspected drug related death in Newcastle. This reflects the local Government’s response to the Report by the Advisory Council on the Misuse of Drugs (ACMD) on Reducing Drug Related Deaths (2000).

1.2All services commissioned through the Pooled Treatment Budget and Drug Intervention Programme Budget will be expected to comply with the process, as specified in the Contractual Overarching Agreement:

• You must also appoint individuals to fulfil the following roles in respect of the Drug Service. The appointed individuals must attend the forums specified. Absence must be notified in advance to the Drug Support Unit.

Monitoring Champion- Drug related death

• The Drug Support Unit will co-ordinate the response from Drug Service providers to the following Public Protection frameworks:

Drug Related Death Reviews

• You must participate in appropriate information sharing in respect of these frameworks and others as may be reasonably determined by the Authorised Officer in order to protect the public whilst ensuring that confidentiality is respected.

2.Definition of “Drug Related Death” (DRD)

2.1 Deaths where the underlying cause is poisoning, drug abuse or drug dependence and where any of the substances are controlled under the Misuse of Drugs Act (1971).

3.Purpose of Review

3.1Identify gaps in service provision

3.2Identify lessons learned and disseminated accordingly

3.3Produce action plans from lessons learned

3.4Adjust policies and practices as necessary

3.5Identify and monitor significant changes in illicit drug use

3.6Ensure services are aware of the death to ensure we reduce the risk of communication errors after the death for example appointment letters being sent out

4.The Review

4.1 The review consists of four stages:

Stage 1 – report of suspected drug related death

Stage 2 – data collection

Stage 3 – the review

Stage 4 – review feedback and ongoing audit

Stage 1 – Report of Suspected DRD

• This Drug Related Death Review procedure intends to act on any immediate issues rising from a suspected drug related death and has been agreed by relevant agencies, Safe Newcastle Adult Commissioning Group and Primary Care Trust legal and clinical governance sections.

• Newcastle Area Command DIP Officer checks the daily police logs for any suspected drug related death and on discovering an incident, telephones the Commissioning Officer or a Safe Newcastle Drug Support Unit (DSU) representative, to report the incident. This is then followed by a Police Report, detailing basic information, which is sent via a secure server and saved in a secure database.

• If a service finds out about a suspected DRD, staff will notify their Service Manager, who will notify the Drug and Alcohol Commissioner (DAC), Treatment Effectiveness and Governance Manager (TEGM) or Commissioning Officer (CO) at Safe Newcastle Drug Support Unit (DSU).

• If DSU have not already received the notification from Northumbria Police, name, date of birth and relevant details are taken and a phone call is then made to Newcastle Area Command DIP Officer to confirm the death.

• On confirmation of death, initials, date of birth, sex and relevant information is recorded on a secure database of which only Drug and Alcohol Commissioner, Commissioning Officer and Treatment Effectiveness and Governance Manager have access.

• All suspected drug related deaths will be reported through a single point of contact with NHS North of Tyne (process to be finalised)

Stage 2 – Data Collection

• An email providing initials, sex and date of birth is then sent to providers to inform them of a suspected drug related death and requests a response as to whether the service had involvement with that person or not.

• The information returned is coded and stored in a secure database.

• If a service has had involvement with the deceased, a questionnaire will be sent out by the DSU CO and a report compiled on return. The questionnaire is in Appendices 1

Stage 3 – The Review

• A date will be set for the Drug Related Death Review meeting. Only those services which had involvement with the deceased will be invited to attend the review. Members of which include:

• All commissioned drug treatment services
• Northumbria Police
• North East Ambulance Service
• Coroner / Coroners Officer
• Accident and Emergency
• HM Prison Service
• Any other service that the client was significantly involved with i.e. mental health, voluntary sector, GP

Consultant members will be invited as and when appropriate:

• Public Health
• Member of Community Safety Unit
• Local Pharmaceutical Advisor
• Safeguarding Adults Coordinator
• NewcastleCity Council Press Office

• A confidentiality form will be signed by all attendees, a copy of which is in Appendices 2

Stage 4 – Review Feedback and ongoing audit

• This meeting will produce 3 outcomes:

• Learning points to be acted upon immediately
• Actions for services and Drug Related Death Group to support service development and outcome improvement
• An action plan for the DRD Group at a strategic level to inform future commissioning, which will be reviewed by the ACG

• A copy of the form used to disseminate this information is in Appendices 3

• The Adult Commissioning Group will receive the Annual Drug Related Death Group work-plan and annual report.

