Recurring concern

Unreliable recognition and treatment of opioid withdrawal

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First reported 22 Aug 2014•Latest report 10 Jan 2019

Definition

What this concern includes

Includes failures in controls dedicated to opioid-withdrawal care, including recognition of withdrawal, use of withdrawal scales, assessment and monitoring, provision of prescribed or clinically indicated treatment, review, escalation and follow-up across healthcare and custody settings.

Not included

  • Excludes alcohol-withdrawal-only concerns without a material opioid-withdrawal component.
  • Excludes methadone prescribing, dispensing, intoxication or toxicity failures where opioid withdrawal is not the unsafe condition.
  • Excludes long-term opioid reduction or substitution support for chronic-pain patients when acute withdrawal recognition or treatment is not the concern.
  • Excludes generic staffing, communication, documentation or training deficiencies unless they directly impair opioid-withdrawal recognition, assessment or treatment.
Reports
2

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2014–2019

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1
HM Inspectorate of Prisons1
Ministry of Justice1
Prisons and Probation Ombudsman1
Royal Sussex County Hospital1
Sodexo1
University Hospitals Sussex NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. 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

  2. Brighton and Hove

    AI-generated summary

    MARTIN ARNOLD HILL · 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

    MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.

    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 adequate treatment for opioid withdrawal

    Wider context from the report

    “(3) Whilst it is noted that Mr. HILL was admitted at lunchtime on a Friday and the critical events took place over a weekend, nonetheless he was known to be an intravenous heroin user on a Methadone prescription and yet he was given no treatment for withdrawal treatment save for 2mg of Diazepam on the 28th March at 22:15 hours and another 2mg of Diazepam at 09:00 on the 30th March. Also on the 30th March PABRINEX was considered and he was written up for this, although this was not given. On the 30th March at 09:50 hours he was given 5ml of METHADONE and later at 13:00 on the 30th March he was given another 5ml of Methadone. (NB: His daily Methadone prescription was 50ml) ”

    Source location

    MARTIN ARNOLD HILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026