Transcript regional audit

Drugs Related Deaths Systems
Audit
Heidi Douglas Specialty Registrar Public Health
Public Health England
Context: DRDs Preventable Deaths
• The majority of drug misuse deaths still involve opiates, in particular
heroin and methadone (56%),
• Increases in cocaine and amphetamine deaths and a marked increase in
mention of benzodiazepines among opiate deaths over recent years
• Opiate users had increased vulnerability to overdose because of using
drugs (including alcohol) in combination with opiates alongside
prescribed opioid substitutes.
• Compromised respiratory systems as a result of smoking related
diseases.
• The physical health of drug users in treatment is impacting on the
number of chronic DRDs, such as liver problems including hepatitis C
and alcohol-related cirrhosis.
ONS 2013 figures on deaths due to drug misuse
www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/2013/stb---deaths-related-to-drug-poisoning-2013.html
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DRDs in the North East
In England, the North East had the highest
mortality rate from drug misuse in 2013
with 52.0 deaths per million population
(England rate 33.9 deaths per million
population)
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ONS 2013 figures on deaths due to drug misuse
www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/2013/stb---deaths-related-to-drugpoisoning-2013.html
North East
Statistical Outlier?
65.0
rate per million population
55.0
45.0
35.0
25.0
15.0
5.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
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England
England Lower Confidence Limit
England Upper Confidence Limit
North East
North East Lower Confidence Limit
North East Upper Confidence Limit
DRD Systems Audit
Project brief:
To undertake a system’s based audit of the
confidential inquiry process undertaken to
review drug-related deaths (DRDs).
Geographical area:
12 local authority areas in the North East of
England
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Aims:
1. Provide a greater understanding of the current approach
to the confidential inquiry process into DRDs for each
local authority area in the North East and assess the
approach taken against national guidelines.
2. Use the audit findings to highlight any gaps and potential
strategic risks to delivery across the North East.
3. Identify opportunities of a North East approach and
highlight these findings as recommendations
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Re-audit to establish if
changes have affected
practice/outcomes
Identify areas of good
practice and highlight
evidence based
recommendations
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Data will include evidence of
systems (capture the
process of reporting,
monitoring and
characteristics of local
DRDs) and the narrative
(capture levels of partnership
working and implementation
of lessons learnt in strategic
planning)
NTA/PHE Guidance:
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The key stages in preventing a DRD, including the role of the confidential inquiry process
Review of literature
“What is the evidence
that confidential
inquiries/enquiries
prevent deaths or reduce
mortality”
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Review of literature
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•
Reduced mortality (Confidential Enquiry Maternal Deaths and National
Confidential Inquiry Suicide and Homicide)
•
Implementation of policies, understanding the role of human error and no
blame approach.
•
HTA: Using a framework to review the lessons learned (RCA) and in the
subsequent action plan (SMART), acknowledging the wider systems and
investing in training and change management.
•
Child death reviews: Prioritising the priorities, include those outside your
reach.
•
Identifying patterns and trends: Surveillance system or undertaking
thematic narrative reviews.
•
Evidence based approach: ensuring the use of NICE recommended
practices
•
Presence of substance misuse in other deaths and review processes
UAM survey 2014
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Results
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•
In February 2015 half (6) of the Local Authorities in the North East Region
ha an active DRD review process in place.
•
Three areas maintained a log of deaths but did not analyse these deaths
and the remaining 3 areas currently had no provision in place.
•
Two areas were actively reviewing their current process.
•
Ten areas had written protocols and policies 3/10 had policies that reflected
current practice.
•
Half of Local Authorities had the active engagement of the coroner in the
review process.
•
All 12 areas had a named coordinator, however it was acknowledged that
there were significant resource pressures and that the reconfiguration of the
former NTA and DAAT structures had resulted in the loss of organisational
memory within the Local Authority and that the previous NTA annual
reporting requirements for DRDs had maintained a focus on the DRD
review process.
Notification and Information Gathering
• One area conducted the review post coroner inquest
• 8/12 areas included DRDs not in treatment
• 5/12 areas included ARDs
• 4/12 areas included suspected suicides/ accidental ODs
(in treatment)
• 8/12 received notification from Services, 6/12 coroner
and 5/12 police.
• Half of areas gathered information to review
• 1 area gathered information and kept a log
• 4 areas discussed DRDs in routine meetings with
commissioned services
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Analysis and Lessons learned
• Focus was on improving treatment service.
•
There was no evidence that learning from near misses fed into the
DRD/ARD review process.
•
SUIs undertaken within the commissioned services were not routinely
shared.
Organisations Engaged in DRD/ARD reviews
Treatment services
Public Health
Probation
Police
Adult social care
Pharmacy
Coroner’s office
Mental Health Trust
NHS FT
Social Housing
Medicine Management
GP
Toxicology
Trading Standards
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Number
9/12
6/12
5/12
4/12
4/12
3/12
3/12
3/12
2/12
2/12
2/12
1/12
1/12
1/12
%
75%
50%
42%
33%
33%
25%
25%
25%
17%
17%
17%
8%
8%
8%
Governance
• The six areas that had an active DRD/ARD review
process all had an overarching governance structure to
which the work of the panel was reported.
• In 2/6 areas there was a direct line of accountability to
the DPH and the other 4 areas reporting to the Health
and Wellbeing boards as well as to Drug and Alcohol
Commissioning Boards.
• Five areas submitted their most recent annual report on
DRDs. Three of these reports were within the last 12
months and the other two were published in 2013.
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Good Practice
1. Good relationship with their local coroner
2. Engagement of local police both in terms or reporting a death and in the
review process
3. Most of these areas have incorporated alcohol related deaths and
suicides/accidental deaths into the review process
4. The review process and supporting documentation is regularly reviewed
and reflects current practice
5. Meet regularly (Bimonthly or quarterly)
6. Have nurtured positive relationships which has manifested into a culture on
no blame/fair blame and information sharing
7. All areas have formal confidentiality agreements and generally receive high
quality information back from services
8. All areas have a governance structure and a formal process of capturing the
lessons learned.
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Recommendations
1. There is a standard process and definition
2. That the review process is pre-coroner inquest
3. The definition includes alcohol related deaths and near misses
4. That the DPH is the accountable officer for the DRD/ARD review process. In
this role the DPH needs to be assured that there is a process in place that
meets local need.
5. There is an expectation that each Local Authority area writes an annual report
that includes statistical, demographical information alongside a forward action
plan and the key achievements from the previous year.
6. Any service improvements identified are evidence based and where appropriate
follow NICE guidance
7. There needs to be a concerted effort to move away from the sole focus on
lessons learned being only relevant to the treatment services. Although this is
an important area, more consideration needs to be given to early identification
and public health interventions that prevent ARDs/DRDs
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Actions:
Short-Term:
Standardising practice
Building relationships
Wider workforce
Undertake a thematic analysis at a regional level
Medium-Term:
Design a minimum data set for the North East
Re-audit (September 16)
Resource a regional alcohol or drug related mortality surveillance system.
Long-term:
Monitor the impact of public health interventions and service improvements on alcohol
or drug related mortality in the North East.
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