The Benefits of a Regional Collaborative Drug Related Death Review and Surveillance System: Insights From Implementation in the North West of England

Author: Howard Reed

Theme: Models of Care Year: 2022

Drug related deaths (DRD) are a major public health issue, and have been increasing in many
countries including the UK. In England and Wales, DRD are at their highest level since records began
in 1993, with deaths from overdose being prominent. In response, the nineteen local authorities
across Cheshire, Merseyside, and Greater Manchester, in the North West England, established a DRD
review process in order to explore common themes, identify recurring issues and share findings.
Description of model of care/intervention:
The system follows national recommendations for good practice; reviews all deaths of individuals in
drug treatment, not just those officially classified as DRD; and engages the coroner and nontreatment agencies in the review process. DRD monitoring is coordinated by the Public Health
Institute (PHI), who collate information from sources including: service-led internal reviews; the
monitoring of drug treatment (NDTMS), needle and syringe programmes (IMS); social services and
coroner records. When a death occurs, it is logged on to the system by either the drug treatment
service or the local coroner via PHI.
Public Health commissioners are automatically alerted that a death has occurred, so that they are
able to access the record of the death prior to quarterly stakeholder panels. These panels review and
scrutinise the cases and identify learning opportunities. The system has examined over 2,000 cases
to date and has informed improvements to patient care, including: the development of new care
pathways involving specialist services such as respiratory and palliative care; exploring medicines
management; and focusing on disguised compliance, whereby individuals who appear well engaged
with addiction treatment may be masking underlying drug use.
Conclusion and next steps:
A collaborative system involving multiple local authorities ensures learning across areas and
stakeholder sectors and also economies of scale. Synthesis summaries to improve cross-learning are
being developed.
Disclosure of Interest Statement:
This work was commissioned and funded by the public health teams within 19 Local Authorities
covering the UK areas of Cheshire, Merseyside, and Greater Manchester.

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