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Attendance Note

Person Attending:

Attendance Date: 22 January 2024 Nature of Attendance: Recording of Coroner’s Summing up Client/Matter Number:

Case Name:
- Inquest of Mr Glenn Lockwood

Welcome back and thank you for bearing with me. Apologies I took slightly longer and anticipated. These are my findings and conclusions for the purpose of the Inquest.

Mr Lockwood had a known history of opioid dependence, spanning at least the last ten years according to the evidence of the GP, probably significantly longer, given what his family have told me today.

He was engaged with drug treatment and support services prior to his hospital admission on 14 April 2023. He was prescribed opioid replacement therapy which was to be collected daily.

In addition the GP confirms that Mr Lockwood was diagnosed with anxiety disorder in February 2021 and depressed mood in December 2022. I ought to say at this stage that the anxiety disorder diagnosis does pre-date February 2021 but the reason it is recorded as that date on the record is because that was when first registered with that practice. Glen’s anxiety disorder was treated with Pregabalin which was last issued probably to Mr Lockwood on 5 April 2023 and the depressed mood was treated with Sertraline, also last issued on 5 April 2023.

The evidence suggests that Mr Lockwood’s Pregabalin prescription was first put in place as I have said, by his GP in Essex prior to his move to London in 2021. reviewed his Pregabalin prescription during a telephone consultation with Mr Lockwood on 9 March 2021. tells me that at this review it was agreed that Pregabalin would be added to Mr Lockwood’s repeat prescriptions because it appeared to control his anxiety symptoms well.

In August 2021 received correspondence from Reset Drug and Alcohol Service which set out Mr Lockwood has failed to collect his daily opioid replacement therapy for a number of days, and reported that he had reverted to using both heroin and crack on a daily basis. Reset advised the surgery to avoid “prescriptions of other opioid based medications without liaison with their team and to be cautious when prescribing other medications which may have potential for interaction as well care with regard to other medicines with potential for misuse”.

Mr Lockwood’s next review took place on 15 December 2021 and no changes appear to have been made to his medication. tells me that Mr Lockwood continued to request his prescriptions for Pregabalin on a monthly basis which were issued accordingly. No additional contact was made with the Practice by Glenn for a number of months.

On 24 June and 1 July 2022, the Practice attempted to contact Mr Lockwood by telephone to invite him to attend an annual routine substance misuse review. Mr Lockwood did not answer either call but a voicemail was left for him on each occasion. In addition a follow-up text message was sent to him on 1 July 2022.

On 12 July 2022 the Practice received an Accident and Emergency discharge summary. Essentially Glenn had been treated with antibiotics for cellulitis following an attempt to inject himself with but missing the vein in his leg.

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Glenn was seen in Accident and Emergency again on 22 September 2022 for a further episode of cellulitis with the lower limb, and a further course of antibiotics was prescribed. The Practice attempted to contact Glenn again on 24 October 2022 to invite him to a substance misuse review. There was no response on the voicemail that was left.

The Practice received further correspondence from Reset on 3 November 2022. The letter set out that Glenn had attended for an in-person review the previous day, when a plan was put in place to restart his Methadone because he had failed to engage previously, and the prescriptions had been withdrawn. The letter also confirmed that a mental health risk assessment had been conducted and there were no reported thoughts of self-harm or suicide.

Glenn attended the Practice on 7 December 2022 having requested a routine appointment. During that appointment Glenn reported feeling withdrawn, suffering from social anxiety and experiencing poor sleep. He disclosed at that appointment the smoking of cannabis and using heroin regularly albeit, he said, at lower levels than he had used in the past, because he was now receiving Methadone from Reset once more.

I am told by that his Pregabalin was increased at that point to milligrams twice daily. He did not report any thoughts of suicide or self-harm.

Glenn attended a follow-up appointment with on 26 January 2023. During this appointment there appears to have been a degree of confusion about the level of Pregabalin that Mr Lockwood ought to have been taking. states “It was agreed to change this to

milligrams three times daily, instead of going straight back to 300 milligrams twice daily. I was concerned regarding managing his ongoing anxiety yet I would not want him to risk issuing surplus medication to a patient with potential for misuse.”

At the same appointment also commenced Glenn on a prescription of milligrams of Sertraline an anti-depressant. This was the last time that Glenn was seen in the Practice despite continued efforts to engage him. However a number of prescriptions I am told continued to be requested and issued by the Practice. Exactly what was issued is not clear despite the fact that the Practice undertook a serious event analysis. Further correspondence from the Practice appears to accept that there is some confusion and that the notes are not clear, and that a further serious event analysis is required.

