Drug Related Deaths in Wales Dr Rossana Oretti Consultant Psychiatrist in Substance Misuse B Sc; MB BS; MSc; MRC Psych

LOCAL CONFIDENTIAL REVIEW PANELS Who are we? Who are we? What is our role? What is our role? How do we do it? How do we do it? What do we achieve? What do we achieve?

The Statistics Two sources -Office of National Statistics and International Centre fro Drugs Policy Two sources -Office of National Statistics and International Centre fro Drugs Policy ONS - Recorded from medical certificates ‘where the underlying cause is poisoning, drug abuse, or drug dependence and where any of the substances controlled by the Misuse of Drugs Act 1971 were involved’ ONS - Recorded from medical certificates ‘where the underlying cause is poisoning, drug abuse, or drug dependence and where any of the substances controlled by the Misuse of Drugs Act 1971 were involved’

ONS Annual average Wales Male Female

ONS Data collected from HM Coroners upon completion of inquest- delays Data collected from HM Coroners upon completion of inquest- delays Latest figures published refer to 2005 Latest figures published refer to 2005 Not broken down to local authority areas Not broken down to local authority areas Information needs to be accurate, timely and specific Information needs to be accurate, timely and specific

ICDP Annual report Annual report Information gathered from HM Coroners – Special Mortality Register (np-SAD) Information gathered from HM Coroners – Special Mortality Register (np-SAD) Area specific Area specific Annual DR per 100,000 Br C/V13.85 NPT SwanseaNRNRN/R Total2317N/A

History of ‘Panels’ Welsh Assembly Government published ‘Guidance on Developing Local Confidential Reviews’ Welsh Assembly Government published ‘Guidance on Developing Local Confidential Reviews’ Based on practice in England and North Wales Substance Misuse Forum Based on practice in England and North Wales Substance Misuse Forum CSPs should form regional panels CSPs should form regional panels Four panels have been established – SW, Gwent, NW, Powys Four panels have been established – SW, Gwent, NW, Powys

‘Panels’ Supported by two drug related deaths co-ordinators Supported by two drug related deaths co-ordinators Development of an All Wales up-to- date register Development of an All Wales up-to- date register View to support a National group View to support a National group

Who? Number of professional and voluntary bodies Number of professional and voluntary bodies Public health, GP, A/E, Psychiatrists in SM, Pharmacy, ambulance, providers, police, probation, social services and prison…..coroners….forensic pathologists Public health, GP, A/E, Psychiatrists in SM, Pharmacy, ambulance, providers, police, probation, social services and prison…..coroners….forensic pathologists

How? Co-ordinator researches all such deaths Co-ordinator researches all such deaths Post inquest files – sudden death reports, witness statements, post mortem results including toxicology Post inquest files – sudden death reports, witness statements, post mortem results including toxicology Standard questionnaires are then sent to all service providers (mental health, housing etc) Standard questionnaires are then sent to all service providers (mental health, housing etc)

How? Individual holistic case studies developed Individual holistic case studies developed Panels then meet for joint analysis of case studies Panels then meet for joint analysis of case studies Voluntary basis Voluntary basis

CASE REVIEW Male, single, 30 years old, CJS involvement for 8 years, long history of alcohol/drug-poor engagement Male, single, 30 years old, CJS involvement for 8 years, long history of alcohol/drug-poor engagement Conditionally released prison on 20/4/05 having served 1 year of a 2 year sentence for robbery Conditionally released prison on 20/4/05 having served 1 year of a 2 year sentence for robbery

Case review Staying in B/B- immediately went on drinking binge and was hospitalised overnight- as a result fails to attend appointment on 21/4/05 with voluntary agency Staying in B/B- immediately went on drinking binge and was hospitalised overnight- as a result fails to attend appointment on 21/4/05 with voluntary agency On 12/5/06 seen by sister and reported to be in a depressed state. On 13/5/05 he visits a friend and informs him he has taken 3 rocks of speed, unknown tablets, and drinking alcohol On 12/5/06 seen by sister and reported to be in a depressed state. On 13/5/05 he visits a friend and informs him he has taken 3 rocks of speed, unknown tablets, and drinking alcohol

Case Review Returns to friends’ house later in day in a drunken state and collapses Returns to friends’ house later in day in a drunken state and collapses Pronounced dead when ambulance arrived Pronounced dead when ambulance arrived Toxicology found – alcohol, paracetamol, mirtazepine, cocaine and metabolite, morphine Toxicology found – alcohol, paracetamol, mirtazepine, cocaine and metabolite, morphine

Case Review Cause of death was given as inhalation of gastric contents and heroin and alcohol intoxication Cause of death was given as inhalation of gastric contents and heroin and alcohol intoxication Verdict of misadventure Verdict of misadventure What could have changed this outcome? What could have changed this outcome?

