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

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
1
2
Document specification
Safe Newcastle’s procedure following notification of a
suspected drug related death in Newcastle for all
commissioned services to follow, as specified in Service
Level Agreements.
Other key
Models of Care: Update (2006), National Treatment Agency
reference
(NTA)
documentation Reducing Drug Related Deaths, Advisory Council for the
Misuse of Drugs (2000), Stationary Office
National Programme of Substance Abuse Deaths (Np-SAD)
Surveillance Reports (Annually)
Reducing Deaths, A Resource for A&E Staff, NTA (2004)
Reducing Drug Related Deaths – guidance for drug
treatment providers, NTA (2004)
Drug Misuse and Dependence – UK Guidelines on Clinical
Management, DH (2007)
Document
purpose
Authorship
Sign off
Date of report
Target
audience
Contact
details
Drug Related Death Group,
Safe Newcastle Drug Support Unit
Adult Commissioning Group
Drug and Alcohol Commissioner
Review: May 2010
To be reviewed annually
Commissioned drug and alcohol services in Newcastle
Safe Newcastle (Drug Support Unit)
Shieldfield Centre, Newcastle, NE2 1AL
0191 278 8125
Awaiting appointment:
Drug and Alcohol Commissioner
Margaret Orange, Chair of Drug Related Death Group
Treatment Effectiveness and Clinical Governance Manager
[email protected]
[email protected]
Claire Toas, Commissioning Officer (Drugs)
[email protected]
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Contents
Contents
Page
Safe Newcastle Drug Related Death
Review Protocol for Commissioned drug
services
5
Safe Newcastle Drug Related Death
Review Protocol flowchart
12
Role of the Newcastle Area Command
DIP Officer in relation to Drug Related
Death Process
13
Appendices
1. Questionnaire
14
2. Confidentiality Statement
18
3. Copy of Outcomes and
Recommendations form used in
review panel
19
4
Safe Newcastle Suspected Drug Related Death Review Protocol
1.
Background
1.1
Safe 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).
1.2
All 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
3.1
Identify gaps in service provision
3.2
Identify lessons learned and disseminated accordingly
3.3
Produce action plans from lessons learned
3.4
Adjust policies and practices as necessary
3.5
Identify and monitor significant changes in illicit drug use
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3.6
Ensure 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)
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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:
o
o
o
o
o
o
o
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:
o
o
o
o
o
Public Health
Member of Community Safety Unit
Local Pharmaceutical Advisor
Safeguarding Adults Coordinator
Newcastle City 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:
o Learning points to be acted upon immediately
o Actions for services and Drug Related Death Group to
support service development and outcome improvement
o An action plan for the DRD Group at a strategic level to
inform future commissioning, which will be reviewed by the
ACG
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 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.
6.2
The 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.
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6.3
This process is supported by Information Sharing Agreement between
Northumbria Police and Safe Newcastle.
6.4
This process supports Information Sharing Guidance from DCSF,
alongside CDRP Information Sharing.
6.5
This process is developed in the spirit of sharing appropriate I
information to support practice and service improvement.
6.6
It 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.
6.7
Any 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
7.1
At 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.
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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.
9.3
Newcastle 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:
o
o
o
o
o
o
o
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.
10.2
This group will support the work of the Drug 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.
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10.3
Any 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.
10.4
The 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
10.5
This 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.
11.3
For 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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Safe Newcastle DRD Protocol
Safe Newcastle Drug Related Death Group to 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).
Definition of “Drug
Related Death”
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).
Risk Management:
The
Common
Case
Management Review Group
(CCMRG) Guideline support
case workers and services of
those clients who are most at
risk,
chaotic
and
socially
excluded-refer if routine case
management is unable to
address risk.
NB: All services commissioned
through the Pooled Treatment
Budget and Drug Intervention Budget
will be expected to comply with the
process, as specified in Service
Level Agreement standards
Information Sharing
It 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.
Any 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.
NB: Always consider staff debrief
and support needs in relation to Drug
Related Death
Service aware of the
death of a service user
Police aware of the
death of a service user
Service staff feed information to
Service Manager / DRD
Representative
Coroner aware of
the death of a drug
user – retrospective
enquiry via
Commissioning
Officer
Report via telephone to DSU Commissioning Officer or Treatment Effectiveness
Manager. CO anonymises info and saves securely (Stage 1)
Immediate response
may be needed by
DAC i.e. key
messages sent to all
services
CO sends email to each service manager notifying of
a suspected DRD giving initials, DOB, sex. Any
media interest managed
Service check information against records (Stage 2)
Known
Not known
Service completes suspected
DRD questionnaire and
returns within 1 week
Response may be
needed by DAC i.e. key
messages sent to all
services following
receipt of further
information
Inform DSU
No further action
required at this stage
CO collates all returned questionnaires into
confidential report and updates data base
Review date
set. All involved
services invited
(Stage 3)
Dissemination of:
 Immediate learning points/actions
 Service/DRD actions
 Commissioning feedback
(Stage 4)
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Role of the Newcastle Area Command DIP
Officer in relation to Safe Newcastle DRD
process
DIP Police Officer aware
of DRD
Suspected DRD
occurs
DSU informed by: DIP Police Officer
 Service Provider
 Coroner
Research & report completed. Sent to
Safe Newcastle to inform DRD process
Suspected DRD
process followed
Coroner
Retrospective
Critical Incident
Review
completed
Person(s) present at scene of DRD
identified
Contact made/home visit by appropriate service – e.g.
commissioned service, DIP Police Officer to discuss
further need/support
Refer to appropriate service/agency where further support is required –
e.g. PROPS, bereavement counselling, treatment service etc.
For those in treatment present at the scene - ensure concerns are raised
at Common Case Management meeting in relation to risk and needs of
the service user
ANY ISSUES
RAISED
THROUGHOUT IN
RELATION TO
PROCEDURE, TO
BE PASSED TO DSU
TO INFORM
STRATEGIC
DEVELOPMENT OF
DRD PROCESS IN
THE FUTURE
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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?
14
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
15
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
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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
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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.
NAME
ORGANISATION
ADDRESS
SIGNATURE
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Appendices 3
Suspected Drug Related Death Critical Incident Review
Outcomes and Recommendations from Review
No. Actions
Lead
Timescale
Learning points to all services to be acted upon immediately
Actions for services and DRD work-plan
Actions to inform commissioning
Additional Notes
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