Recurring concern

Unreliable alcohol detoxification care and support

First to latest report 30 Jul 2013 — 9 Dec 2020

Reports that mention this concern
9
Times this concern has been raised
11
Stated actions linked to this concern
5

What this concern includes

Includes failures in alcohol detoxification care and support arrangements, including assessment of detoxification need, specialist referral or support, follow-up, monitoring, care planning and protocols for managing detoxification in primary, hospital or mental-health settings.

What is not included
  • Excludes detoxification for substances other than alcohol unless the assertion explicitly concerns the same alcohol-detoxification process.
  • Excludes general substance-misuse service capacity or treatment failures where alcohol detoxification care is not the deficient condition.
  • Excludes generic GP, hospital, staffing, documentation or communication deficiencies unless they directly impair alcohol detoxification care and support.
  • Excludes failures occurring after alcohol detoxification has been safely completed when the remaining issue is unrelated downstream care.
  • Excludes inpatient detoxification bed-capacity shortages where the material concern is placement availability rather than the safety and support of the detoxification-care process.

Reports and published responses 9 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Kimberley Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kimberley Smith, who had a history of mental health conditions, alcohol dependency and self-harm, died by suicide after leaving an inpatient psychiatric unit while on unescorted leave and being found with a plastic bag over her head. The concerns included inadequate risk assessment and management of alcohol use and leave, failures in observation and missing-person procedures, and the absence of clear written policies for informal and detained patients leaving the unit.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Alcohol detoxification protocols lacking specific care plans on mental health wards

    Wider context from the report

    “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation, ‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’ The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans, minimum monitoring or the management of leave request during treatment. It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency. ”

    Source location

    Kimberley Smith · Prevention of Future Deaths report
    Page 6 · concerns

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Alcohol detoxification protocols lacking minimum monitoring on mental health wards

    Wider context from the report

    “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation, ‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’ The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans, minimum monitoring or the management of leave request during treatment. It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency. ”

    Source location

    Kimberley Smith · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Alcohol detoxification protocols lacking management of leave requests during treatment

    Wider context from the report

    “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation, ‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’ The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans, minimum monitoring or the management of leave request during treatment. It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency. ”

    Source location

    Kimberley Smith · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete guidance on alcohol detoxification for people admitted to inpatient wards.

    Verbatim wording from the response

    “Our response: The Trust has now completed its guidance regarding “Alcohol detoxification for people admitted to inpatient wards”.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop guidelines for managing people with alcohol use disorders on mental health wards, covering withdrawal monitoring, leave, risk assessments and care planning.

    Verbatim wording from the response

    “We are also developing new guidelines for “Management of People with Alcohol Use Disorders (AuDs) Admitted to Mental Health Wards”. The new guidelines cover the following: monitoring of patients during withdrawal and detoxification (both physical and mental health), leave, risk assessments and care planning.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train and support inpatient staff to implement the alcohol-use-disorder guidelines through collaboration between detoxification nurses and inpatient Advanced Clinical Practitioners.

    Verbatim wording from the response

    “Once complete, i-access detoxification nurses will work with the inpatient Advanced Clinical Practitioners to train and support inpatient staff to put the guidelines into practice.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 6 January 2021

    Open published response

  2. Manchester South

    AI-generated summary

    David Alan Price · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Alan Price had a long history of alcohol use to cope with mental health difficulties and was found at home on 12 November 2018. The inquest heard that he would have benefited from an integrated mental health counselling and detoxification service, which was not available in Stockport.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of integrated mental health counselling and alcohol detoxification services

    Wider context from the report

    “The inquest heard evidence that David Alan Price had a long standing problem with alcohol which he used to self-medicate his anxiety in particular. He made a number of attempts to give up alcohol. These were ultimately unsuccessful. The inquest heard that one of the challenges was to provide support which would enable him to treat his mental health difficulties e.g. anxiety alongside detoxification and supporting him in staying alcohol free. The inquest heard that he would have benefited from an integrated mental health counselling/detoxification service. This would have enabled joint treatment. Such a programme is not available in Stockport. ”

    Source location

    David Alan Price · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing services are considered sufficient to meet the needs of people with co-occurring mental health and alcohol problems.

    Verbatim wording from the response

    “We recognise that with these services in place Mr Price should have been able to benefit from them, but did not. The CCG and Local Authority have reviewed and are recommending the following actions:”

    Source location

    2019-0145-Response-by-Stockport-NHS-CCG
    Page 2 · response
    Published 29 July 2019

    Open published response

  3. Inner North London

    AI-generated summary

    Steffan Kuenzel · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Steffan Kuenzel, who had longstanding alcohol-related problems and previous withdrawal seizures, reduced his alcohol consumption and became unwell before losing consciousness and dying in hospital on 11 November 2018. The inquest concluded that his death was alcohol related, with a cardiac arrest following a 10-day period of alcohol withdrawal. The concerns were that he was advised to reduce his drinking without specific guidance on how to do so, and that he and his partner were unaware of other alcohol-withdrawal symptoms requiring urgent medical treatment besides seizures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of specific advice for people independently reducing alcohol consumption

    Wider context from the report

    “1) The decline in Mr Kuenzel’s health appears to coincide with the reduction from 750 ml vodka per day to 375 ml. Mr Kuenzel had attended hospital with alcohol withdrawal related seizures on a number of occasions. He was advised to gradually reduce his drinking but not given any specific advice as to how this should be done. Whilst alcohol reduction is most safely undertaken with the support of specialist agencies, there will be some people who present at hospital with serious alcohol withdrawal related problems that will not engage with services. Those individuals may develop withdrawal related problems through deciding to reduce their alcohol consumption independently. ”