What for? Data analysis : Inform stakeholders at local, regional and national levels Inform stakeholders at local, regional and national levels Indicators of drug misuse patterns/trends so that appropriate and timely action can be taken Indicators of drug misuse patterns/trends so that appropriate and timely action can be taken Recommendations to WAG and commissioners Recommendations to WAG and commissioners

Data NW annual report- 26 deaths in 2006 NW annual report- 26 deaths in panel areas-since November 2006, almost 50 DRDs have been reviewed (Aug 04 and July 06) 3 panel areas-since November 2006, almost 50 DRDs have been reviewed (Aug 04 and July 06) Not all such deaths but those that could be easily identified Not all such deaths but those that could be easily identified Have to await completion of inquests Have to await completion of inquests

Data 96% male; 4% female 96% male; 4% female 80% aged between years 80% aged between years Three between (ecstasy) Three between (ecstasy) 35% at defined residential addresses 35% at defined residential addresses Further 21% at friends/relatives Further 21% at friends/relatives Friends/relatives had attempted CPR in most cases Friends/relatives had attempted CPR in most cases

Data 36% were currently accessing SM treatment 36% were currently accessing SM treatment Majority had accessed SM treatment in past Majority had accessed SM treatment in past 82% unemployed 82% unemployed 16% low skilled work 16% low skilled work Only 1 in management role Only 1 in management role

DATA 30% lived with parents 30% lived with parents Only 2 homeless Only 2 homeless 11 cases in Swansea, 7=NPT, 6=RCT, 5=Newport 11 cases in Swansea, 7=NPT, 6=RCT, 5=Newport NW = dual diagnosis is more common NW = dual diagnosis is more common

DATA Heroin was contributory in 47% of deaths Heroin was contributory in 47% of deaths Alcohol 24% Alcohol 24% Multiple Drug use 15% (NW = cocaine becoming more prevalent in toxicology reports) Multiple Drug use 15% (NW = cocaine becoming more prevalent in toxicology reports) Other notable substances included amphetamine (3), cocaine (3), ecstasy (3) and methadone (3) Other notable substances included amphetamine (3), cocaine (3), ecstasy (3) and methadone (3)

DATA Alcohol 1 in 4 deaths Alcohol 1 in 4 deaths Outside of remit of panels to review acute deaths directly related to alcohol Outside of remit of panels to review acute deaths directly related to alcohol Model could be used Model could be used

DATA Prescribed medication- lack of GP statements on inquest files Prescribed medication- lack of GP statements on inquest files Need to close this gap in order to understand role Need to close this gap in order to understand role 6 deaths – recent release from prison 6 deaths – recent release from prison 5 occurred within a three week period 5 occurred within a three week period

Near misses Not remit of group per se Not remit of group per se Need - collaborative approach/sharing information, audits, early warning cascades, care pathways from ambulance/casualty into treatment for patient and carers/families, take home naloxone pilots, police at scene etc. Need - collaborative approach/sharing information, audits, early warning cascades, care pathways from ambulance/casualty into treatment for patient and carers/families, take home naloxone pilots, police at scene etc. National Group could make recommendations on best practice National Group could make recommendations on best practice

Conclusions Gaps in information – need robust electronic surveillance system Gaps in information – need robust electronic surveillance system Engaging professionals Engaging professionals Engaging clients/patients Engaging clients/patients Engaging carers/families Engaging carers/families Fragmented treatment and communication between services Fragmented treatment and communication between services Prison Prison

Conclusions Work in progress – ‘All Wales Drug Related Deaths Register’ Work in progress – ‘All Wales Drug Related Deaths Register’ GP statements GP statements Action Learning Groups Action Learning Groups SM Action plans SM Action plans Welsh SM strategy – harm minimisation Welsh SM strategy – harm minimisation

Conclusions Early warning systems- map problem areas Early warning systems- map problem areas Police policy Police policy