Guidance

Preventing drug and alcohol deaths: partnership review process

Published 26 September 2024

Applies to England

Introduction

Purpose of this guidance

The information in this guidance is to help local partnerships set up and evaluate their review processes for:

• drug-related deaths
• alcohol-related deaths
• near-fatal overdoses

Local areas should interpret and implement this guidance as appropriate to their local circumstances. The Office for Health Improvement and Disparities (OHID) in the Department of Health and Social Care will monitor how areas do that, and how useful they find the guidance, with a view to reviewing and revising it.

In-depth reviews of cases of drug and alcohol-related deaths (DARDs) and near-fatal overdoses aim to:

• identify ways to improve services and how they work together
• develop opportunities for shared learning
• challenge and change practice to prevent further DARDs

This guidance will be of particular interest to people who commission and plan the strategic response to drugs and alcohol, including:

• directors of public health
• senior responsible officers in combating drugs partnerships (CDPs)
• partners in the commissioning and delivery of services for people who use drugs and alcohol, including voluntary and NHS services

Service providers may also find it useful in considering their own internal processes for assessing DARDs.

This guidance relates to drug and alcohol deaths in adults. Deaths of children and young people under the age of 18 are reviewed as part of child death overview panels. You can find more information about child death review panels in the government’s Child death review: statutory and operational guidance. However, deaths of older young people may be relevant to, and provide learning for, adult review panels.

Trends in drug and alcohol deaths

The Office for National Statistics (ONS) statistical bulletins Avoidable mortality in England and Wales show that drug-related and alcohol-specific deaths are the only categories of causes of death where the age-standardised mortality rate (the rate of deaths corrected for changing ages in the population) has significantly increased since 2001.

You can see trends for drug-related deaths in England and Wales in the ONS reports Deaths related to drug poisoning in England and Wales. These show that drug poisoning deaths have been rising sharply since 2012. The reports also show that mortality rates vary widely across regions in England. The drugs most involved in drug deaths are opiates (especially heroin), but deaths involving cocaine and benzodiazepines have been rising significantly.

Similarly, the ONS reports Alcohol-specific deaths in the UK show that alcohol-specific deaths, which had been stable in the UK between 2012 and 2019, increased by 32.8% between 2019 and 2022 to the highest number on record. These are deaths that are solely caused by alcohol, primarily alcoholic liver disease, and do not include the many deaths in which alcohol was a contributory factor. The rates of alcohol-specific deaths also vary by region across England.

The ONS report Alcohol-specific deaths in the UK: registered in 2021 further shows that adults in England who were drinking at the highest levels increased their alcohol use at the beginning of the COVID-19 pandemic. And for many people, this drinking did not return to pre-pandemic levels. It’s likely that the increase in alcohol-specific deaths (about 80% of which were liver disease) was mainly caused by increased consumption in that group. Reduced access or engagement with healthcare services during the pandemic may also have contributed.

National and local frameworks

Local drug and alcohol related death (DARD) and near-fatal overdose review processes can help partnerships understand their population most at risk of death and implement effective interventions to prevent future deaths.

Local partnerships can measure their progress using:

• Public Health Outcomes Framework indicators E06a (under-75 mortality rate from liver disease) and C19d (deaths from drug misuse)
• OHID’s Alcohol Profile

The National Combating Drugs Outcomes Framework: supporting metrics and technical guidance includes metrics to measure progress on reducing drug-related deaths and harm. CDPs should collect and review local data to cover the headline and supporting measures associated with reducing drug-related harm and drug-related deaths.

The review panel and process

Forming multi-agency panels

Local partnerships should form multi-agency panels to review DARDs and near-fatal overdoses. These ‘partnership panels’ should include representatives from services working with people affected by problem drug and alcohol use. This will show that preventing deaths is the responsibility of all partners, not just treatment and recovery services.

Many other local people and organisations should contribute and take action to prevent DARDs. You can find more detailed information about the different partners that should be involved in the panels in the ‘Membership of the panel’ section.

A partnership approach to reviewing DARDs and near-fatal overdoses is essential. By including a broad range of relevant partners, a panel can gather all relevant information to help understand the causes of deaths and near-fatal overdoses, including the events and social circumstances that may have contributed to them.

The panel can then identify changes across the wider public health, health and social care and criminal justice systems that could reduce the risk of death. It can also provide oversight to ensure that any agreed actions are implemented and make sure that all the organisations within the panel learn from the review’s findings.

Summary of the review process

The aim of a review process is to prevent DARDs. To achieve this, the panel will need to:

• agree definitions for drug and alcohol deaths and near-fatal overdoses (see ‘Definitions for reviews’ section)
• have appropriate governance arrangements in place, such as clear terms of reference for the review panel (see ‘Governance’ section)
• identify other parallel processes and decide on the most appropriate type of review (see ‘Governance’ section)
• have processes for sharing information before, during and after case reviews (see ‘Information sharing’ section)
• have effective processes in place to notify the panel about deaths and near-fatal overdoses for potential review (see ‘Identifying cases for review’ section)

• bring all main partners together for regular panel review meetings (see step 1 in the ‘How to conduct a review process’ section)

• discuss circumstances surrounding the death and identify immediate and contributory causes of death, and emerging patterns (see step 2 in the ‘How to conduct a review process’ section)
• agree actions that partners can take to prevent future deaths (see step 3 in the ‘How to conduct a review process’ section)
• monitor progress on actions (see step 4 in the ‘How to conduct a review process’ section)
• improve accountability for actions and develop a culture of learning and response (see step 5 in the ‘How to conduct a review process’ section)

• evaluate the impact of the panels (see ‘Evaluating impact of panels’ section)

• support people affected by a DARD (see ‘Support for people affected by drug and alcohol deaths’ section)
• support staff and volunteers involved in reviewing DARDs (see ‘Support for staff and volunteers’ section)

We encourage panels to sign up to the Knowledge Hub group Reducing drug and alcohol related deaths and share useful resources, such as example terms of reference.

 Definitions for reviews

It is essential that partnerships have clear definitions of:

• drug-related deaths
• alcohol-related deaths
• near-fatal overdoses

These definitions will need to be agreed by all local partners involved in the DARD review process to clarify which cases should be referred to panels. There is guidance below to help you agree a definition.

