Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report

Between 26ᵗʰ February 2024 and 29ᵗʰ February 2024, evidence was heard before a jury touching the death of Mr Lee Martin Hughes, also known as Martin Lee Hughes. He had died on the 25ᵗʰ December 2021, aged 50 years whilst remanded in HMP Wandsworth.

Medical Cause of Death

1 a Methadone and Benzodiazepine intoxication

Lee Martin Hughes was remanded to HMP Wandsworth on 18ᵗʰ December 2021.
He was found deceased in his cell in HMP Wandsworth on 25ᵗʰ December 2021 at approx. 0500.
On arrival, the nurse gave him a COWS score of 12 and a CIWA score of 12-13. He was familiar to the nurse based on previous visits and she noted him looking healthier than previously.

• Mr Hughes reported drug use of ████████ heroin /day; ████████ cocaine; ████████ diazepam tablets; cannabis.
He also reported ████████ alcohol/week.
We consider this report to be unreliable based on other evidence we heard.
• His urine test was positive for opiates (not specifically heroin); cocaine; diazepam; cannabis. His urine was negative for methadone.
• He was prescribed ████████ diazepam twice daily, administered on 18ᵗʰ, 19ᵗʰ, and 20ᵗʰ; and methadone ████████ on the 18ᵗʰ; and ████████ 19ᵗʰ and 20ᵗʰ.

• Based on a COWS score of 2 found on 19ᵗʰ December 2021 we understand that this medication was sufficient to control his signs of withdrawal.
• On 20ᵗʰ December 2021, the Doctor increased his methadone prescription to ████████ to be titrated up over the following days. Our understanding is this was reasonable and appropriate based on a COWS score of 7 and BNF guidance.
• We believe this increase in methadone is the route to his death, but does not equate to a failure in care.
• He was declined an increase in methadone on 23ʳᵈ December 2021. Our understanding is this was appropriate.
• He showed signs of intoxication on 23ʳᵈ December 2021 (nodding off).
• We believe based on the evidence in hindsight it would have been appropriate to omit a dose of methadone on 23ʳᵈ December 2021, despite confounding factors.
• We found evidence of multiple events where Mr Hughes was unrousable on 24/12/2021, in order to administer diazepam.
• Based on the evidence, we do not believe this was appropriately managed by healthcare.
• We have seen insufficient evidence to believe he was seen awake or vaping on 24ᵗʰ December 2021 at 2100.
• Based on the evidence, we understand his consciousness to have been impaired when he was visited by the nurse at c. 2110 on 24ᵗʰ December 2021.
• Medical help should have been sought:
• Code Blue should have been called at 2110.
• Medical escalation to the HOTEL nurse when the medication could not be administered by the Pharm Tech at 18:10.
• Based on this evidence, we believe there a really serious (gross) failure to care for Mr Hughes, encompassing the behaviour of the nurse who entered the call at 21:10.
• Had care been sought, we believe Mr Hughes would have survived at this time.
• We believe this was a lost opportunity.
• We find the medical cause of death to be methadone and Benzodiazepine Intoxication.
• As a footnote, we believe Mr Hughes's knowledge of the system (drug seeking behaviours) contributed to his death.
• We note the lack of communication between disciplines in HMP Wandsworth was a contributing factor to Mr Hughes's death, specifically –
• Pharmacy techs not adequately escalating the reason that Mr Hughes could not be medicated, including the lack of real time and accessible written notes.
• The delay in trying to medicate Mr Hughes between the pharmacy techs alerting the day nurses for a second time at 18:10 and the night nurse first visiting Mr Hughes at 20:42.

Conclusion of the Jury as to the death:

Drug-related Misadventure contributed to by Neglect.

1. That clinicians, wishing to believe their patients, are relying too heavily on what patients tell them (symptoms) rather than looking for evidence (physical signs) of withdrawal, As such, given the particular difficulties of prescribing to prisoners, that objective signs of withdrawal assessments (OWS) should be used to determine whether methadone should be prescribed rather than the COWS score which contains many subjective factors and may be more easily manipulated by an inmate to appear as if that inmate is experiencing withdrawal from drugs necessitating an increase in methadone.

2. That prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners, who should therefore be more experienced as to when, whether and how much to prescribe.

3. That guidelines are followed without sufficient consideration as to whether they apply to the individual patient.

4. That practitioners when prescribing consider whether time spent in custody prior to remand may have reduced an individual's tolerance to opiates, especially when methadone is to be prescribed with a synergistic agent such as a benzodiazepine.

5. That methadone should be withheld and or reduced if the patient/inmate is showing signs of sedation.

6. That there should be tests available for illicit drugs from near patient testing to allow a clinician to better assess a patient showing signs of intoxication.