• All Drug Related Death Group members will take improvement action within their own organisation and feedback to the following meeting.

• Non patient identifiable information will be cascaded to the DRD Group, Adult Treatment Group, Adult Commissioning Group and agencies as appropriate in Newcastle to support service and outcome improvement.

• In the case of media interest, Newcastle City Council Press Office will co-ordinate multi-agency response and inform Government News Network and National Treatment Agency. This will be discussed with appropriate personnel within partner agencies, including NHS North of Tyne and the police.

• The media strategy in relation to specific investigations will rest with Northumbria Police

5.HM Coroner’s Inquests

5.1 The Chair of the Drug Related Death Review Panel maintains close contact with the HM Coroner’s Office as to dates of inquests for deaths under review and where appropriate, attends the inquest as an observer.

5.2 Each quarter Safe Newcastle's Commissioning Officer will visit the coroner office and view the files of all inquests where the verdict was related to abuse of drugs. A standard range of information is collected from the inquest which is entered onto the secure anonymised database held by Safe Newcastle. This information is then compared to all the suspected DRD we have reviewed. The information is then analysed to give us an accurate picture of Drug Related Deaths in Newcastle.

6.Confidentiality and Information sharing

6.1 Confidential records and a database will be maintained at the DSU

office.

6.2The Local Authority Information Governance Section has confirmed

that the process carried out by DSU does not compromise data protection due to the person being deceased. There is the duty of confidentiality owed to the relatives and next of kin, however the only information being shared is ‘Initials, Gender and DoB’, and it is extremely unlikely that this person could be identified.

6.3This process is supported by Information Sharing Agreement between

Northumbria Police and Safe Newcastle.

6.4This process supports Information Sharing Guidance from DCSF,

alongside CDRP Information Sharing.

6.5This process is developed in the spirit of sharing appropriate Iinformation to support practice and service improvement.

6.6It is expected that all commissioned Drug and Alcohol Services

support the underlying principles of the process and will therefore support the protocol in terms of their attendance at review meetings and information sharing within the scope of the protocol.

6.7Any concern regarding confidentiality and information sharing should

be reported to Chair of the Drug Related Death Group to support resolution and overall good practice in information sharing, in order to achieve improved outcomes.

7.Agreement with Newcastle PROPS

7.1At Stage 2 in the process, once the email is sent out to providers

requesting to check records, the Manager of Newcastle PROPS will contact the Commissioning Officer to obtain the name of the individual. This is to enable records to be checked within the PROPs Service to address any family or carer support up to this point.

7.2 Without a name, this part of the process could not occur and valuable information around carer support would not be obtained.

7.3 If the family or carer is being supported by Newcastle PROPS, a plan will be put in place with the Family Support Worker for extra support at this time.

7.4 If the family or carer is not being supported, Newcastle Area Command DIP Officer will address the need for referral within their role (see flow chart)

8. Agreement with North East Prisons (NOMS)

8.1 At Stage 2 in the process, once the email is sent out to providers requesting to check records, the NOMS North East Regional Office will contact the Commissioning Officer to obtain the name of the individual. This is to enable records to be checked within HMPS as initials and date of birth are not enough to run an information search.

8.2 Without a name, this part of the process could not occur and valuable information around contact with the prison service would not be obtained.

9. People present at the scene of Suspected Drug Related Death

9.1 It is important that the welfare and needs of those present at the scene of a drug related death are addressed wherever possible.

9.2 The first Police Officer attending the scene will preserve life wherever possible, preserve the scene, address the scene in terms of potential witnesses and suspects but, they also have a duty of care to consider the immediate welfare of any third party at the scene.

9.3Newcastle Area Command DIP Officer will subsequently review the presence of any third party at the scene and address the need for follow up.

9.4 Those present may be family, carer /significant other, staff or perpetrator who may all have a range of needs beyond the incident.

9.5 These needs may include:

• Referral to drug services
• Risk assessment
• Emotional/bereavement support
• Carer support
• Practical/social support
• Overdose/Naloxone training
• Debrief and support for staff

9.6 Newcastle Area Command DIP Officer will support access to appropriate services as required in conjunction with appropriate commissioned services.

9.7 All third parties who are present at a DRD and known to be in drug treatment will automatically be raised within the Common Case Management Group to support system wide response to need and risk.

