Oliver Winson
PFD Report
All Responded
Ref: 2024-0699
All 2 responses received
· Deadline: 14 Feb 2025
Sent To
Response Status
Responses
2 of 1
56-Day Deadline
14 Feb 2025
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provided details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time, as at the time of his death Mr Winson had been waiting for four years. I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country. It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment, their condition is not monitored and there is a risk as with Mr Winson, that their condition may deterioration or lead to risk or harmful behaviour and death.
Responses
NHS England acknowledges extensive national waiting lists for adult ADHD services and the medication shortages, referring to 2023 national guidance for Integrated Care Boards on improving access. They mention ongoing work with the Department of Health and Social Care to manage medication supplies, noting most ADHD medicine availability has been restored.
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Oliver James Winson who died on 10 June 2024
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 December 2024 concerning the death of Oliver James Winson on 10 June 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Oliver’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Oliver’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Oliver’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them. Your Report notes that, despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country. You raised the concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD remain on significantly lengthy waiting lists, during which time they are not receiving treatment, their condition is not monitored and there is a risk that their condition may deteriorate or lead to risk or harmful behaviour and death.
NHS England are aware that there are extensive waits for ADHD services nationally, including for assessment of ADHD. The number of people requesting assessments for attention deficit hyperactivity disorder (ADHD) has grown exponentially in recent years, with the number of adults waiting for a first appointment doubling each year since 20181.
We recognise that those awaiting support for ADHD might have other conditions which may be impacted by their ADHD symptoms, and that those with ADHD are at higher risk of a range of adverse outcomes, including substance abuse disorder, suicide and accidental death compared with those without ADHD.
1 Darzi Report National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
27 February 2025
ADHD services are a complex landscape. They are commissioned locally by Integrated Care Boards (ICBs) with significant national variation existing in pathways and provision, including independent sector providers operating under the Right to Choose framework.
Considering the challenges being reported about ADHD services, NHS England undertook a rapid review in December 2023. This identified several key areas of work in relation to ADHD which are now underway, including improving available data, developing resources to support commissioners in improving the quality and consistency of ADHD services nationally, and facilitating the sharing of information, innovation and good practice. NHS England has also convened the independent ADHD Taskforce, which works cross-sector to understand more about the issues impacting those with ADHD and their families, and how service provision can be better joined up to meet people’s needs, including access to early support. It is increasingly recognised that ADHD is not solely a health concern, and that a cross-sector approach is needed to effect change.
NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD, including exploring opportunities to:
• Revise information on ADHD available to patients, families and carers via the nhs.uk website, the NHS’s primary patient information resource (led by NHS England, anticipated February 2025).
• Standardise pathways to improve consistency and transparency for those with ADHD, their families and carers.
• Expand the scope of existing care pathways to offer greater support for those with ADHD, their families and carers. This may include pre-diagnostic or ‘waiting well’ support, which focuses on what can be done to support the individual ahead of assessment and/or diagnosis.
• Move to a needs-based approach, which focuses on understanding the specific challenges an individual is facing, ensuring they receive the most appropriate support for those challenges. This might include support outside of health services, such as at school or in the workplace.
Your Report also referred to there being a shortage of medication for those patients who have been diagnosed with ADHD. NHS England works closely with the Department of Health and Social Care (DHSC), who are responsible for medication supplies in England. NHS England has developed specific guidance for systems, shared via the Specialist Pharmacy Service, to support the system response to the medication shortages. At this time, the availability of most medicines used to treat ADHD has been restored, though there remains some disruption to supplies of methylphenidate prolonged-release capsules and tablets2.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are
2 Prescribing available medicines to treat ADHD – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice
discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Oliver, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 December 2024 concerning the death of Oliver James Winson on 10 June 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Oliver’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Oliver’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Oliver’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them. Your Report notes that, despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country. You raised the concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD remain on significantly lengthy waiting lists, during which time they are not receiving treatment, their condition is not monitored and there is a risk that their condition may deteriorate or lead to risk or harmful behaviour and death.
NHS England are aware that there are extensive waits for ADHD services nationally, including for assessment of ADHD. The number of people requesting assessments for attention deficit hyperactivity disorder (ADHD) has grown exponentially in recent years, with the number of adults waiting for a first appointment doubling each year since 20181.
We recognise that those awaiting support for ADHD might have other conditions which may be impacted by their ADHD symptoms, and that those with ADHD are at higher risk of a range of adverse outcomes, including substance abuse disorder, suicide and accidental death compared with those without ADHD.
