Clare Louise BAIN · Prevention of Future Deaths report

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Issued 5 Aug 2014•Exeter and Greater Devon

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to correctly identify the opiate overdose and assess the adequacy of a single naloxone dose
  2. Failure to provide repeat naloxone treatment doses while opiates remain active
    Part of recurring concern: Unsafe access to and application of Naloxone guidance

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. South Western Ambulance Service NHS Foundation Trust

    Present methadone-overdose case learning to the Controlled Drug Local Intelligence Network and participating healthcare and police agencies.

  2. South Western Ambulance Service NHS Foundation Trust

    Work with other agencies to address challenges arising from methadone overdose.

  3. South Western Ambulance Service NHS Foundation Trust

    Review the Trust’s practices for providing effective care to patients with methadone overdose.

  4. South Western Ambulance Service NHS Foundation Trust

    Use a new detailed mental health guideline to support robust assessments of patients’ capacity under the Mental Capacity Act.

  5. South Western Ambulance Service NHS Foundation Trust

    Issue a clinical notice guiding clinicians on methadone overdose treatment, hospital conveyance, refusal of transport, monitoring and escalation.

  6. South Western Ambulance Service NHS Foundation Trust

    Trial and roll out an electronic patient record system with a structured Mental Capacity Act assessment process.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. South Western Ambulance Service NHS Foundation Trust

    Mandatory hospital transport cannot be imposed when a methadone-overdose patient has capacity to refuse treatment under the Mental Capacity Act 2007.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to correctly identify the opiate overdose and assess the adequacy of a single naloxone dose

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) That given Deceased had declined to go to hospital the paramedics were under the impression that this was a heroin overdose and the use of one dose Naloxone was sufficient to counteract the effects of the opiate. (2) If paramedics are unaware that the respiratory depressive effects of Methadone last longer that the antagonism afforded by Naloxone there is a danger of further deaths because lack of repeat treatment doses of Naloxone when opiates are still active. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide repeat naloxone treatment doses while opiates remain active

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) That given Deceased had declined to go to hospital the paramedics were under the impression that this was a heroin overdose and the use of one dose Naloxone was sufficient to counteract the effects of the opiate. (2) If paramedics are unaware that the respiratory depressive effects of Methadone last longer that the antagonism afforded by Naloxone there is a danger of further deaths because lack of repeat treatment doses of Naloxone when opiates are still active. ”

Is this part of a recurring concern?

Yes — Unsafe access to and application of Naloxone guidance.

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

Present methadone-overdose case learning to the Controlled Drug Local Intelligence Network and participating healthcare and police agencies.

Verbatim wording from the response

“More generally, the Trust is also working with other agencies to address some of the particular challenges methadone overdose presents. Our Accountable Officer, along with one of our senior clinicians, presented a similar case study at the Controlled Drug Local Intelligence Network (Bristol, North Somerset and South Gloucestershire) Annual Learning Meeting in July this year. This meeting is attended by the Police and other healthcare agencies including those concerned with substance misuse and harm reduction. The Police commented that even if they transport the patient to hospital, there was currently not a mechanism to detain the patient against their wishes.”

Source location

2014-0359-Response-by-South-Western-Ambulance-Service
Page 3 · response
Published 5 August 2014

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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

Work with other agencies to address challenges arising from methadone overdose.

Verbatim wording from the response

“More generally, the Trust is also working with other agencies to address some of the particular challenges methadone overdose presents. Our Accountable Officer, along with one of our senior clinicians, presented a similar case study at the Controlled Drug Local Intelligence Network (Bristol, North Somerset and South Gloucestershire) Annual Learning Meeting in July this year. This meeting is attended by the Police and other healthcare agencies including those concerned with substance misuse and harm reduction. The Police commented that even if they transport the patient to hospital, there was currently not a mechanism to detain the patient against their wishes.”

Source location

2014-0359-Response-by-South-Western-Ambulance-Service
Page 3 · response
Published 5 August 2014

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

Review the Trust’s practices for providing effective care to patients with methadone overdose.

Verbatim wording from the response

“I hope the information contained within this letter provides you with assurance that the Trust is committed to reviewing its own practices and working alongside our colleagues in the wider health community to provide effective care to methadone overdose patients. If I can provide any further information, please do not hesitate to contact me.”

Source location

2014-0359-Response-by-South-Western-Ambulance-Service
Page 3 · response
Published 5 August 2014

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

Use a new detailed mental health guideline to support robust assessments of patients’ capacity under the Mental Capacity Act.

Verbatim wording from the response

“As you will be aware, our clinicians can only transport a patient to hospital without his/her consent if he/she is assessed as lacking capacity to make their own decision regarding their medical treatment under the provisions of the Mental Capacity Act 2007. However, in methadone overdose cases, a patient who does not feel unwell will often have sufficient capacity and awareness to make decisions regarding their treatment. To assist clinicians in the effective and robust assessment of patient capacity we have recently issued a new and detailed mental health guideline, which provides clear and detailed guidance regarding capacity assessments. I have enclosed a copy for your reference. In addition, the Trust has now started to trial an electronic patient record system which will be rolled out more widely going forward.”

Source location

2014-0359-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 5 August 2014

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

Issue a clinical notice guiding clinicians on methadone overdose treatment, hospital conveyance, refusal of transport, monitoring and escalation.

Verbatim wording from the response

“On the 1st October, the Trust will be issuing further guidance for clinicians to raise awareness of methadone overdose and how it should be treated. The guideline will highlight:”

Source location

2014-0359-Response-by-South-Western-Ambulance-Service
Page 1 · response
Published 5 August 2014

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

Trial and roll out an electronic patient record system with a structured Mental Capacity Act assessment process.

Verbatim wording from the response

“As you will be aware, our clinicians can only transport a patient to hospital without his/her consent if he/she is assessed as lacking capacity to make their own decision regarding their medical treatment under the provisions of the Mental Capacity Act 2007. However, in methadone overdose cases, a patient who does not feel unwell will often have sufficient capacity and awareness to make decisions regarding their treatment. To assist clinicians in the effective and robust assessment of patient capacity we have recently issued a new and detailed mental health guideline, which provides clear and detailed guidance regarding capacity assessments. I have enclosed a copy for your reference. In addition, the Trust has now started to trial an electronic patient record system which will be rolled out more widely going forward.”

Source location

2014-0359-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 5 August 2014

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Mandatory hospital transport cannot be imposed when a methadone-overdose patient has capacity to refuse treatment under the Mental Capacity Act 2007.

Verbatim wording from the response

“As you will be aware, our clinicians can only transport a patient to hospital without his/her consent if he/she is assessed as lacking capacity to make their own decision regarding their medical treatment under the provisions of the Mental Capacity Act 2007. However, in methadone overdose cases, a patient who does not feel unwell will often have sufficient capacity and awareness to make decisions regarding their treatment. To assist clinicians in the effective and robust assessment of patient capacity we have recently issued a new and detailed mental health guideline, which provides clear and detailed guidance regarding capacity assessments. I have enclosed a copy for your reference. In addition, the Trust has now started to trial an electronic patient record system which will be rolled out more widely going forward.”

Source location

2014-0359-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 5 August 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026