Laurence Boyens

1. 1. lack of compliance with DH guidelines on blood pressure monitoring before methadone administration

   “There appeared to be a general misunderstanding how health care professionais should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4 b. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.”

2. 2. failure to escalate abnormal blood pressure readings

   “Nurse | was called during the course of the inquest, and although given the opportunity, did not have legal representation in the proceedings. The evidence from a himself that caused concern included: e Ablood pressure of 93/58 was not a worry to be brought to the attention of a doctor.”

3. 3. omission of blood pressure recording before methadone administration

   “Nurse BM was called during the course of the inquest, and although given the opportunity, did not have legal representation in the proceedings. The evidence from Nurse [herself that caused concern about risks to future patients included: e She did not record a BP at 18.35 on 10th, or at 09.25 on 11th, prior to administration of Methadone.”

4. 4. inadequate patient assessment before prescribing multiple psychotropic drugs

   “MEE was represented at the inquest and the following evidence gave rise to concerns: ¢ He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison”

Linked reports