Peter Malcolm THOMAS · Prevention of Future Deaths report

On 3 February 2022 I commenced an investigation into the death of Peter Malcolm THOMAS . The investigation concluded at the end of the inquest 02/09/2025 . The conclusion of the inquest was the following narrative:

Peter Malcolm Thomas was aged 78 and had developed peripheral vascular disease which led to necrotic and subsequently gangrenous toes. This became osteomyelitis of the foot, and a wider spread, more significant infection. On 15th January 2022, Peter collapsed and was taken into the Royal Glamorgan Hospital, Llantrisant, where he was treated with antibiotics and fluids. Sadly, his condition deteriorated significantly, and his infection became a systemic sepsis until he became unconscious and sadly died on 19th January.

Although Peter was given diazepam as a sedative, a treatment he did not require, on balance it did not contribute more than minimally to the development of bronchopneumonia, from which he ultimately died.

His cause of death was found to be:

1a Bilateral Bronchopneumonia

1b Osteomyelitis of the Foot

1c Peripheral Vascular Disease

II

It was identified early upon admission that Peter was likely suffering from a serious infection as well as delirium. A clinician undertaking an examination took an account from Peter which led him to instruct the CIWA protocol to be used, due to information provided by Peter and some concerning signs and symptoms.

In fact, CIWA was a red herring, as Peter was not in alcohol withdrawal, he was confused and delirious and gave an erroneous account of having been drinking. The signs and symptoms he exhibited were more likely due to the serious infection taking hold of him and leading to shaking, sweating, agitation and anxiety. His false account was likely due to confusion or delirium.

No collateral information was sought from medical records, nor from capacious family (who would have been available by phone very easily) and when Peter’s symptoms scored against the CIWA protocol, he was given 80mg of diazepam over 6 hours. He did not require this drug and at 78 with serious comorbidities and a developing sepsis, his metabolism of it was likely hindered. 2 doses of the antidote were subsequently given but Peter did not regain consciousness. He went on to die from pneumonia.

The Inquest focused upon:-

a. The use of CIWA with Peter at all

b. The dosing suggested within CIWA

c. The effect of the diazepam and its contribution to Peter’s death

(1) I am concerned that the CIWA protocol is something of a blunt instrument, not at all nuanced to take account of for example, advancing age and different metabolic rate, delirium and confusion and lack of collateral evidence

(2) Clinicians without further guidance on its use, will continue to be at risk of implementing the CIWA protocol and prescribing sedatives at significant dose and frequency when it is not required, which presents risks of over-sedation and its consequences, particularly in the elderly and potentially delirious cohort, based upon pattern recognition rather than reliable evidence

(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