1 Darzi Report National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
27 February 2025
ADHD services are a complex landscape. They are commissioned locally by Integrated Care Boards (ICBs) with significant national variation existing in pathways and provision, including independent sector providers operating under the Right to Choose framework.
Considering the challenges being reported about ADHD services, NHS England undertook a rapid review in December 2023. This identified several key areas of work in relation to ADHD which are now underway, including improving available data, developing resources to support commissioners in improving the quality and consistency of ADHD services nationally, and facilitating the sharing of information, innovation and good practice. NHS England has also convened the independent ADHD Taskforce, which works cross-sector to understand more about the issues impacting those with ADHD and their families, and how service provision can be better joined up to meet people’s needs, including access to early support. It is increasingly recognised that ADHD is not solely a health concern, and that a cross-sector approach is needed to effect change.
NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD, including exploring opportunities to:
• Revise information on ADHD available to patients, families and carers via the nhs.uk website, the NHS’s primary patient information resource (led by NHS England, anticipated February 2025).
• Standardise pathways to improve consistency and transparency for those with ADHD, their families and carers.
• Expand the scope of existing care pathways to offer greater support for those with ADHD, their families and carers. This may include pre-diagnostic or ‘waiting well’ support, which focuses on what can be done to support the individual ahead of assessment and/or diagnosis.
• Move to a needs-based approach, which focuses on understanding the specific challenges an individual is facing, ensuring they receive the most appropriate support for those challenges. This might include support outside of health services, such as at school or in the workplace.
Your Report also referred to there being a shortage of medication for those patients who have been diagnosed with ADHD. NHS England works closely with the Department of Health and Social Care (DHSC), who are responsible for medication supplies in England. NHS England has developed specific guidance for systems, shared via the Specialist Pharmacy Service, to support the system response to the medication shortages. At this time, the availability of most medicines used to treat ADHD has been restored, though there remains some disruption to supplies of methylphenidate prolonged-release capsules and tablets2.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are
2 Prescribing available medicines to treat ADHD – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice
discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Oliver, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
The Royal Pharmaceutical Society (RPS) highlighted its November 2024 report, 'Medicines Shortages: Solutions for Empty Shelves,' which addresses ADHD medicine shortages and makes recommendations to the UK Government. The RPS will continue to raise awareness and engage with professional bodies on these issues.
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Dear Ms Samantha Goward,
RE: Regulation 28 Prevention of Future Death Report for Mr Oliver James Winson, deceased.
We are writing to you regarding the report into the death of Mr Oliver James Winson dated 20th December 2024. We would like to express our sincere condolences to the family of Mr Winson.
The Royal Pharmaceutical Society (RPS) is the professional leadership body for pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. Our role is to lead and support development of the pharmacy profession including the advancement of science, practice, education and knowledge in pharmacy. We transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 2010 and they now regulate pharmacy and pharmacy professionals in Great Britain.
The RPS has taken the opportunity to write to you regarding this Prevention of Future Death report (PFD), as we believe that any PFD reports published involving pharmacy and the pharmacy profession should be responded to, to allow any learning to be shared more widely and help to prevent future deaths.
The RPS in November 2024 published a report entitled Medicines Shortages: Solutions for Empty Shelves, which articulates some of the concerns raised in your report (in relation to the national shortage of ADHD medicines), and through the
implementation of some of the recommendations for collaborative action, may help to address them. The Report is a culmination of extensive engagement and collaboration with patients, the pharmacy profession, wider healthcare professionals and the key local, regional and national stakeholders integral to ensure the continuity of medicines supply. The RPS Report and its recommendations have been presented to UK Government bodies during November and December 2024.
There is growing concern about the impact of medicines shortages on patient care in the UK. All medicines shortages have the potential to raise concerns for patient safety. Through the engagement and research phase of the RPS Medicines Shortages project, together with feedback from our members, we know this is having a significant and distressing impact on patients and professionally frustrating for pharmacists who want to see patients get the best care they can.
Patient safety concerns are multifactorial with medicines shortages. These issues are explored in detail in our Medicines Shortages Report following a comprehensive assessment of what is causing medicines shortages, their impact on patients, pharmacists and healthcare professionals and what more can be done to mitigate and manage medicines shortages.
Thank you for highlighting your concerns in this prevention of future death report. We will consider how we can continue to raise awareness of these important issues through our future communications and engagement with the wider pharmacy sector. We will also raise these issues with our colleagues at the professional and representative bodies for pharmacy as they also play an important role in providing advice and support to the pharmacy professions.
Should you require any further information on the RPS Medicines Shortages Report please contact Alwyn Fortune, Policy Lead for the Medicines Shortages work, via email Alwyn.Fortune@rpharms.com
RE: Regulation 28 Prevention of Future Death Report for Mr Oliver James Winson, deceased.