    Source location

    Steffan Kuenzel · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Surrey

    AI-generated summary

    Natasha Learline CHIN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unclear and incomplete protocols for opiate and alcohol withdrawal

    Wider context from the report

    “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff. 2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend. 3. Nurses failed to make any datix referrals in respect of missed medications. 4. The following matters have to date not been formally audited by Sodexo Justice Services: i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded. ii.) Whether critical medication is administered on time. iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal. iv.) Whether medical records on System 1 are accurately recorded. v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive. 5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed. 6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter. 7. Whether there is adequate training: i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal. ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales. ”

    Source location

    Natasha Learline CHIN · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  5. Worcestershire

    AI-generated summary

    Mr Taylor · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Taylor suffered a fall at home on 27 July 2018, sustaining a head injury and later being transferred to the Trust. Following a respiratory arrest, chest infection and deterioration, he died in the Trust on 31 July 2018. Concerns included insufficient consultant physician support for neurosurgical patients and an alcohol withdrawal protocol that was difficult to understand, resulting in diazepam being prescribed instead of lorazepam.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the alcohol withdrawal protocol to provide clear instructions

    Wider context from the report

    “(2) I was told that the alcohol withdrawal protocol was difficult to understand. This resulted in the doctor prescribing diazepam when Lorazepam should have been used. I was told and shown an action plan that the Trust intends to implement to improve the process. ”

    Source location

    Mr Taylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner South London

    AI-generated summary

    Jamie Pashley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Limited availability of hospital alcohol liaison nurse support

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

    Source location

    Jamie Pashley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider a business case to increase the Alcohol Liaison team and improve patient access to liaison staff.

    Verbatim wording from the response

    “The Trust acknowledges that there is demand for an increased team so that patients can access staff that they worked with whilst an in-patient. Approach approaches have been made to local CCGs and charities without success to date, and so the Trust is considering a business case to increase the Alcohol Liaison team. The benefits to”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 2 · response
    Published 4 August 2017

    Open published response

  7. South Yorkshire (Western)

    AI-generated summary

    Neil Budziszewski · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Risk of fatal acute alcohol withdrawal syndrome when unmanaged

    Wider context from the report

    “(29) Expert evidence was given that acute alcohol withdrawal syndrome is associated with a high risk of death if not managed properly. The early symptoms such as shaking or retching (both displayed by Mr Budziszewski) indicate a rather lower risk but that could grow with time. ”

    Source location

    Neil Budziszewski · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  8. County Durham and Darlington

    AI-generated summary

    David Peter Greenfield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Peter Greenfield, aged 29, was admitted to hospital for alcohol detoxification and was found unresponsive in his bedroom less than 24 hours later. The report states that his death involved pre-existing heart disease, respiratory depression linked to obesity and the effects of drugs. Concerns included staff experience and understanding of risks associated with methadone and respiratory depression, and the absence of drug screening for patients admitted for alcohol detoxification, which impeded meaningful risk assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of drug screening for patients admitted to alcohol detoxification programmes

    Wider context from the report

    “2. Evidence was given if a patient enters The Priory with a view to a drug treatment issue then that patient would be screened for drugs. If a patient is admitted to The Priory for an alcohol detoxification programme then there is no screening for drugs. The deceased was known to take methadone. Other drugs were found at post mortem in his system and in combination with alcohol detoxification medication there is an increased risk of respiratory depression and in the absence of the prescribing doctor knowing with a degree of certainty (notwithstanding any statements made by a patient) as to what drugs are in a patients system then a full and proper risk assessment as to the nature of the treatment to be offered and the level of supervision and observations to be instituted (i.e. a meaningful risk assessment) cannot be undertaken and this lacuna in admission procedures could well lead to an increased risk of similar fatalities in the future. ”

    Source location

    David Peter Greenfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide detoxification hospitals with urine drug-screening kits and instruct staff to test patients where illicit-drug use is indicated.

    Verbatim wording from the response

    “We are in agreement with you that we should routinely use urine drug screens across all of our detoxification services as part of the assessment process and where necessary on an on-going basis thereafter. Since the request we have reviewed this practice and learnt that a number of hospitals are routinely undertaking urine drug screens on those patients who are admitted for alcohol detoxification. Our intention is to ensure that our hospitals all have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs prior to or at the point of admission. Our intention is to ensure that these kits are readily available at relevant hospital sites by the end of February 2014.”

    Source location

    2014-0518-Response-by-Priory-Group
    Page 2 · response
    Published 27 November 2014

    Open published response

  9. West Sussex

    AI-generated summary

    Phillip Arthur Pratt · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Phillip Arthur Pratt died on 2 November 2012 at St Richards Hospital after a fall-related fracture, surgery, and a sudden deterioration attributed to bronchopneumonia. The report raised concerns about incomplete medication information, delayed consideration of alcohol detoxification, delayed discontinuation of tramadol after confusion developed, delayed shoulder X-rays, and the unavailability of requested additional nursing staff for a high-risk patient.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess and reassess the need for alcohol detoxification

    Wider context from the report

    “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken. (1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication; (2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed; (3) The onset of agitation and confusion had been recognized, with a (4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication; (5) There was a delay in x-raying the shoulder. The report comments (6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not available. ”

    Source location

    Phillip Arthur Pratt · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026