Definitions of drug-related deaths

Most partnerships follow the definitions for drug misuse deaths from the ONS, which you can find in their reports Deaths related to drug poisoning in England and Wales. The glossary says:

“Death classified as drug misuse must be a drug poisoning and meet either one (or both) of the following conditions:

• the underlying cause is drug abuse or drug dependence
• or any of the substances controlled under the Misuse of Drugs Act 1971 are involved”

However, panels should broaden this definition to include substances covered by the Psychoactive Substances Act 2016, meaning all illicit drugs.

Panels should also include deaths of people in drug treatment in their definition. They should also include people who have left treatment in the 6 months before their deaths, where this information is available, irrespective of the cause of death.

Definitions of alcohol-related deaths

The term ‘alcohol-related deaths’ used in OHID’s Alcohol Profile covers a broad range of deaths, but most of these will not be reviewed by panels. Panels are likely to focus on a narrower definition. For this guidance, alcohol-related deaths will mean people dying:

• in alcohol treatment, and those who had been in alcohol treatment but left in the 6 months before their death, irrespective of the cause of death
• from alcohol-specific causes, defined in the glossary of the ONS report Alcohol-specific deaths in the UK: registered in 2022

The report uses the National Statistics definition of alcohol-specific deaths, which means “it includes those health conditions where each death is a direct consequence of alcohol misuse”.

The vast majority of these are caused by:

• alcoholic liver disease
• mental and behavioural disorders due to alcohol use
• external causes of deaths, including accidental poisoning by exposure to alcohol

Definitions of near-fatal overdoses

Evidence shows that a person having a recent overdose increases their risk of death, so local panels should also review near-fatal overdoses.

A non-fatal overdose occurs when someone takes too much of a drug or medicine, leading to dangerous and potentially life-threatening side effects, but does not result in them dying. Non-fatal overdoses may or may not need a life-saving intervention.

Near-fatal overdose is a subset of non-fatal overdoses. This is where someone was closer to dying and they received a life-saving intervention.

In the case of a near-fatal overdose involving (or thought to involve) opioids, a life-saving intervention will usually include administering naloxone (the drug that reverses the effects of an opioid overdose) and rescue breaths.

A ‘first responder-attended near-fatal overdose’ is one in which the life-saving intervention was administered as part of a monitored arrangement (where administering naloxone is recorded and reported) by a first responder, typically a paramedic or police officer. So, these overdoses are likely the only ones that national agencies will be able to count reliably.

Scope of review

What panels should review

Partnership panels should review:

• drug-related deaths
• alcohol-related deaths (where this is listed as the primary underlying cause of death)
• deaths in drug and alcohol treatment (including people who left treatment within 6 months of their death) regardless of the cause of death
• near-fatal overdoses

Prioritising cases for review

Some panels review all deaths that fit their criteria, while others will select only those that they expect to learn the most from.

Some panels may choose to narrow their definitions for inclusion (using the definitions in this guidance) to reduce the number of deaths they review. Some may also have subgroups to look at particular incidents, like near-fatal overdoses.

Prioritising the cases that the panel can learn most from can be a pragmatic approach when resources are limited. But panels should be aware that it risks missing important learning or new trends, which may not be apparent before a review. It may also reduce opportunities to take action.

What drug-related deaths to include

Reviews of deaths caused by overdose and deaths of people in treatment should be the main focus of the review. However, some panels may want to expand their definition of drug-related deaths to review a broader set of deaths. For example, they could also include:

• other deaths caused by drug use, such as infections or damage caused by injecting
• drug-related homicides
• deaths from volatile substances (such as fuel gases, aerosol propellants, nitrous oxide and some glues)
• suicides by drug poisoning
• deaths where drugs are listed on the death certificate as a contributory factor

What alcohol-related deaths to include

Panels should review alcohol-specific deaths where possible, but they should prioritise reviewing deaths of people who were in treatment or who had left treatment in the 6 months before their death.

If some areas have high levels of alcohol-specific deaths and the panels do not have capacity to review them all, they may decide to review:

• overall trends
• demographic data
• a smaller sample

As doctors can determine the cause of death in the case of alcoholic liver disease, these deaths do not need an inquest process. In contrast, the Ministry of Justice’s Notification of Deaths Regulation 2019 guidance (paragraph 20) makes it clear that acute alcohol poisonings should be notified to the coroner. This can lead to a delay in panels being able to review these deaths. However, panels may choose to review cases they feel are likely to be alcohol-related, based on their own inclusion criteria, ahead of a coroner’s confirmation.

What deaths in treatment to include

While we recommend panels review deaths in treatment and deaths of people who left treatment in the 6 months before their death, it may not be necessary or appropriate to review all deaths. This is because for people who are in alcohol or drug treatment and are already very unwell, treatment can improve quality of life towards the end of life. Panels should consider the circumstances of each case.

What near-fatal overdoses to include

To establish inclusion criteria for near-fatal overdoses for review, panels may need to first understand:

• how near-fatal overdoses are identified in their local system
• where there are gaps in data on near-fatal overdoses
• how to improve reporting of near-fatal overdoses

Understanding these may help panels to establish their own definitions for reviews, based on which cases can be most easily identified by the panel and how many cases they are likely to identify.

It might be easier for panels to begin by focusing on first-responder-attended near-fatal overdoses, because this data is recorded. Doing this will also highlight the importance of panels engaging with ambulance services and emergency departments to get the data.

However, panels may be able to go further and obtain data that has not been recorded by emergency services. For example, panels can get data on near-fatal overdoses from drug and alcohol treatment services, if they collect information from people accessing their services about instances when they have been given naloxone.

There are information governance considerations (see the ‘Information sharing’ section) when a panel considers people who have had overdoses and are still alive.

