A name not a number

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Nov-2016) is a guest post-it written by Judith Yates and appears below with kind permission from DDN.

Post-it Past Practice – from the RCGP Conference 2016
A guest post-it by Judith Yates

I first met David in the 1980s when, as a small child, his mother kept him away from school all too often. She struggled to cope with life. By the end of the 1990s, in his early twenties, David was a regular attendee at my surgery, prescribed methadone and supported by my drug worker.

One night he banged on the back door of the surgery after 7pm when we were supposed to be closed and trying to pack up and go home. Our gentle hearted nurse Angela opened the door to ask what he needed and stepped back as he staggered in, fell to the floor, stopped breathing and turned rapidly blue. My quick-witted partner ran to the emergency cupboard and dug out our newly acquired naloxone kit. Naloxone is the antidote to opiate overdose and David was breathing again, although still groggy when the ambulance arrived.

When he returned to my surgery for his routine appointment the following Tuesday he was surprised to be met joyfully by the reception staff who had thought he might have died. On waking in the hospital he had had no idea how he got there, how close he had been to death, nor the role played by the surgery team. His was the first life I had known to be saved by naloxone.

It was therefore a shock two weeks ago, to see David’s name in the stark “drug related death” summary I was reading on a clear sunny day in Birmingham. I had trodden a familiar path to our local Coroner’s Office to review the thick ring-bind folder containing reports of all inquests held in the city during 2016, as part of the preparation for our newly re-formed “Drug Related Death (DRD) Local Inquiry Group”.

It seems that David had no longer been in treatment at the time of his death as only heroin had been found on toxicology. I suppose there was nobody around to administer naloxone on this occasion.

This reviewing of the inquest reports is a miserable job, not only because beneath the terse language of the certificates lie the shocking stories leading to these sudden and unexpected deaths, but also because having been a GP in the area for over 30 years, I have known many of the people who have now come to the end of their lives in ways which might have been avoidable. It is always especially upsetting to find that one of my old patients has died in this way.

Last week, standing at the podium to address the audience at the 21st RCGP/SMMGP “Managing Drink and Drugs problems in Primary Care” conference, I felt the warm glow of a room full of people who have been working together for all of the 21 years and more, but my subject matter, a review of drug related deaths in Birmingham, replaced this with an icy chill and a feeling that we must be missing something. I thought of David and the other people I have known who have died suddenly and unexpectedly in this way.

We have all read the headlines telling us that heroin related deaths have more than doubled in England and Wales, between 2012 and 2015 (Ref 1). Prof David Nutt speaking at the same conference asked the question “Why are we collecting all these statistics if we aren’t doing anything about them?” It is only by looking behind the statistics that we can have a chance of understanding what may be the causes and more importantly, what solutions can be found.

It is shocking that in many parts of the country, as in my city, drug related death inquiry groups fell victim to the financial cuts in services, and often no longer meet at all. As a result, nobody has been investigating the deaths of people not actually engaged with treatment services at the time of their death. The latest analysis by PHE shows that more than half of people who die in this way have never been involved with drug treatment services, at least since NDTMS records began seven years ago, and more than 70% were not engaged with treatment services at the time when they died (Ref 2).

We need to learn from each of these tragedies and add to the frequently simple and usually not even expensive actions, which we already know from international evidence contribute to reducing future deaths. These include: low threshold prescribing (and welcoming rapid re-engagement for those who drop out), supervised consumption facilities offering cups of tea, conversation and a safe hygienic place to inject for the most vulnerable who are not ready or able to come into treatment, and wide access to take-home-naloxone wherever it might be used to save a life.

David was only in his late thirties when he died, an increasingly common age for people to suffer accidental overdose. He was of course more at risk because of his age and history, because he had fallen out of treatment, and because he had a history of non-lethal overdose in the past. His death almost certainly could have been avoided.

We have powerful examples of effective analysis and action, for example from the airline industry, the maternal deaths confidential inquiry groups, and the investigations into every road traffic accident death, all of which have found ways to prevent avoidable deaths.

In 2009 Airline pilot Captain Sullenberger astonished the world when he made an emergency landing of his plane on the Hudson River, saving every life on board. When asked how he knew what to do, he said, “Everything we know in aviation, every rule in the rulebook, every procedure we have, we know because someone somewhere died. We cannot have the moral failure of forgetting these lessons and have to relearn them” (Ref 3).

Local inquiry groups are needed now more than ever to look at every fatality and ideally at the near misses as well, to inform our treatment efforts and perhaps even more powerfully to inform people who use drugs how to keep themselves alive and safe into the future.

– Judith Yates


1. www.ons.gov.uk
2. www.nta.nhs.uk
3. Quoted in “Black Box Thinking” by Matthew Syed, 2015

Note: Previous Post-its from Practice can be found in the Resource Library on the main SMMGP web site.

Favourite patients, shame and redemption (it takes time)

Jonathon Tomlinson, an “ordinary GP” in Hackney, writes in a recent blog post on “A Better NHS” about caring for patients who are ashamed. He writes against the backdrop of two books, one fictional, one fact, about dealing with shame brought upon by childhood trauma.

We are very grateful to @mellojonny (on Twitter) for granting us permission to reproduce extracts of his article on our website, and for giving us the opportunity to reflect for a moment on what brings these favourite patients to our doors, and why there is often no “quick fix” when they do seek help:

Extract from Shame and Redemption, a blog post by Jonathon Tomlinson:

“Almost every GP I know is overwhelmed with caring for adults who suffer from shame, many of whom have been abused. They present with chronic pain, medically unexplained symptoms, anxiety and OCD, paranoia, fatigue and drug and alcohol addiction. We label them with medical syndromes, psycho-somatic, psychiatric and personality disorders. We refer them for medical investigations, specialist opinions, psychiatric assessments and psychotherapy. They leave us shattered, demoralised, burned out. They are chaotic, exhausting, and also among our most loved patients.

I’ve recently been doing work with old and young GPs about our favourite patients. For young doctors, favourite patients are friendly, cooperative, honest, and grateful. They present with symptoms that lead to a diagnosis and a cure or failing that, a good death. Gratification is quick. Dreaded patients are the opposite of all these things.

I asked four experienced GP trainers each to describe one their favourite patients to a room full of trainees. The patients they described were hard to form relationships with, took time and hard work to get to know, they were argumentative, dishonest, chaotic and disruptive, unwilling partners in care. For some it took years, decades even to reach a point of mutual trust and respect, but eventually they were rewarded with the kinds of relationships that can only come with going through and overcoming hardship together.

Evidence about resilience of doctors who work in challenging areas concluded that they were sustained by a deep appreciation and respect for the patients they cared for. Gratification with challenging patients comes slowly. Those who frustrate us most will eventually be the ones that sustain us, but only if we preserve the continuity of care that we are in grave danger of losing in an increasingly transactional NHS.”

Read the complete article on:

More reading:

A qualitative exploration of favorite patients in primary care. (Lee et al) 2016