We are writing to you regarding the report into the death of Mr Oliver James Winson dated 20th December 2024. We would like to express our sincere condolences to the family of Mr Winson.
The Royal Pharmaceutical Society (RPS) is the professional leadership body for pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. Our role is to lead and support development of the pharmacy profession including the advancement of science, practice, education and knowledge in pharmacy. We transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 2010 and they now regulate pharmacy and pharmacy professionals in Great Britain.
The RPS has taken the opportunity to write to you regarding this Prevention of Future Death report (PFD), as we believe that any PFD reports published involving pharmacy and the pharmacy profession should be responded to, to allow any learning to be shared more widely and help to prevent future deaths.
The RPS in November 2024 published a report entitled Medicines Shortages: Solutions for Empty Shelves, which articulates some of the concerns raised in your report (in relation to the national shortage of ADHD medicines), and through the
implementation of some of the recommendations for collaborative action, may help to address them. The Report is a culmination of extensive engagement and collaboration with patients, the pharmacy profession, wider healthcare professionals and the key local, regional and national stakeholders integral to ensure the continuity of medicines supply. The RPS Report and its recommendations have been presented to UK Government bodies during November and December 2024.
There is growing concern about the impact of medicines shortages on patient care in the UK. All medicines shortages have the potential to raise concerns for patient safety. Through the engagement and research phase of the RPS Medicines Shortages project, together with feedback from our members, we know this is having a significant and distressing impact on patients and professionally frustrating for pharmacists who want to see patients get the best care they can.
Patient safety concerns are multifactorial with medicines shortages. These issues are explored in detail in our Medicines Shortages Report following a comprehensive assessment of what is causing medicines shortages, their impact on patients, pharmacists and healthcare professionals and what more can be done to mitigate and manage medicines shortages.
Thank you for highlighting your concerns in this prevention of future death report. We will consider how we can continue to raise awareness of these important issues through our future communications and engagement with the wider pharmacy sector. We will also raise these issues with our colleagues at the professional and representative bodies for pharmacy as they also play an important role in providing advice and support to the pharmacy professions.
Should you require any further information on the RPS Medicines Shortages Report please contact Alwyn Fortune, Policy Lead for the Medicines Shortages work, via email Alwyn.Fortune@rpharms.com
Report Sections
Investigation and Inquest
On 20 June 2024 I commenced an investigation into the death of Oliver James WINSON aged 33. The investigation concluded at the end of the inquest on 19 December 2024. The medical cause of death was: 1a) Cocaine Toxicity The conclusion of the inquest was: Drug related
Circumstances of the Death
Oliver Winson was a 33 year old man who had a history of drug misuse and he was under the care off substance misuse services since December 2013. He had previously been diagnosed with a mixed anxiety and depressive disorder for which he was prescribed medication. In 2017 he was referred to the adult ADHD (attention deficit hyperactivity disorder) service as his GP was concerned that his attention span was limited, and he had become quite hyperactive. In a response to a request for further information, his GP confirmed that Mr Winson had been concerned for many years about his low attention span and found it difficult to concentrate and there were concerns that this might point to hyperactivity and drug related behaviour. He had a history of impulsive behaviour, and this led to a risk of him becoming aggressive and a risk of going back to significant drug abusing behaviour. The GP felt that he was at quite a high risk of significant harm to himself in the long run if he was not diagnosed and managed appropriately. As Mr Winson was under the care of the drug and alcohol service it was felt that someone in that team could see him so the referral was not accepted at that time. However, the service misuse team referred Mr Winson back to the mental health Trust on 19th June 2020 for an adult ADHD undiagnosed assessment. They confirmed that he had been abstinent from drugs for four to five years and was on daily methadone. The adult ADHD service said they would accept the referral on to the undiagnosed wait list but indicated he should remain abstinent from drugs to benefit from the service. At that time, it was indicated that the waiting list was likely to be in the region of two years. The substance misuse service regularly sought updates on the waiting list and were advised that this was very lengthy due to unprecedented referrals and that the COVID pandemic had also impacted on this. By May 2023 when seeking an update, the service raised the concern that it had taken five years and a lot of hard work for Mr Winson to get to the point that he was at and that they were concerned that his historic drug use was chaotic, and he was at risk of death by overdose. Sadly, Mr Winston did relapse into drug use and on 10th June 2024 police were called to his home address where he was found deceased and toxicology evidence confirmed drug use prior to death and that death was as a result of cocaine toxicity.
Copies Sent To
Norfolk and Suffolk NHS Foundation Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.