In February 2023 Glenn was taken to Accident and Emergency by the police, following an overdose of Temazepam and Diazepam. Following a period of observation Glenn was discharged, and the discharge summary sent to the Practice confirmed that Mr Lockwood had no suicidal thoughts at that time. Neither of these medications were prescribed to Glenn at the time.

Reset have confirmed in the report to me that Glenn had missed three consecutive Methadone doses in February 2023. Following this he did attend a face-to-face medical restart appointment with at Reset on 11 April 2023. At that appointment he reported using approximately grams of daily. He also told that his recent hospital admission for a drug overdose was the result of an accidental overdose. A urine drug screening test was conducted by and Glenn tested positive for opiates,

commenced Glenn on an initial daily Methadone prescription of millilitres on daily supervised consumption, to be increased over time to millilitres per day.

I find that there is clear evidence that Mr Lockwood’s engagement with his GP and Reset Addiction Service was somewhat sporadic. However, I note that there is no evidence to suggest that Glenn lacked mental capacity, and as such he was in entitled to make decision not to engage in treatment, even if those decisions later seemed unreasonable to others.

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Another thing that is clear both from the medical evidence and from Glenn’s own disclosures during appointments, is that throughout 2022 and up to the time of his last admission to hospital in April 2023, Glenn had clearly relapsed into the misuse of drugs. Those appear to have included more usual drugs for want of a better way of putting it, as well as illicitly obtained medication, that was ordinarily prescription only, such as the Diazepam referred to earlier.

of the Royal London Hospital confirms that Glenn was brought to Accident and Emergency on 14 April 2023 having been found unresponsive on the platform of Westferry DRL station. He was treated for a suspected heroin overdose and moved to a ward on the eleventh floor.

states the treatment seems to improve Mr Lockwood’s condition, and his condition improved further overnight. confirms that Mr Lockwood was seen by doctors on up to five separate occasions during this short admission. But despite this Mr Lockwood sought to discharge himself from hospital on the basis of having been in hospital for 24 hours without having seen a doctor. I have been provided with a copy of the self-discharge documentation signed by Glenn. As set out by , Glenn wrote words to the effect that he wanted to self-discharge because he needed to go to the pharmacy and because he had not been seen by a doctor for 24 hours. He reportedly says that he would return to A&E if his chest worsened. But the evidence from

is clear that there is no question had not been seen by doctors. Indeed, there is clear evidence that at least three separate doctors had seen Glenn numerous times throughout that short admission.

I then move on to the events of 16 April 2023 which is when for a short time at least the evidence becomes much less clear. What is clear from the London Ambulance Service records is that a 999 call was made regarding Glenn on the afternoon of 16 April 2023, and the call was connected at 13:41. On arrival of the ambulance at 13.47 paramedics were met by someone who purported to be a friend of Glenn. The London Ambulance Service documentation advises of the telephone number from which the 999 call was made. However during the course of my investigation I have not been able to identify who made that call, because the number relates to an unregistered mobile telephone which was confirmed in the evidence of , the Coroner’s Officer.

The response time of the ambulance on that occasion is documented at less than six minutes, which is well within the target response time set for Category 1 lift threatening emergencies. I mention this simply because it answers one of the questions that you the family had asked me to consider.

Whoever the mystery friend with Glenn was, they stayed with him and commenced CPR as per the instructions provided by the London Ambulance Service call handler. It was evident that the numerous paramedics that attended Mr Lockwood worked tirelessly for well over an hour to attempt to resuscitate, stabilise and convey Glenn to hospital.

The further curious matter which needs to be mentioned at this stage is that the paramedics noted that Glenn’s temperature was 27.2⁰ Celsius and he was therefore hypothermic. However, he was noted to be in a warm environment and in appropriate clothing. As far as the paramedics were concerned there was no obviously clinical answer as to how Mr Lockwood’s temperature had dropped to such a level. Unfortunately, having been unable to identify the potential witness to this fact, I cannot offer a definitive answer to that point either. I note that initial documentation provided a suggestion that Glenn’s friend found him outside and then took him back inside before calling an ambulance. While this is possible, and it is also possible that Mr Lockwood collapse may have taken place elsewhere, I can make no formal finding in that regard in the absence of any reliable evidence. I also note the mismatch in the evidence between what paramedics were told by the mystery friend, and the view of about the overdose that led to the hospital admission on 14 April 2023. The friend appears to have told paramedics that Glenn had overdosed on Pregabalin, whereas worked on the assumption that it had been a heroine overdose.