Panels can choose to review near-fatal overdoses in the main DARD review panel or to have a sub-group to look at these. They can also decide to either discuss individual cases in-depth, or review aggregated local data (data about groups rather than individuals), depending on:

• information-sharing arrangements (more information in the ‘Information sharing’ section)
• how many cases need to be discussed

Geographic areas for the panel

Many panels will cover a single upper-tier local authority area since this often aligns with other governance structures and pre-existing data sharing arrangements. However, in some areas, there may be benefits to considering deaths over a wider geographic area. While this increases the number of deaths to be reviewed, it can help to:

• uncover trends
• engage partners that are organised at a regional or sub-regional level (such as police, ambulance and probation services)

Governance

Potential governance structures

The panel should report into an appropriate local partnership group. The most appropriate governance arrangements will depend on local circumstances, but most panels will report into one of the following:

• combating drugs partnership (CDP)
• integrated care safeguarding adults board
• health and wellbeing board
• community safety partnership
• scrutiny committee

Reporting to combating drugs partnerships

CDPs are the local structures responsible for helping prevent drug-related deaths. The Drugs strategy guidance for local delivery partners encourages CDPs to include alcohol-related harms in their remit. In this capacity, they will be well placed to oversee the work of partnership DARD panels.

Embedding DARD review panels into existing statutory functions could encourage positive engagement from partners. However, if panels report to committees or boards other than the CDP, then they will also need to regularly feed back to the CDP to make sure the CDP is aware of DARD issues in their area.

The importance of information sharing

Comprehensive information-sharing procedures can help to:

• notify the panel about deaths and near-fatal overdoses that meet their criteria for review
• gather relevant information to allow meaningful review at the panel
• communicate the panel’s findings to partner organisations so they can take action
• keep or publish records of findings and actions (such as in an annual report)

Other local review processes

The work of the panel may overlap with other local review processes, including:

• safeguarding adults and serious case reviews
• near-real-time suicide surveillance
• domestic homicide reviews
• hospital alcohol-related death reviews
• confidential inquiry processes within treatment and recovery services
• reviews of people who die while under probation supervision, including those in approved premises and those recently released from custody

Panels should identify other local review processes, contact these partners and identify the best way to share information. This will prevent duplication, but also make sure that no deaths go unexamined due to disagreements about which process they should fall under.

The panel may have agreements with local partners to receive anonymised recommendations following the outcomes of other review processes, where drugs or alcohol are thought to have contributed.

Panel findings and recommendations may also feed into other local strategies, such as domestic abuse and suicide prevention strategies.

Membership of the panel

Lead officer

In most partnerships, the panel will be convened by a lead officer, often employed by the local authority or police. The lead officer is responsible for:

• collecting and summarising information
• briefing the panel
• producing the output of the review process

These responsibilities should be specified in the lead officer’s job description.

Having a designated lead officer working to prevent DARDs reduces the burden on the existing workforce and allows for neutrality when working across organisations. The costs for employing a lead officer can be funded using:

• the public health grant
• funds from single organisations
• joint funding from local partners

The panel should determine the most appropriate funding source and employing organisation.

Chair

The panel should be chaired by somebody who is able to:

• effectively engage relevant partners
• manage the panel meetings
• agree actions arising from the process
• review and monitor previous actions

This could be a senior leader in the local system, such as a director or consultant in public health.

Panel members

Drug and alcohol deaths often occur among people who are not in treatment but are known to other services. So, panels need input from a range of local agencies to ensure they have a complete picture. These stakeholders include:

• local authority public health teams
• commissioners of drug and alcohol treatment and recovery services
• drug and alcohol treatment and recovery providers
• police forces
• local pharmaceutical committee
• adult social care
• adult safeguarding
• NHS acute trusts (for example, from emergency departments and alcohol care teams)
• NHS mental health trusts, including community mental health teams
• lived experience recovery organisations (LEROs)
• people with lived or living experience (see ‘People with lived and living experience’ section)
• hostels and other homelessness services, and their commissioners
• primary care network or integrated care partnership leads
• JobCentre Plus

Other organisations to consider involving

Other organisations are important, but they may cover a larger area that makes it more difficult for them to engage in local panels. However, where they can attend meetings in their area, these organisations may add extra value by sharing learning across multiple panels.

Panels may want to consider how to share information and action planning with:

• integrated care board leads (for example, leads for substance use, co-occurring conditions, medicines management or tackling dependence-forming medications in primary care)
• NHS ambulance trusts, particularly for near-fatal overdoses
• prisons, young offender institutions and immigration removal centres
• probation services and approved premises
• police and crime commissioners
• local drug information system (LDIS) panel or professional information network members (if this not already part of the panel) - for more information, see the guidance Issuing public health alerts about drugs
• academic partners who can be commissioned to run panels across multiple local authority areas

Some teams or partners will not be required for every panel meeting but should be invited where they have knowledge of particular individuals or events. These may include:

• individual GPs or GP practice managers
• a primary care officer who can liaise with GPs about specific cases and attend the panel on their behalf
• prison ombudsman for deaths or near-fatal overdoses of people who have recently left secure settings
• hepatology and blood-borne virus services
• sexual health services
• other NHS services that may have been involved in the care of an individual who died, such as diabetes specialist nurses, respiratory teams and district nurses
• fire and rescue services
• children and young people’s drug and alcohol treatment providers
• specialist drug and alcohol liaison midwives
• NHS England controlled drugs accountable officer
• children’s social care (where the deceased had children under 18 known to services)
• further education representatives
• community pharmacies that provide injecting equipment or opioid substitution treatment
• culturally specific services and diversity and inclusion specialists
• voluntary and community sector, such as LGBTQ+ organisations, ethnic minority groups and faith communities

People with lived and living experience

Involving people with lived and living experience

Involving people with lived and living experience in DARD review processes is essential. You should carefully consider how to best involve people with lived and living experience, including those who do and do not access services and the family and friends of people who have died.

OHID guidance Recovery support services and lived experience initiatives defines lived experience as:

the experience of people and families who were previously affected by problem drug or alcohol use and are now in recovery.

It defines living experience as:

the experience of people who are currently affected by their own or a family member’s problem alcohol or drug use.

There needs to be good communication between panels and people with lived and living experience, to make sure they are fully included in the review process. This should happen in a meaningful way, avoiding tokenistic participation.

People with lived and living experience can volunteer, be paid, or be employed to contribute to (and lead) review processes.

How you involve people with lived and living experience will vary from area to area, depending on existing local practices, relationships and organisations.

New panels should work with LEROs (if they exist locally) and people with lived and living experience to involve them from the start, including designing the DARD review process. You can involve people from other lived experience groups, including:

• charities (including national charities)
• family support groups
• bereavement services
• support workers
• volunteers from treatment and recovery services

You can also have lived or living experience representatives, who are specifically trained and supported to provide their perspective at DARD panels.