10.Common Case Management Arrangements

10.1 The Common Case Management Review Group (CCMRG) Guideline supports case workers and services of those clients who are most at risk, chaotic and chronically excluded.

10.2This group will support the work of theDrug Related Death Group

within a multi-agency forum to reduce risks for cases referred into the group where there are concerns which existing coordination of care is unable to address. Multi-agency actions to address the client’s needs, reduce risk and minimise the risk of chronic exclusion will be agreed.

10.3Any case which poses an immediate risk should be acted upon immediately and if appropriate referred to a Complex Case Panel (see CCMRG Guidelines) to support a system wide risk management plan.

10.4The CCMRG will provide Outcome based-anonymous data on:

• Rough sleeping
• Supported Housing Evictions
• Hospital Admissions
• Prison Releases
• Overdose
• Offending
• Engagement with Mental Health
• Referrals to safeguarding

10.5This data will also be used to support the Drug Related Death Group work-plan in relation to near miss, service gaps/duplication and operator error, all of which will support feedback into the commissioning cycle.

11.Procedure for out of area deaths

11.1 Regardless of where a service user resided, engaged in treatment or received services from, if a suspected DRD occurs in Newcastle, this protocol will be followed.

11.2 If the suspected DRD resided outside the area and the death occurred outside the area, but the individual received treatment in Newcastle, the process will be followed to review the treatment from Newcastle Commissioned Services as well as to support the DRD review procedure in the area of death where appropriate.

11.3For all out of area deaths, the Commissioning Officer will discuss with the DAT Coordinator in the relevant locality to support the sharing of information as appropriate to their processes.

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Appendices 1

Suspected Drug Related Death Review Procedure Questionnaire

Client identifier:

Box 1.

Your name

Position

Organisation

Telephone

Email

Date

Box 2.

Client other names, aliases or nicknames

Box 3.

Was this person a known drug user?Yes No

Box 4.

What drugs do you know they were using in the month before their death

How long they had been using drugs

Were they injecting?

Did you know this person had died?

Box 5.

How was this person referred to you?

When did this person first contact your organisation?

What appointments were offered?

When was the most recent contact?

Was this:

Telephone

Face to face

Planned

Unplanned

Were there any recent missed appointments?

In the last 3 months has the person attended appointments?

All times

Usually

Rarely

Never

Did you / others in your organisation refer this person to other services?

If yes, which organisations this person was referred on to

Please list other services you or your organisation had contact with about this person

What were their goals regarding drug use?

No goals

Abstinence

Harm minimisation

Don’t know

Controlled use / stabilisation

Other

Box 6.

Please comment on any of the areas below where there was a significant issue or identified problems:

Housing

Homelessness

Finances / Debt

Employment

Physical health

Mental health

Suicidal behaviour

Self harm

Learning difficulties

Harassment

Exploitation

Bullying

Criminal justice system

Prison

Relationships

Domestic violence

Contact with family

Bereavement

Children

Own children in care

Past experiences

Child abuse

Schooling

Childhood

Box 7.

Were you or your organisation involved in prescribing medications for this person? Yes/No

What medications were currently being prescribed?

As far as you know, who else was prescribing medications for this person?

Box 8.

Type of accommodation person lived in

Staffing level 24 hour

Non-24 hour

Floating support

Location of death

Box 9.

Reason for suspicion of drug related death

Box 10.

Please add any other information you would feel be significant in a review of this incident

Appendices 2

Safe Newcastle Drug Related Death Review Meeting

MEETING HELD ON:

CONCERNING: (Reference Number)

DECLARATION OF CONFIDENTIALITY

The persons listed below have attended this review meeting and have agreed that the main objective and focus of the meeting is to support immediate learning, service and system improvement and to inform commissioning intentions. It is agreed by the meeting members that matters discussed at this meeting will remain confidential within the organisations attending, unless otherwise agreed (and where individuals do not represent an organisation, with the individual themselves). All information distributed beyond the review will be for learning and improvement purposes only and will not contain patient identifiable data.

PLEASE ENSURE YOU WRITE YOUR NAME AND ADDRESS CLEARLY AS THIS WILL BE REQUIRED FOR DISTRIBUTION OF THE MINUTES.

Appendices 3

Suspected Drug Related Death Critical Incident Review

Outcomes and Recommendations from Review

Additional Notes

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