Drugs Related Deaths Systems Audit

Heidi Douglas Specialty Registrar Public HealthPublic Health England

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Context: DRDs Preventable Deaths

• The majority of drug misuse deaths still involve opiates, in particular heroin and methadone (56%),

• Increases in cocaine and amphetamine deaths and a marked increase in mention of benzodiazepines among opiate deaths over recent years

• Opiate users had increased vulnerability to overdose because of using drugs (including alcohol) in combination with opiates alongside prescribed opioid substitutes.

• Compromised respiratory systems as a result of smoking related diseases.

• The physical health of drug users in treatment is impacting on the number of chronic DRDs, such as liver problems including hepatitis C and alcohol-related cirrhosis.

ONS 2013 figures on deaths due to drug misusewww.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/2013/stb---deaths-related-to-drug-poisoning-2013.html

DRDs in the North East

In England, the North East had the highest mortality rate from drug misuse in 2013 with 52.0 deaths per million population (England rate 33.9 deaths per million population)

3ONS 2013 figures on deaths due to drug misuse

www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/2013/stb---deaths-related-to-drug-poisoning-2013.html

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North East Statistical Outlier?

DRD Systems Audit

Project brief:

To undertake a system’s based audit of the confidential inquiry process undertaken to review drug-related deaths (DRDs).

Geographical area:

12 local authority areas in the North East of England

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Aims:1. Provide a greater understanding of the current approach

to the confidential inquiry process into DRDs for each local authority area in the North East and assess the approach taken against national guidelines.

2. Use the audit findings to highlight any gaps and potential strategic risks to delivery across the North East.

3. Identify opportunities of a North East approach and highlight these findings as recommendations

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Data will include evidence of systems (capture the process of reporting, monitoring and characteristics of local DRDs) and the narrative (capture levels of partnership working and implementation of lessons learnt in strategic planning)

Re-audit to establish if changes have affected practice/outcomes

Identify areas of good practice and highlight evidence based recommendations

NTA/PHE Guidance:

8 The key stages in preventing a DRD, including the role of the confidential inquiry process

Review of literature“What is the evidence

that confidential inquiries/enquiries

prevent deaths or reduce mortality”

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Review of literature• Reduced mortality (Confidential Enquiry Maternal Deaths and National

Confidential Inquiry Suicide and Homicide)

• Implementation of policies, understanding the role of human error and no blame approach.

• HTA: Using a framework to review the lessons learned (RCA) and in the subsequent action plan (SMART), acknowledging the wider systems and investing in training and change management.

• Child death reviews: Prioritising the priorities, include those outside your reach.

• Identifying patterns and trends: Surveillance system or undertaking thematic narrative reviews.

• Evidence based approach: ensuring the use of NICE recommended practices

• Presence of substance misuse in other deaths and review processes

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UAM survey 2014

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Results• In February 2015 half (6) of the Local Authorities in the North East Region

ha an active DRD review process in place.

• Three areas maintained a log of deaths but did not analyse these deaths and the remaining 3 areas currently had no provision in place.

• Two areas were actively reviewing their current process.

• Ten areas had written protocols and policies 3/10 had policies that reflected current practice.

• Half of Local Authorities had the active engagement of the coroner in the review process.

• All 12 areas had a named coordinator, however it was acknowledged that there were significant resource pressures and that the reconfiguration of the former NTA and DAAT structures had resulted in the loss of organisational memory within the Local Authority and that the previous NTA annual reporting requirements for DRDs had maintained a focus on the DRD review process.

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Notification and Information Gathering

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• One area conducted the review post coroner inquest

• 8/12 areas included DRDs not in treatment

• 5/12 areas included ARDs

• 4/12 areas included suspected suicides/ accidental ODs (in treatment)

• 8/12 received notification from Services, 6/12 coroner and 5/12 police.

• Half of areas gathered information to review

• 1 area gathered information and kept a log

• 4 areas discussed DRDs in routine meetings with commissioned services

Analysis and Lessons learned • Focus was on improving treatment service.

• There was no evidence that learning from near misses fed into the DRD/ARD review process.

• SUIs undertaken within the commissioned services were not routinely shared.

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Organisations Engaged in DRD/ARD reviews Number %Treatment services 9/12 75%Public Health 6/12 50%Probation 5/12 42%Police 4/12 33%Adult social care 4/12 33%Pharmacy 3/12 25%Coroner’s office 3/12 25%Mental Health Trust 3/12 25%NHS FT 2/12 17%Social Housing 2/12 17%Medicine Management 2/12 17%GP 1/12 8%Toxicology 1/12 8%Trading Standards 1/12 8%

Governance

• The six areas that had an active DRD/ARD review process all had an overarching governance structure to which the work of the panel was reported.

• In 2/6 areas there was a direct line of accountability to the DPH and the other 4 areas reporting to the Health and Wellbeing boards as well as to Drug and Alcohol Commissioning Boards.

• Five areas submitted their most recent annual report on DRDs. Three of these reports were within the last 12 months and the other two were published in 2013.

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Good Practice 1. Good relationship with their local coroner

2. Engagement of local police both in terms or reporting a death and in the review process

3. Most of these areas have incorporated alcohol related deaths and suicides/accidental deaths into the review process

4. The review process and supporting documentation is regularly reviewed and reflects current practice

5. Meet regularly (Bimonthly or quarterly)

6. Have nurtured positive relationships which has manifested into a culture on no blame/fair blame and information sharing

7. All areas have formal confidentiality agreements and generally receive high quality information back from services

8. All areas have a governance structure and a formal process of capturing the lessons learned.

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Recommendations1. There is a standard process and definition

2. That the review process is pre-coroner inquest

3. The definition includes alcohol related deaths and near misses

4. That the DPH is the accountable officer for the DRD/ARD review process. In this role the DPH needs to be assured that there is a process in place that meets local need.

5. There is an expectation that each Local Authority area writes an annual report that includes statistical, demographical information alongside a forward action plan and the key achievements from the previous year.

6. Any service improvements identified are evidence based and where appropriate follow NICE guidance

7. There needs to be a concerted effort to move away from the sole focus on lessons learned being only relevant to the treatment services. Although this is an important area, more consideration needs to be given to early identification and public health interventions that prevent ARDs/DRDs

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Actions:Short-Term:

Standardising practice

Building relationships

Wider workforce

Undertake a thematic analysis at a regional level

Medium-Term:

Design a minimum data set for the North East

Re-audit (September 16)

Resource a regional alcohol or drug related mortality surveillance system.

Long-term:

Monitor the impact of public health interventions and service improvements on alcohol or drug related mortality in the North East.

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