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On balance I consider that it is most likely to have been a heroin overdose. This is because

is clear that three doses of Naloxone were administered to seeming good effect, and I bear in mind that Naloxone had previously been provided to Glenn by Reset to self-administer in the event of accidental overdose, it being an antidote to opiates such as heroin.

In terms of Glenn’s admission at Royal London Hospital thereafter, I consider that there is little for me to say. The medical evidence sets out in clear terms that Glenn’s prognosis was not good from the outset, due to the length of time he was in cardiac arrest. He was showing clinical signs of hypoxic brain injury. Essentially following some improvement an attempt was made by the Adult Critical Care Unit to extubate Glenn but he was not able to sustain independent breathing at that time.

Further medical and neurological reviews came up with the possibility of inserting a tracheostomy. However, family concerns and subsequent medical concerns regarding Glenn’s minimally conscious state was such that the medical decision was made with the support of Glenn’s family that tracheostomy procedure should not be attempted. The decision was taken again with the support of Glenn’s family to extubate him and place him on a palliative care pathway.

Glenn sadly died on 2 June 2023.

conducted the post-mortem examination on behalf of the Coroner and also undertook numerous toxicological tests including the taking of hair samples. offers a proposed medical cause of death in the following terms: -

1a – hypoxic brain injury, multiple organ failure and bronchopneumonia following cardiac arrest. 1b – mixed drug toxicity.

The proposed cause of death, if accepted, would mean that the underlying cause of Mr Lockwood’s death was mixed drug toxicity.

Given the lack of direct evidence to suggest that Mr Lockwood took any form of drug in the relatively brief period after his self-discharge from hospital on 15 April 2023, this is something I have considered particularly carefully to avoid jumping to conclusions.

was able to exclude traumatic injury as a cause of the hypoxic brain injury. He also notes that on examination Glenn’s myocardial damage “did not appear to be due to significant coronary artery atheroma”. In addition, he notes that cocaine can be a known cause of myocardial fibrosis. report continues “Toxicology reveals that Mr Lockwood had taken several compounds during the six months leading up to his death, with heroin and cocaine at levels associated with heavy use. Opiates can produce collapse or indeed fatality if taken in sufficient quantity due to severe respiratory depression/respiratory arrest. Cocaine can cause cardiac arrest or sudden death irrespective of its concentration.”

is clear that the hypoxic brain injury, multiple organ failure and bronchopneumonia all developed as a result of the cardiac arrest. He concludes in light of the toxicology results “It is therefore more likely than not that drug use and subsequent toxic effects are responsible for the cardiac arrest, either directly on the vital controlling centres of the brain, or indirectly via an action on the heart or coronary artery”.

I see no reason to question the logic and medical reasoning employed by and therefore accept his proposed cause of death. In doing so I have additionally borne in mind Mr Lockwood’s self-discharge the day before his cardiac arrest in which he wrote of his need to go to the pharmacy. This indicates that having spent approximately 24 hours in hospital, Glenn was likely experiencing withdrawal from opiates and wishing to obtain his methadone prescription and

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possibly take other substances which by his own admission a few days earlier at the Reset appointment, on 11 April 2023, he was taking on a daily basis.

Turning then to the formal Record of Inquest I record as follows: -

Box 1: Name of the deceased: Glenn Anthony Lockwood. Box 2: Medical cause of death –

1a. Hypoxic Brain Injury, multiple organ failure and bronchopneumonia following cardiac arrest. 1b. mixed drug toxicity.

Box 3: How, when and where the deceased came by their death: Glenn Lockwood was admitted to hospital on 14 April 2023 following a suspected heroin overdose. On 15 April 2023 he self-discharged from hospital against medical advice. On 16 April 2023 Mr Lockwood had an out of hospital cardiac arrest. He was admitted to the Royal London Hospital and despite treatment he died in hospital on 2 June 2023.

Box 4 – Coroner’s conclusion as to death: Drug related death.

Finally, I considered whether my duty to issue a report aimed at preventing future death is engaged. In my view it is. I will be issuing a report to the Limehouse Practice on the basis that the evidence of their Serious Event Analysis provides insufficient reassurance that practices and procedures surrounding the prescribing and documentation of medication to patients has been sufficient addressed.

You as a family will also be provided with a copy of my report. The law also states that the Practice has 56 days to respond to the report.

