“That clinicians, wishing to believe their patients, are relying too heavily on what…”

The coroner’s concerns

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. 6 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 for near patient testing to allow a clinician to better assess a patient showing signs of intoxication.

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, 2024-0120

Added to Minute Book

8 Oct 2026

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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