DARD reviews should not include family and friends who are recently bereaved and whose significant others are being discussed in the panel. Instead, you should appoint family and friend representatives (people who have previously experienced bereavement due to drugs or alcohol) through established family and friend services that can provide ongoing support.

Engaging people with lived and living experience

A good first step to work out how best to involve people could be a local engagement and consultation exercise. There may be local organisations that can help to engage people, such as Changing Futures in Plymouth, which employed peer researchers to improve service engagement.

For people with lived and living experience who work in services, partnerships may want to consider fair reimbursement for people’s time and using incentives for engagement. People contributing should be reassured that the information they provide will be treated sensitively, with the aim of preventing further deaths.

Support for people with lived and living experience

Where people with lived and living experience participate in panels, it’s essential that appropriate training, support and debriefing is in place, either through the organisations they are representing or organised by the panel. Support should be delivered by people with the appropriate skills.

Partnerships should recognise that panel discussions may be triggering or traumatic for people with lived and living experience and that people based in the area may be connected to the deceased.

Panel members should also ensure that the language they use during panel discussions is accessible for everyone involved. It would be useful for all panel members’ induction to include specific guidance on using non-stigmatising language.

Alternatives to being on the panel

Panels may decide that having people with lived and living experience attend DARD panels is not the most appropriate way to involve them in the DARD review process. Alternative approaches could include:

• feeding back findings, themes and recommendations from DARD panels to lived and living experience reference groups, panels or charities, to share learning and to allow them to co-produce reports and take actions to prevent deaths
• bringing anonymised case studies to lived and living experience groups so they can offer their reflections and insights
• engaging with other community groups who may be able to collect information on the experiences of people with lived and living experience who are not currently in treatment
• creating safe spaces for people who use services to share their views, or collecting views using paper or online surveys, which are then shared with the panel

Further advice on including people with lived and living experience

Chapter 3 of the Drug strategy guidance for local delivery partners includes advice on involving people who use and have used drugs and their families.

You can find further information on involving people with lived and living experience in OHID’s Recovery support services and lived experience initiatives guidance (in Part 3: how to develop systems of care that support recovery).

NHS England’s Working in partnership with people and communities: statutory guidance will also be a useful resource for panels trying to involve people with lived and living experience.

Coroners

Due to their judicial independence, coroners and their officers will not usually be members of panels. However, panels need to work in partnership with coroners’ offices to gather necessary information for them to operate effectively.

To support effective working, the panel should share their objectives with the coroner. Panels should try to establish a 2-way information flow with the coroner’s office. This could include receiving information from the coroner’s office following an inquest and sharing local DARD trends with coroners.

What information is shared and how will be at the discretion of individual coroners. One option may include a coroner allowing panel members to visit their offices to review case files and records of inquest in person.

Requests for information from coroners should be clear and made as early as possible.

It may be appropriate to have a designated liaison person to work with the coroner’s office to share information.

Where there are multiple panels within one coroner’s jurisdiction, a simple, standardised process of data sharing could be established for consistency across the panels. Lead officers from the different panels can work together to agree or develop a data sharing process that they can then get approved by the coroner.

Panels can learn from local established processes for working with coroners used for:

• domestic homicide reviews
• safeguarding adult reviews
• serious case reviews
• suicide audits

These reviews and audits may have set up processes with coroners that DARD panels can use or learn from.

Information sharing

Local considerations

Panels should consider making use of existing information governance arrangements, where available. For example, they could choose to report into an oversight group that already has the necessary information-sharing agreements between partners in place, such as a community safety partnership.

We advise all partners to consult information governance experts in their organisations to inform their information-sharing arrangements, including an NHS Caldicott guardian (a senior person responsible for protecting the confidentiality of people’s health and care information). When the correct safeguards are in place, we expect that it should be possible for all partners to share relevant information with panels to inform action to prevent future deaths.

Information-sharing procedure

Every review process needs a procedure for sharing information on:

• people who have died
• the circumstances of a person’s death
• a person’s recent use of services
• people who have had a near-fatal overdose

In most cases this will involve an information-sharing procedure between all partner agencies. Information-sharing rules and restrictions are set out both in the UK General Data Protection Regulation (GDPR) as brought into law and adapted by the Data Protection Act 2018. Any information-sharing procedures need to consider and ensure compliance with these.

How UK GDPR affects information sharing

Data protection legislation requires organisations to have a valid legal reason to process and use personal data. This is often called a ‘legal basis’. Under the UK GDPR, organisations need to be clear about the legal basis they are relying on to process personal data.

Data protection principles

Article 5 of the UK GDPR sets out 7 principles for the lawful processing of personal data, including:

• lawfulness, fairness and transparency
• purpose limitation
• data minimisation
• accuracy
• storage limitation
• integrity and confidentiality
• accountability

You can read more about article 5 of the UK GDPR in the Information Commissioner’s Office (ICO) guidance on data protection principles.

Data about the deceased

UK GDPR does not apply to deceased individuals, although there is a duty of confidentiality that applies to their personal information. For more information, see the ICO detailed guide on personal data.

This duty of confidentiality is not a barrier to information sharing where disclosures are necessary to assist a coroner, or if there is public interest in sharing information, for example to prevent future deaths. You should consider whether the information relating to the deceased person also includes third party details about another living person.

UK GDPR may also be waived for someone who is still alive (such as when considering near-fatal overdoses) if you can make a case that there is a lawful basis for processing and sharing the data. For example, you do not need to comply with UK GDPR if disclosing the information is in the overriding safeguarding interest of the person or others, or in the public interest.

Processing personal data

For some organisations, panel officers can lawfully process personal data of a living person under the ‘public task’ basis in the UK GDPR (article 6(1)(e)). For others, which are not statutory bodies constituted in law, panel officers can process personal data under the ‘legitimate interests’ basis (article 6(1)(f)). When using the legitimate interests basis, panels must ensure that article 5 principles are upheld. The ICO’s data sharing checklists will help you ensure you meet all UK GDPR requirements.

Panels should ensure that they are clear about the basis on which they are processing data. They should seek guidance from information governance specialists in their organisation on the most appropriate basis on which to share information. You can find more information about processing personal data in the ICO’s guidance on lawful basis for processing.

Special category data

In some cases, panels may need to share special category data (data that needs more protection because it’s sensitive), such as a person’s health care records. For more information, see ICO’s guidance on special category data.

