A mental health patient was prescribed methadone as part of a care plan at Farmfield Hospital in Horley, Surrey, an Inquest heard, and this led to the death of the 37-year-old man. The Inquest concluded that a series of failings amounted to neglect, which was a contributory factor in the patient’s death.

Ricky Keenan lived in Sheffield and was a former labourer who was diagnosed with a schizoaffective disorder in 2015. In 2021 he became heroin dependent and was put on an opiate substitution treatment in November 2021, which continued until the following March. He was admitted to Accident & Emergency in Sheffield on 16th August 2022 after an acute psychotic episode, assessed under the Mental Health Act and placed under S2 detention. During this assessment there were some eight references to the fact that Ricky had been free of heroin, and methadone, since March, due to his efforts to stay clean so that he could have unsupervised contact with his two children.

Care plan failings

On 17th August Ricky was transferred to Farmfield Hospital in Surrey, run by Elysium Healthcare, as Sheffield had no beds available; upon admission he declined to give a urine drug sample, repeating that he wasn’t a current drug user. However, on 18th August Ricky claimed that he was withdrawing from heroin use, and complained of suffering some symptoms relating to heroin withdrawal. At this point Ricky was prescribed with Opiate Substitution Therapy which included a methadone prescription which, after consultation, was agreed should not exceed a dosage of 30mls over a 24-hour period, whilst, for any PRN dose, the on-call doctor should be consulted.

The care plan also required various observations which, from the afternoon of 18th August, did not take place at the required intervals.

Methadone was not available until 20th August. Ricky was given his first PRN dosage of methadone at 08.55 that morning, followed by a second prescribed dosage at 12 noon and further PRN at 23.30. The next day he was given further PRN doses which exceeded his prescribed 30mls limit in a 24-hour period. There were no discussions with doctors over his dosage and no observations made relating to possible opiate toxicity. Ricky was discovered dead at 11.46 on 22nd August 2022.

A series of hospital failings listed by the Inquest Jury

The Inquest hearing at HM Coroners’ Court Woking began on 12th February 2024 and the following conclusions were recorded:

  • The cause of death was methadone intoxication with associated complications
  • There was a failure to adequately investigate whether Ricky was heroin dependent on 18th August 2022
  • A urine sample should have been insisted upon before prescribing the patient with methadone
  • Collateral information was not obtained from clinicians in Sheffield and the hospital should also have talked to the patient and his family about his history
  • The patient was not correctly diagnosed as heroin-dependent and methadone should not have been prescribed at all
  • Once it became known that methadone would not be available until 20th August, three days after he could conceivably have used heroin, the prescription should have been cancelled
  • A proper care plan was not drawn up to include adequate supervision and observations, or communication with and between nurses, and the plan that was in place was not suitably communicated to or followed by the nursing staff present who were not trained in the provision of opiate substitution therapy. Elysium had no policy or protocol in place for OST.
  • The patient’s response to the methadone treatment was not properly monitored or recorded
  • No appropriate action was taken when the patient twice appeared drowsy and disorientated on 21st August 2022
  • No relevant handover information was given to nursing staff on 22nd August 2022
  • The death was avoidable and contributed to by neglect

The Family’s Inquest lawyer comments on the Inquest findings

Mr Keenan’s family were represented at the hearing by Ruth Bundey of Harrison Bundey, who made the following comments:

“This Inquest revealed shocking failures of care by Elysium Healthcare through Ricky’s Responsible Clinician and nursing staff untrained in the use of Opiate Substitution Therapy. OST should never have been initiated at Farmfield Hospital without recourse to Substance Abuse Specialists. Basic simple checks as to whether he was truly heroin dependent were omitted. Opiate withdrawal is not life-threatening but opiate toxicity is. The prescription provided to Ricky, which was never reviewed, led to this tragic and avoidable death.”

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