Recurring concern

Unreliable recognition and response to alcohol withdrawal

First to latest report 23 Mar 2015 — 3 Sep 2025

Reports that mention this concern
6
Times this concern has been raised
9
Stated actions linked to this concern
2

What this concern includes

Includes failures of controls specifically dedicated to alcohol-withdrawal recognition and response, including patient and family safety information, clinical guidance and protocols, staff training, assessment, monitoring, treatment, escalation and urgent referral.

What is not included
  • Excludes alcohol-intoxication controls where withdrawal is not the identified unsafe condition.
  • Excludes opioid or other drug-withdrawal concerns unless the assertion explicitly links them to the same alcohol-withdrawal process.
  • Excludes generic clinical training, communication or documentation deficiencies that are not specifically tied to alcohol-withdrawal recognition or response.
  • Excludes general mental-health, substance-misuse or emergency-care access failures where no alcohol-withdrawal control deficiency is identified.

Reports and published responses 6 reports

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

  1. South Wales Central

    AI-generated summary

    Peter Malcolm THOMAS · 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

    Peter Malcolm Thomas, aged 78, was admitted with a serious infection and delirium after collapsing, but was treated under the CIWA protocol after giving an erroneous account of alcohol use. He received 80 mg of diazepam over six hours, did not regain consciousness after antidote treatment, and died from bronchopneumonia associated with osteomyelitis and peripheral vascular disease. The principal concerns were that CIWA may not account adequately for age, delirium, confusion, metabolic differences, or lack of collateral information, and that its use could result in unnecessary high-dose sedation and future deaths.

    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 NICE alcohol-withdrawal guidelines to explicitly address the relevant clinical situation

    Wider context from the report

    “(3) the NICE guidelines on the management of alcohol withdrawal do not explicitly deal with the situation here, which could well recur and lead to future deaths ”

    Source location

    Peter Malcolm THOMAS · Prevention of Future Deaths report
    Page 3 · 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

    Review the alcohol-withdrawal guidance topic and conclude that an update should be considered.

    Verbatim wording from the response

    “The prioritisation board has previously considered the topic of alcohol withdrawal, and considering the volume of new evidence in this area, and the time since our guidance on this topic area was originally published, the board concluded that an update should be considered.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 16 September 2025

    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

    Reconsider the alcohol-withdrawal guidance, including CIWA-Ar and pharmacological treatment, at the February–March 2026 prioritisation board meeting.

    Verbatim wording from the response

    “In the case of the CIWA-Ar scale, this protocol was not produced by NICE, and so we are unable to amend it, but it is appropriate for us to consider whether it is still relevant for NICE to recommend its use as an assessment and monitoring tool in our guidance.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 16 September 2025

    Open published response

  2. 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

    Failure to provide information about alcohol withdrawal signs and symptoms requiring urgent medical treatment

    Wider context from the report

    “2) The deterioration in Mr Kuenzel’s health from late October 2018 may be attributable to alcohol withdrawal. Mr Kuenzel and his partner knew that he needed to seek medical attention if he had a seizure but did not know of any other signs or symptoms of alcohol withdrawal which would require urgent medical treatment. ”

    Source location

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

    Open source report

  3. 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

    Lack of audit of opiate and alcohol withdrawal observations

    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

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate training on opiate and alcohol withdrawal signs and dangers

    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

    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

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate training of clinical staff in completing withdrawal scales

    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

  4. 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

  5. East London

    AI-generated summary

    Mr Valdas Jasiunas · 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 Valdas Jasiunas, who had serious underlying health problems including chronic alcohol liver disease and seizures, was arrested and held in police custody on 1 September 2010. He collapsed in his cell the following morning and died in hospital on 2 September 2010. Concerns included the identification and management of alcohol dependency, erroneous custody-record entries that could provide false reassurance, and communication difficulties where English was not the detainee’s first language.

    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 alcohol-withdrawal information leaflets in different languages

    Wider context from the report

    “3. There were some questions marks around the full understanding of Mr Jasiunas as English was not his first language. The Medical Director of the Forensic Healthcare services has confirmed that a very helpful leaflet is now provided to detained persons in custody setting out the signs and symptoms of alcohol withdrawal. The leaflet is not yet available in different languages. The FME stated that in East London, a number of detained persons are of Eastern European origin. The leaflet may well assist in ensuring that relevant signs and symptoms are brought to the attention of custody staff. Availability of the leaflet in the most common presenting languages is likely to ensure that more detained persons are able to understand and communicate significant concerns. ”

    Source location

    Mr Valdas Jasiunas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. 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

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