If panels are sharing special category data, they need to ensure they can rely on one of the exemptions set out in article 9 of the UK GDPR, in addition to their Article 6 lawful basis. You might need to read these exemptions together with schedule 1 to the Data Protection Act (2018).

You need to specify the purpose for processing personal data, and limit processing to what is necessary. The way in which you share data will also need careful consideration. For example, considering if you need to send the information using secure email addresses or encrypt it, and if you need to redact some of the information.

Identifying cases for review

Identifying drug and alcohol deaths

Notifying panels about drug and alcohol deaths

DARD review panels can be notified of deaths through multiple routes, including:

• the local coroner
• the police
• treatment and recovery providers
• homeless services
• local acute and mental health trusts

Local partnerships will need to establish processes for:

• partners to notify panels about deaths that meet the local criteria for review
• collecting information about the case before the next panel

The notification process should be simple, to encourage local organisations to quickly notify a case to the panel for discussion.

Gathering information about drug and alcohol deaths

When a panel has been notified that a death has taken place and is within the scope of the panel, the lead officer will share this information and seek input from relevant partners before the panel meets.

It may be useful to set up shared data collection website or a surveillance system that partners can use to notify the panel about cases. These systems will alert other partners of notified cases and invite them to input relevant information that they hold about the person before the panel meets.

Most panels will start collecting information shortly after they are informed about a death that is within their scope, recognising that some information will not be immediately available, such as toxicology findings.

A full coroner’s record of inquest is unlikely to be available for some months after the death, so the panel will need to consider whether to review a death before or after a coroner’s inquest. Reviewing cases before the inquest may be useful in identifying current system issues. However, an inquest may provide important information about the death that is useful in the review process.

Some partnerships may choose to review cases before a coroner’s inquest, then later review the coroner’s record of inquest to integrate its findings with the panel’s findings. Others might choose to review cases only after inquest, unless panel members raise issues that suggest a need for an earlier review.

As well as information provided directly to the panel by partners, panels may be able to use existing information sources, such as:

• serious incident reviews conducted by treatment and recovery providers after a death in a service
• sudden or unexpected death forms used by the police

Panels may need to agree a ‘step-down’ process for notified cases. This is where a notification has been made to the panel about a death, but information suggests it does not meet the criteria for a review.

Deaths in custody and prison leavers

For DARDs that occur in custody, there is a separate process outlined by the Crown Prosecution Service in its information on deaths in custody. The Special Crime and Counter Terrorism Division manages all deaths in custody cases.

The Prisons and Probation Ombudsman (PPO) publishes reviews of deaths of:

• people in custody
• people in approved premises
• people recently released from prison

You can find these type of reviews at the fatal reports page on the PPO website.

Identifying near-fatal overdoses

Notifying panels about near-fatal overdoses

To be able to review near-fatal overdoses, panels will usually require ambulance services and hospital trusts to notify them about cases. Panels will need to consider how to get this data from ambulance or hospital trusts, to understand the scale of the issue locally. This will require panels to develop relationships with these trusts, particularly with data analysts, to help understand the data sets, including the limitations of the data.

Other services may also become aware of near-fatal overdose cases and can notify the panel, including:

• treatment and recovery providers
• LEROs
• adult safeguarding services

To effectively monitor near-fatal overdoses, partners need to consistently record them using a clearly defined list of substances to include (determined by the panel).

Gathering information about near-fatal overdoses

As with drug and alcohol deaths, a data collection website or surveillance system can support effective data sharing between partners. Useful sources of information could include statistics on:

• naloxone use
• hospital admissions
• incident reports
• referrals made to treatment and recovery services after near-fatal overdoses

Reviewing incidents involving people who are still alive will require additional information governance arrangements. This will need to be supported by comprehensive information-sharing agreements and confidentiality statements. See the ‘Information sharing’ section for more details.

When DARD panels discuss near-fatal overdoses, they could justify that disclosing the information about a case is in the overriding safeguarding interest of the person or others, or in the public interest.

Where information-sharing agreements are not in place, partners can collect aggregated, anonymised data on near-fatal overdoses to review for trends and learning. This data could include:

• gender
• age
• location
• substances involved

Links to local drug information systems

Panels should link in with their local drug information system (LDIS). An LDIS collects information from partners on potential dangerous, new, potent, adulterated or contaminated substances in the local area and can issue alerts about these. In many areas, the LDIS and the DARD panel will share members, which makes it easier to work together.

The LDIS may provide valuable information to the panel on drug-related deaths and overdoses. Occasionally, DARD panel findings may initiate an LDIS process.

For more information about LDIS, see the guidance Issuing public health alerts about drugs.

How to conduct a review process

Undertaking a DARD review involves 5 steps. This section describes the main activities in each step.

Step 1: bring partners together and be ready to share information

Getting arrangements in place for the review

Panels should meet regularly, 4 to 6 times a year, to review any deaths that have occurred since they last met, and any new information arising from coroners’ records of inquest.

Before the review process can begin, partners should be aware of the process and ready to contribute.

Providing training and feedback to partners to improve the consistency and completeness of the information they share will save time in the long term. Partners may choose to have a designated person in their organisations to collate information and ensure good quality data goes into the review process.

Engaging partners

Panels will likely face difficulties engaging some partners. In cases where this problem persists, panels should use local partnership groups (for example, the CDP) or regional OHID teams to encourage participation. Where organisations are members of the CDP, it will encourage them to participate in the panel. The CDP senior responsible officer can have an important role in securing engagement from all partners. Partners should understand that DARDs are avoidable deaths and that their co-operation can help to prevent future deaths.

Other options include exploring whether the panel could access the necessary information from other sources.

