“I am concerned that the CIWA protocol is something of a blunt instrument, not at all…”
Dated 3 Sep 2025, from the coroner for South Wales Central. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 29 Oct 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated3 Sep 2025
- Deadline29 Oct 2025
- Published on judiciary.uk16 Sep 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| National Institute for Health and Care ExcellenceNamed in the report as “National Institution for Health and Care Excellence” | Response publishedPublished on judiciary.uk in September 2025. |
The coroner’s concerns
(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
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0450
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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