Dr Lee Winslow · Prevention of Future Deaths report

On 29th September 2021, an inquest was opened into the death of Dr Lee Winslow, who died at his home on 12th June 2021, aged 56 years. The investigation concluded at the end of the inquest which I heard on 28th July 2022.

The inquest determined that Dr Winslow died as a consequence of ████████ toxicity. The conclusion of the inquest as to Dr Winslow’s death was one of Suicide.

Dr Winslow was found dead at his home on 12th June 2021 having taken ████████ with the intention of ending his life. The inquest determined that, whilst the ████████ had probably been taken from one of the hospitals where he worked, the ████████ had been taken from Manchester Royal Infirmary.

In August 2020, Dr Winslow had previously attempted to end his life by taking an overdose of ████████ Aside from the ████████ which had been left over from a previous prescription, Dr Winslow freely admitted having taken the remainder of these medicines from Trust stocks.

Following this overdose, Dr Winslow was absent from the Trust on sick-leave until 14th December 2020. After a period of supervised practice, Dr Winslow returned to unrestricted duties in the week commencing 18th January.

1. Following the admission by Dr Winslow in 2020 that he had taken medicines from the Trust with a view to ending his life, it is a matter of concern that the case was not formally referred to the Police and the General Medical Council.

Making such referrals would have had the potential benefit of:-

i) Providing the Trust with ready access to external advice as to the adequacy (or otherwise) of steps taken to mitigate the future risk of staff members misappropriating medicines with a view to self-harming; and

ii) Offered access to a mechanism whereby objective analysis of Dr Winslow’s fitness to practise as a Consultant Anaesthetist (both from a health and broader perspective) could have taken place;

2. In December 2020, the Trust became aware that, whilst on sick leave from the NHS, Dr Winslow had continued with his private practice notwithstanding an explicit instruction from his manager to the effect that he should refrain from all work. It is a further matter of concern that this development did not, of itself, cause the Trust to reconsider its position and make the referrals set out above;

3. In the absence of any meaningful external review of the case as a whole, it is a particular concern that most of the actions which followed the theft of medication by Dr Winslow in 2020 appear to have been taken as a result of decisions made by members of the Trust’s medical hierarchy.

In view of the gravity of the issues raised by Dr Winslow’s misappropriation of drugs in 2020, and the previous suicide of a Consultant Anaesthetist employed by the Trust involving the misuse of prescription medicines, it is a matter of concern that a more multi-disciplinary approach was not taken, perhaps overseen by someone such as a non-executive director of the organisation.