To enable easier engagement from partners, panels may consider:

• requesting that partners contribute to the panel in writing if they are unable to attend in person
• having a single shared place for collecting and sharing information (as outlined in the section ‘Identifying cases for review’)
• having virtual meetings with a clear agenda, enabling people to join for the relevant cases if they are not able to attend the whole meeting
• having larger, annual panel meetings for partners that are unable to attend regularly - these could focus on cases that are relevant for hard-to-engage partners, or summarise themes identified at the regular DARD panels
• ensuring partners understand the process and the importance of the review panels
• having a single point of contact in larger organisations, whose job includes working with the panel to help agencies communicate better
• reducing the frequency of meetings, by integrating them with neighbouring local authorities to form a larger panel
• having a designated person employed at a regional level who would attend all panels within their catchment area and be responsible for monitoring the implementation of actions by partners
• developing a memorandum of understanding about roles and responsibilities of panel members
• sharing learning and actions with partners, including annual reporting through organisational governance arrangements

Reviewing near-fatal overdoses

How the panel reviews near-fatal overdoses will affect how it is set up. The same panel that reviews drug and alcohol deaths can review near-fatal overdoses. Or the panel (or a subgroup of the panel) may choose to meet more often to review near-fatal overdoses. This allows panels to identify and deal with current issues.

Where the panel does not have access to individual-level information on near-fatal overdoses, they may instead choose to look at data trends as a standing item on the agenda of the main panel.

Representatives from criminal justice agencies

If the person who has died left prison recently, the panel should consider inviting representatives from prison, probation or police and crime commissioners to the panel. But as a minimum, the panel should request information about the case from these partners.

Step 2: identify immediate and contributory causes of death and emerging patterns

Collating information provided to the panel

In most panels, the lead officer will prepare a summary of information provided by partners that the panel can review, which includes a timeline highlighting important events surrounding the death.

A timeline is particularly valuable for piecing together the order of events and to provide an overview of everything that the panel knows about the case.

Identifying immediate and contributory causes

The panel will use the information provided to identify immediate and contributory causes of death.

Example questions that the panel can use to guide the review process include the following.

1. Which services was the person known to and which ones were they engaged with at the time of their death?
2. What long-term conditions did the person have and what treatment were they receiving for these?
3. Had the person been subject to a safeguarding referral, care act assessment or other interaction with services and if not, would this have been appropriate?
4. Had the person had an overdose recently, for example in the last 12 months, and what actions were taken following this?
5. Had the person recently been released from prison?
6. Had the person recently been discharged from hospital?

In many cases, the full circumstances relating to the death will not be known at this point, as the coroner’s inquest may not have concluded, or even be underway. In particular, the immediate cause of death may not be determined. However, by seeking input from relevant partners, the panel can build up a good picture of the contributing causes, many of which will be useful to plan action to prevent other deaths in future.

If the review happens before the inquest, panels should review the coroner’s record of inquest when it is available and integrate its findings with their own.

The panel will need to identify which agencies have a risk management plan for the person. It is good practice for service providers to share their risk management plan with the panel.

Panels could use the NHS England patient safety incident response framework if they lack their own framework or believe they can learn from using the NHS framework. You can find more information in the Patient safety incident response framework and supporting guidance.

Overlap with suicides

There may be overlap between DARDs and suicides, which will be unclear until classified by the coroner.

Some people who use opioids and have had a near-fatal overdose have described their ambivalence to living or dying at the time of the overdose. Panels should consider if feelings of ambivalence contributed to premature deaths and review the implications and system responses to these situations.

Panels may consider many opioid overdoses to have been suicidal in nature, or at least in part, even though they may not be recognised as such in the coroner’s findings.

Identifying trends

Using the information compiled by the lead officer, and information from the local coroner, the panel will be able to identify emerging trends and patterns including:

• changes in causes of death
• demographic characteristics deceased people
• service engagement before a person’s death

Summarising findings

A standardised format for writing up investigations and recommendations could help panels collate and interpret findings relating to causes of deaths.

Each year, panels should produce a summary of deaths they have reviewed, to share with partners. The summary should include a review of relevant coroners’ records of inquest during that year, drawing out trends and providing a comprehensive overview of the causes of deaths in the area. For this report, panels can also draw on national data sources and consider local intelligence, to add context to local findings.

Step 3: agree actions that partners can take to prevent future deaths

Determining actions to take

Once the panel has reviewed a death, or a group of deaths, it will need to determine what actions partners should take to prevent future deaths.

The actions arising from a review will vary depending on:

• the information available
• the partners involved
• what the review process has looked at

However, it is important that the actions relate directly to the findings of the review.

Partners with access to National Drug Treatment Monitoring System (NDTMS) data on the NDTMS website can use the health and mortality unmet need toolkit to support the actions they identified in the review.

Access to this toolkit and some data on the NDTMS website is restricted to particular professionals (like drug and alcohol treatment commissioners and health professionals involved in collecting treatment data), who can register for a login through the website. The NDTMS website allows panels to compare their data with other matched local authority areas and with their region.

Actions should be shared and owned by all relevant partners. Individual people should not be responsible for actions. Organisational representatives on the panel should feedback progress on actions.

Involving people with lived and living experience

Panels should also consider how people with lived and living experience can be involved in taking some actions forward, where appropriate. Specific actions could include their involvement in, and leadership of:

• overdose awareness exercises
• publicity and communications campaigns
• peer-led initiatives
• disseminating important information to people affected by problem drug and alcohol use

It can also be helpful for partner organisations to hear personal stories to inspire change.

Example findings and possible actions to take

Example findings by panels and examples of actions that they could agree in response to the findings are provided below.

People are dying from long-term physical health conditions

Provide physical health services in treatment, recovery and other community settings, for example:

• wound care
• chronic obstructive pulmonary disease (or COPD) clinic
• smoking cessation support
• weight management interventions
• routine screening and health checks

Use trusted individuals, like peer support workers, to help people in specialist treatment and recovery settings to access mainstream healthcare services.

People experienced near-fatal overdoses in the year before their death

Ambulance crews refer any person they think is at risk of future overdose to drug and alcohol treatment and recovery services.

First responders, including the police, are not equipped to provide life-saving interventions

Police officers who come into contact with people who use opioids to be equipped with naloxone.

People are overdosing on opioids in the company of others

Provide overdose training and distribute naloxone to groups of people who are at risk or who support those at risk. Provide the training and naloxone through peers, or in settings identified in the review process.

For people who refuse to carry naloxone, proactively engage with them to identify and overcome their perceived barriers to carrying naloxone.

People are dying from using multiple substances (polydrug use)

Work with locally commissioned lived and living experience groups to design and test interventions to raise awareness of the risks associated with polydrug use and change behaviour.

The period following release from prison or hospital is particularly high risk for overdose

Drug and alcohol treatment services provide in-reach to prisons, and outreach after people are released. This will help to engage people into treatment and ensure optimal dosing of a person’s opioid substitute medication, such as methadone or buprenorphine.