That concludes the Inquest and all that remains if for me to offer you my sincere condolences for your loss.

Dear Mr Potter, Regulation 28 Report to Prevent Future Deaths I write on behalf of the partners of the Limehouse Practice to respond to your Prevention of Future Deaths Report dated 17 November 2023. Firstly, the partners and I would like to offer our condolences to Mr Lockwood's family following his sad death. The Limehouse Practice serves a population of around 11,500 patients in Tower Hamlets, looking after a diverse group of patients, with high rates of poor mental health and often facing significant economic adversity. A particular characteristic of the practice is that it also serves a large number of hostels, including the largest women's hostel provision in the borough, as well as a refuge for south Asian women, a supported living facility supporting adults with learning difficulties. Several other hostels within the Practice area provide accommodation for a large number of adults with high rates of substance misuse, a history of trauma and adversity, and facing poor mental health and psychosocial challenges. As a Practice we have worked for many years along with the local drug and alcohol service to provide excellent care for our patients who face difficulties with drug and alcohol use. The experience of the partnership and team at the Limehouse Practice supports this work. Opiate substitute treatment is only prescribed by doctors within the practice who have completed at least part 1 RCGP substance misuse training, and this is something we encourage all doctors at the Practice to achieve. We operate a personal list system and each prescribe opiate substitute therapy to the patients on our own list to ensure continuity or care. We also believe the continuity of personal lists assists in the safe management of high risk and complex patients within the Practice. We also have a substance misuse key worker employed by RESET, the local drug and alcohol service, who operates a satellite clinic at the Practice. We only prescribe opiate substitute therapy to patients as part of shared care with RESET. We have 2 network employed pharmacists based at the Practice who have supported us in monitoring high risk drug prescribing, including prescribing of drugs with a potential for abuse. There are four partners and four salaried GPs at the Practice. Three of the partners are GP trainers and also have other roles outside the Practice. I have a special interest in alcohol and

THE LIMEHOUSE PRACTICE

GILL STREET HEALTH

11 GILL STREET, LONDON E14 8HQ TEL: 020 7515 2211 mEMAIL: THCCG.limehouse@nhs.net substance misuse, having completed part 1 and 2 RCGP substance misuse training. I am the locality lead for primary care drug and alcohol management, supporting local practice teams in managing patients with drug and alcohol problems and providing physical health checks for this vulnerable patient group. I also train GPs and other primary care team members in alcohol management in primary care as an approved alcohol trainer for the RCGP. We note that the conclusion of the inquest was that Mr Lockwood's death was a drug related death, the medical cause of death being: 1 a - hypoxic brain injury, multiple organ failure and bronchopneumonia following cardiac arrest. 1 b - mixed drug toxicity. We also understand that you found that the overdose that led to Mr Lockwood's admission to hospital on 14 April 2023 was like to have been a heroin overdose. We have and continue to consider the concerns raised seriously and respond to the two concerns raised and summarised below:
1. That the evidence you received during the inquest did not reassure you that sufficient steps were taken for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse.
2. The statement from Mr Lockwood's named GP alluded to the fact that there were possible record keeping issues surrounding Mr Lockwood's prescriptions for Pregabalin. A Serious Event Analysis (SEA) was conducted but, as there were errors in the original SEA, we decided that the SEA needed to be re-opened and revisited. You were not reassured that the relevant risks have been fully explored and acted upon. We have undertaken a further SEA, and this has been completed with agreed actions. Prescription of Pregabalin and monitoring for signs of abuse: We are aware of the recommendation in the British National Formulary that Pregabalin should be monitored for signs of abuse. All patients have medication reviews and those patients who are known to have problems with substance misuse are be invited to have an annual substance misuse health check which would involve physical health checks carried out by an HCA/ nurse followed by a comprehensive review of physical and mental health by the registered GP. We were aware of the recommendations made by CGL (the drug treatment provider at the time) in August 2021 that care should be taken when prescribing other medications for Mr Lockwood that may have misuse potential, for example Pregabalin. Since prior to registering at the Practice in 2021, Mr Lockwood had been receiving a prescription of Pregabalin, which was issued at 4 weekly intervals. This continued with the knowledge and recommendation of RESET, who were ma·naging the patient's substance misuse including prescribing him methadone. Until December 2022, Mr Lockwood continued to receive prescriptions for Pregabalin at four weekly intervals when the duration was changed to two weekly. There had been no previous incidences of early requesting of Pregabalin, or concerns that the patient was misusing or over- using this medication.