Work with hospital liaison leads to develop pathways and ensure treatment and recovery providers are aware when people are discharged from hospital.

Work with housing services to provide good housing for people leaving prison. This can be a protective factor and help them to engage with other services.

Provide peer support workers and volunteers to support people at these high risk transition points (leaving prison or hospital).

The period following a benefits back-payment can be high risk for overdose

Work with local Department of Work and Pensions colleagues to make sure they are following guidance about supporting vulnerable adults who receive benefits, especially when a person is due a benefits back-payment (underpaid benefits leading to a larger amount being paid).

Most deaths are of people not in treatment

Consider how effective local outreach services are, how well they work with other services, and whether they need to focus their activity on specific groups at risk, as identified by reviews.

Increase local alcohol screening to increase the number of people accessing treatment.

New substances or patterns of use are contributing to deaths

Ensure there is an effective LDIS that can quickly identify new substances or contaminants and issue targeted alerts to reduce harm.

Engage local lived and living experience forums to undertake research to improve understanding of how new drugs are being obtained and emerging patterns of use.

Barriers to effective mental health services and support are contributing to deaths

Develop shared pathways and care plans between treatment and recovery providers and mental health services supported by regular meetings between services.

Prescriptions for pain management are contributing to increased risk of overdose

Provide training or professional development sessions for GPs and other prescribers about the risks for people using opioids or prescribed opioid substitution treatment.

Ensure all prescribers, including private providers, are aware of prescriptions made by colleagues in different organisations.

People living alone and using drugs alone are at increased risk of overdose and death

Promote awareness about overdose risks among local groups you know to be at most risk. Encourage them not to be alone when they use drugs and develop a safety plan if they are going to use drugs alone, including asking someone to check on them and that they have naloxone available if needed.

Stigma has contributed to people not seeking help from services

Promote campaigns to reduce stigma around drugs and alcohol, like the See Beyond Campaign in Scotland.

Encourage responsible reporting by local media to reduce stigma.

Communicating agreed actions

Panels should consider how best to communicate agreed actions with relevant stakeholders. For example, a consultant psychiatrist may be well placed to write to NHS colleagues about changes to primary care or mental health services. And a lived experience recovery organisation staff member could be the best person to train staff to encourage people to enter into treatment.

Step 4: monitor progress on actions

Keeping records

Panels should keep records of:

• findings
• emerging patterns
• recommendations
• agreed actions

They should ensure these records are reviewed to assess progress and to make sure lessons are learned. Some panels will publish these (for example in an annual report) but all are likely to keep minutes and action plans for internal use. Public reporting can help demonstrate the impact of the panel.

Types of progress measures

Panels should consider having:

• outcome measures (the end result or the direct impact of actions taken, such as reducing DARDs)
• process measures (how processes work to achieve the outcome desired)

These can help to monitor progress on actions.

Panels need to carefully consider the measures they will review and monitor. These should be measures that they and partner organisations can influence.

Some potential measures are outlined in the ‘National and local frameworks’ section. Examples might include the number of:

• DARDs
• emergency department admissions for overdoses
• ambulance callouts for overdoses
• referrals into drug and alcohol treatment
• organisations and individuals who have access to naloxone

Reporting into governing bodies

Panels will report into a partnership structure or board as set out in the ‘Governance’ section. Panels should submit their action plans and recommendations to these bodies. The governing partnership structure or board should take responsibility for:

• implementing recommendations from the panel
• holding partners to account for their actions
• identifying barriers to implementing actions
• providing strategic oversight of the effectiveness of the panel

Step 5: develop a culture of learning and response

Approaches to develop a culture of learning and response

Best practice in review processes is to use a ‘systems approach’ and seek to understand causes rather than to assign blame. You can read more about implementing a systems approach for case reviews in Social Care Institute for Excellence guidance Learning together to safeguard children: developing a multi-agency systems approach for case reviews.

However, it is important that panels have a process for taking action where they identify unsafe practice. It may be helpful to refer to NHS England’s A just culture guide to determine whether a particular member of staff needs support or intervention to be able to practice safely, or whether it’s more appropriate to change services or wider local systems.

To make sustainable changes in response to panel recommendations, partner organisations may use approaches such as:

• audit (see the Healthcare Quality Improvement Partnership guidance Best practice in clinical audit)
• quality improvement (see the BMJ guide on quality improvement)
• human learning systems (see the Human Learning Systems website)

Partner organisations may want to establish cross-sector working arrangements to support innovation and improve the quality of care, as outlined in The Health Foundation guidance Cross sector working to support large-scale change.

Quality assurance

The panel can have a quality assurance role, making sure that reviews are carried out to a high standard by:

• highlighting good practice
• drawing attention to practice that does not meet the expected standards

One option is to have a ‘gold standard’ that partners have agreed. Panels can then use this example as a benchmark against which to review cases to see where practice could be improved in the future.

For more information on a quality assurance role, see the Social Care Institute for Excellence guidance Safeguarding Adults Boards - quality assurance.

Sharing actions, findings and progress

It is important to have a process in place to share findings and actions from the panel to all relevant partners, some of whom may not attend panel meetings. The best process will vary depending on your local context, but CDP members may be able to share findings and take action with their organisations.

Partnerships can share their findings and progress with neighbouring panels to encourage shared learning. It could be helpful to collate findings with other local avoidable death reviews to look for common themes. Local partnerships can also share their learning to the national level through their regional OHID teams.

Where appropriate, panels should consider sharing reports and reviews with the public and can engage with communications teams to do this.

Evaluating the impact of panels

Evaluating the impact of panels is challenging. But partnerships have a responsibility to:

• try to understand what difference their panel is making
• make their panel as effective as possible
• maintain support from partners

We encourage panels to undertake regular self-assessment to identify areas for development. The following questions may be helpful in guiding this:

1. Which partners are missing from the panel?
2. Which partners does the panel struggle to get information from?
3. How well do current information governance arrangements work?
4. Do any barriers to information sharing exist, and how are these managed?
5. How well are people with living and lived experience supported to be involved in the panel (this must include feedback from those involved)?
6. How well attended are panel meetings?
7. What are the barriers to attendance?
8. Who is best placed to support engagement from partners?
9. What resources are available to support the work of the panel and are they sufficient?
10. How effective are the governance arrangements at holding partners to account?
11. In the last year, what has changed as a result of the work of the panel?

Preventing deaths and managing risk

Some partnerships already complement the work of DARD panels by identifying specific people who are at higher risk of death, and then taking action to reduce that risk. Partnerships will decide locally whether this is best done through the panel, alongside their work on deaths, or by a different group convened specifically for this purpose.

You can identify increased risk of death through specific events, such as a person having a:

• near-fatal overdose
• recent hospital admission

Or by considering a range of risk factors, such as a person’s:

• underlying health conditions
• chronic pain
• housing status
• involvement with the criminal justice system
• recent increase in drug use

When partnerships are considering event-based risk factors, they are unlikely to have knowledge of all cases (such as all near-fatal overdoses), and those they are aware of may not be representative.

Some partnerships will maintain a ‘red flag system’, which is a regularly updated list of the people most at risk and focus risk reduction efforts on this group. In other areas, there are processes to convene a multi-disciplinary group when a person is identified as being at heightened risk.

Partnerships may be able to adopt a model similar to the multi-agency risk assessment conference (MARAC). This is a regular meeting between representatives of relevant partners and services where information is shared to provide a fuller picture of risk to adult and child victims of domestic abuse or other serious harm. After information sharing, the MARAC agrees co-ordinated actions to reduce risk. For more information, the Safe Lives website has published MARAC resources.

Work focused on named people at risk of death is different from the actions agreed during the DARD review process. This is because these actions will be specific to an individual person, although they could also lead to wider change in practice. In contrast, recommendations from DARD reviews will generally relate to groups of people, based on risk factors, and be focused on system change.

When a review identifies specific risk to life (such as a recent near-fatal overdose) to a person who is still alive, panels will need additional information governance arrangements. It is likely that the panel can use safeguarding as a justification to share people’s information to reduce this risk and save lives. However, where possible, it is always better to seek consent to share the information from the person concerned. See the ‘Information sharing’ section for more guidance.

Support for people affected by drug and alcohol related deaths

Identifying and communicating with friends and family of people who have died

It may or may not be straightforward to identify the friends and family of the person who has died. The panel should define their role in identifying friends and family, working out:

• whether to contact them
• the purpose in contacting them

Partner organisations might have relevant details of friends and family. For example, the police might have information about the next of kin and who was present at the time of death. And coroners can often speak with family members (or other ‘interested persons’). However, they cannot share details without the specific permission of the interested persons.

It may not be productive to start reaching out to people, particularly if no partners know about family involvement or the type of relationship with the deceased. The panel should recognise that family and friends may not want to be involved in any activities related to the death. There might also have been safeguarding issues to consider concerning the person who has died.

Where an organisation has an existing relationship with family and friends of the person who has died, it may be best for that organisation to continue to be the main point of contact. Although this will not always be the case.

Support services for people bereaved due to drugs or alcohol

In the aftermath of a drug or alcohol related death, the family and friends of the person who has died are likely to want to understand the circumstances of the death, and whether anything could have been done to prevent it.

Due to social stigma, people who have been bereaved through drugs and alcohol may experience ‘disenfranchised grief’. This is where people may feel less able to access support and can experience prolonged mental health and wellbeing issues. This is discussed in research by the Bereaved through Alcohol and Drugs (BEAD) project. For more information, you can download the BEAD project scoping review (PDF, 355KB).

Families and friends may have to wait a long time for a coroner’s inquest to conclude, which may further contribute to their distress. Where appropriate, relevant organisations should contact them as soon as possible to offer their support. Panels (through their member organisations) may be able to identify friends and family who have not previously been contacted, offer or signpost to support.

In the case of a death in custody, families and friends are informed by the governing governor (this may be with the support of a family liaison officer or the chaplain).

Panels can help ensure that support is in place for family members and friends by appropriate agencies, by understanding what is already in place locally and advising agencies about avoiding duplication. Families going through inquests may have support provided through The Coroners’ Courts Support Services (CCSS), where these are available in their area.

The most appropriate organisations to provide support to family and friends will vary depending on:

• local circumstances
• the needs of the individuals
• where they live

Many partnerships will have local support networks (including LEROs) or organisations, for example Y-Smart in Devon which is aimed at supporting young people. These are sometimes commissioned by the local authority and treatment and recovery providers may also be appropriately positioned to provide support. National support organisations with expertise in this area include:

• DrugFAM
• Cruse Bereavement Support
• The Compassionate Friends
• Adfam

Involvement in the review process

It is unlikely to be appropriate for family and friends to attend panel meetings. However, they may be interested in any:

• conclusions reached
• themes identified
• actions agreed

Panels should consider the needs of family and friends and agree processes for how they are kept informed. One option may be to have a trained single point of contact (or professional already known to the family) to work with them who can:

• explain the process, including that the aim of the panel is to improve services and reduce future deaths, not to assign blame
• feed back the experiences or views of family and friends to the panel
• feed back the panel findings to the family and friends

Support for staff and volunteers

We recognise that working with information relating to deaths can affect staff and volunteers, and that their employers will want to ensure support is available to reduce the impact this kind of work has on their wellbeing.

Staff and volunteers should be encouraged to look out for signs of stress arising from this work, which may show in different ways, including:

• sleep problems
• irritability
• changes in appetite
• difficulty concentrating
• feeling overwhelmed
• withdrawal from relationships

For more information, read about stress on the NHS website.

Ideally, staff and volunteers should receive training on how to prevent and cope with stress, including spotting early warning signs and techniques for managing stress.

The working environment can also support staff and volunteers. To help people to feel supported, employers should:

• make opportunities to debrief with colleagues
• provide high-quality supervision
• recognise that at times staff and volunteers may need to step away from aspects of their role

Organisations should encourage their teams to consider whether other aspects of their working environment could be modified to support their staff, such as limiting work reviewing deaths data to a certain number of hours or part of the day.

Organisations should signpost staff and volunteers who have worked directly with the deceased to support services.

There are many resources available for staff and volunteers to support their wellbeing. You can find more information in the Every Mind Matters programme on the NHS website. Managers can support staff and volunteers to develop plans to protect their wellbeing, using tools such as Mind’s Guide to wellness action plans (PDF, 604KB).