THE LIMEHOUSE PRACTICE

GILL STREET HEAL TH CENTRE 11 GILL STREET, LONDON E14 8HQ TEL: 020 7515 2~11 EMAIL: THCCG.limehouse@nhs.net Between December 2022 and 26 January 2023 there were further reviews of the Pregabalin. In December 2022 Mr Lockwood was reviewed and he reported increased anxiety symptoms. The GP suggested this dose increase as a response to Mr Lockwood's reported increased anxiety. The dose is within the BNF recommended ranges, and this medication was prescribed for anxiety, one of the licenced indications for this drug. This does therefore seem a reasonable course of action. That doctor reduced the length of the prescription to two weeks instead of the
- usual four weeks. There was a mistaken concern on 17 January 2023 that Mr Lockwood had requested the prescription for Pregabalin early (after two weeks rather than four weeks). It would be · appropriate to reject any ~rescription, particularly for a controlled drug or a drug with potential for addiction, if this is requested early, to avoid the patient over-using and being exposed to the risks of overdose. This would have been in accordance with the recommendations of CGL in August 2021 to monitor for signs of abuse. As we have identified in the SEA, between 17 January 2023 and 26 January 2023 three doctors were involved in reviewing and altering the prescription for Pregabalin with a view to reducing the tablet burden and address the reported increasing anxiety. Unfortunately, there was some confusion and lack of clarity about the prescribing (which I will deal with further below). After 26 January 2023 Mr Lockwood was not seen face to face again at the Practice prior to his death on 2 June 2023, although the Practice made 4 attempts to contact him to invite him (on three occasions for a substance misuse health check, which would involve physical health checks carried out by an HCA / nurse followed by a comprehensive review of physical and mental health (including an assessment of abuse of the medication) by the registered GP, and on one occasion to invite him for immunisation) in the intervening period. He did continue to receive his Pregabalin prescriptions at regular 4 weekly intervals. We were also made aware that Mr Lockwood had been admitted to hospital on 16 February 2023 having taken an overdose of clonazepam and diazepam. We attempted to contact Mr Lockwood on 24 February 2023 and 6 March 2023 but the phone did not connect. Record keeping issues As part of the SEA we have established that the reasons for the change in the dose and the frequency of the prescription of Pregabalin between December 2022 and January 2023 was not clearly documented in the records meaning that there was an element of confusion for both the reviewing GPs and, most likely, Mr Lockwood. Action taken by the Practice As set out in the SEA we have taken the following steps to address the concerns which you have identified:
1. We will ensure 3 monthly face to face reviews for patients on Pregabalin, gabapentin, benzodiazepines, oxycodone and other dependence inducing medications.
2. We are carrying out a search to identify all patients on Pregabalin/ diazepam or similar medications who are also prescribed opiate substitute treatment, either at RESET or in shared care. We will carry out a medication review for those patients and discuss with RESET and

THE LIMEHOUSE PRACTICE

GILL STREET HEALTH

11 GILL STREET, LONDON E14 8HQ TEL: 020 7515 2211 EMAIL: THCCG.limehouse@nhs.net the possibility of them prescribing of opiate substitute medication as well as other medications with potential for dependence if appropriate.
3. If any changes are made in doses of medication or tablet strength, this must be documented in EMIS consultation notes so there is a clearly identifiable rationale for any change. Patients should also be notified of any change in drug dosage / tablet strength.
4. Protected Learning Time is to be used to provide refresher training to all prescribers about EMIS prescribing function and how to view previous medication issues/ amendments, as well as further training on prescribing drugs with potential for dependence. I have contacted the CGL/RESET consultant and am awaiting a response from them about agreeing a date for training.
5. All prescribers to undergo further training on prescribing drugs with potential for dependence. Unfortunately, we did not receive any further information from the hospital or notification of Mr Lockwood's death until a letter dated 30 June 2023 was received from the Senior Coroner's officer on 3 July 2023. At that stage we were unaware of the medical cause of death to allow us to consider arranging for an SEA to be carried out. We only received details of the medical cause of death following the conclusion of the inquest. We have taken steps to ensure that requests for reports and correspondence with the Coroner's office are brought to the attention of the partners so that we can ensure that all matters relevant to the Coroner's investigation and inquiry are dealt with and that, where appropriate, we can arrange for an SEA to be undertaken in a timely manner. I hope this information provides you with reassurance that your concerns about the risk of future deaths have been addressed.

GP Partner & on behalf of:
- GP Partner
- GP Partner
- GP Partner