The NHS has admitted to failings that “may have caused or contributed” to the death of a 32-year-old who was in its care for the treatment of his alcoholism.
Adam Parry, who was “handsome, charming and fiercely bright”, according to his family, died in May 2021 after struggling to manage his alcohol addiction for many years.
His father, Fred, spoke to The Ferret a year ago to highlight the need for better alcohol treatment options.
Now, following a review by NHS Greater Glasgow and Clyde, which identified missed opportunities for interventions, Parry is calling for urgent reform.
The review, which is still in draft form, was shared with The Ferret by the family. It found that though Adam fitted the “critical” category in the months leading up to his death – which would have led to specialist monitoring for his alcoholism – he was put in the “green” category, with minimal monitoring required.
As a result Adam – who was hospitalised four times between January 2021 and his death on 5 May that year – was not considered a priority case. Due to staff shortages he was not allocated a care manager and appointments were by phone only.
Other issues highlighted include poor record keeping, including of the decision not to change his medication just months before his death and “confusion” about whether his family had Adam’s permission to be kept informed of his care. His father said this meant they were not listened to when they said their son was not coping and needed more support.
Despite highlighting the need for lessons to be learned, the review also claims Adam’s treatment and care was “satisfactory, with perhaps an overly-optimistic assessment of risk”.
But campaigners say the Parry family’s case is far from unique. They claim alcohol and drugs services are “broken” and insist that without a new approach, too many more will die.
Figures, released earlier this month by the National Records of Scotland, show that alcohol deaths rose by five per cent to 1,245 in 2021 compared to the previous year. It is an increase of 20 per cent on the 2020 figures.
Last year’s figures did not include Adam’s death, because it was recorded as a sudden death due to epilepsy, although his medical records show that his seizures were triggered by alcohol withdrawal. The seizure that killed him was the sixth Adam had suffered that year.
His father said the real figure of people dying due to harm caused by alcohol is likely to be far higher than is officially acknowledged.
Adam first started struggling with addiction to alcohol when he was a student at St Andrew’s University. He was hospitalised with an alcoholic seizure in 2012, aged 21.
Dissatisfied by the service offered by the Community Addiction Team (CAT) in Glasgow, his parents paid thousands of pounds for private rehab at Castle Craig, where Fred – a recovered alcoholic – had also attended for treatment several decades ago. It is currently not funded by Glasgow authorities.
But following a four-year period of stability, Adam’s drinking became problematic again. His father claimed he never received the support he needed.
After his son’s death he requested that NHS Greater Glasgow carry out a Serious Adverse Event Review (SAER) – an internal investigation which aims to “identify lessons learned” and “prevent similar incidents occurring in the future”.
The review, sent in draft form to Fred in June, revealed that when the Alcohol and Drug Recovery Service (ADRS) nurse dealing with Adam’s case left her post in early March 2021, she allocated his case as a “green” or low risk.
He was judged as less vulnerable due to his “supportive family”, and Adam’s claim during telephone consultations that he was abstinent from alcohol.
It meant he was “not identified as a priority for reallocation” and did not have a case manager when he died though the report found hospitalisations should have seen him “flagged up as a person at risk”. The report also noted a “possible risk” of workers “under-rating” patients due to the “excessive workloads” caused by so many staff leaving.
Adam was readmitted to hospital later in March and again on 16 April. Records, claimed the report, are not clear about what follow-up was made.
He had a phone appointment with his ADRS nurse a week later. The report notes that if Adam had been categorised as “amber” or “red” he would have been seen face-to-face.
On the call Adam told the duty nurse he was not drinking and his mood seemed to be “bright”. Twelve days later he was dead.
An initial version of the report found that the issues identified “did not contribute to the event”. But following a meeting between Fred and the medical director of the health board’s addiction services, it has been agreed a final version will state “issues identified may have caused or contributed to the event”, which in this case is Adam’s death.
Fred cannot know if Adam would have survived had his care been different. But he says it is essential that issues are highlighted. “I believe they are responsible for some dreadful omissions of care,” he added.
“It would be nice to get an apology for these failures, without a ‘but’ at the end of it, or an excuse. But I also want to see action rather than just words.
“These things that are highlighted shouldn’t be allowed to happen anymore. They are costing lives. It’s not good enough to keep blaming staffing or Covid. We need proper accountability.”
It angers Fred that the family was not included in Adam’s treatment.
He said: “They would ask him if he was drinking and he’d say: ‘No, everything is hunky dory’. I tried to tell them numerous times what was going on. But they would say they couldn’t speak to me because of data protection.”
Fred says Adam had given permission for the family to be involved but it is suggested in the review that information may not have been transferred from written to electronic notes. No next of kin detail was included on Adam’s records.
Last year Fred was treated for cancer and says the difference in the two services was “stark”. “My family was involved at every stage,” he said. “They phoned my wife before and after my operation to tell her how I was. If she asked a question they would give the information freely and gladly.”
He insists reform must lead to families being included as standard, as well as put an increased emphasis on recovery models, with more people with lived experience of drug and alcohol recovery embedded within the service to offer empathy, support and model positive outcomes.
“Money isn’t always the answer,” he added. “Having the right people in place is much more important. We need people who believe in the service, in recovery, and in offering the right treatments.”
Treatment options should be considered, including residential rehabilitation, he said.
Justina Murray, chief executive of Scottish Families Affected by Alcohol and Drugs, claimed involving families in alcohol and drug treatment could actually help save lives.
“Families are often not fully included even where there has been a death,” she added. “There are lessons for the service – families can contribute and the learning can prevent future tragedy.”
She called for “family inclusive practice needs to be built-in throughout the system” but admitted it was not always in a service’s interests to implement this.
She added: “If you have cancer there’s a clear treatment plan. But when people go for support with alcohol and drug use, that’s not the case.
“Having someone else in the room exposes that. They are the ones who are going to be asking the questions and advocating.” As a result, she says, families are often “hit by a brick wall of GDPR [data protection]”.
“What’s so frustrating for families is they have so much information they want to share,” she said. “Let them share what they know. It benefits everyone.”
Annemarie Ward, chief executive of recovery charity Favor UK, said the experience of the Parry family was a familiar one.
“These kinds of failings are constant,” she added. “When there has been a death like this, services talk about lessons learned. But I’ve seen the same story many times before and so it’s clear lessons haven’t been learned.”
Ward claimed the problem was “cultural” with workers for “multi-million pound services” trying to “manage symptoms of the unmanageable beast of addiction” rather than help people fully recover.
She added: “Many workers have worked there for 25 years and never seen someone recover – they don’t believe it is possible. So people are not met with hope at the door.”
Ward is one of a growing number in the sector who believe it is time to look at partnership services with the third sector – an approach adopted in England in 2012 – which employ a greater percentage of workers with lived experience of recovery.
NHS and the COVID-19 Impact
A spokesperson for NHS Greater Glasgow and Clyde (NHSGGC) said it could not discuss the individual circumstances of any case but added: “We are sorry that Mr Parry feels the care his son received was not up to the standards he would have expected, and that the report he received did not fully answer any questions he might have.
“NHSGGC’s Alcohol and Drug Recovery Services have been impacted by Covid. At times, to comply with nationally agreed Infection Prevention and Control guidance, it has been necessary to manage our contact with individuals and families differently.
“Nevertheless, our services have remained open throughout the pandemic and have maintained contact with people through face-to-face meetings in our offices or at service users’ homes, or by telephone, dependent as far as possible on an assessment of risk and need.”
All treatment referrals have been met within the 21 day waiting time target, they noted, adding: “The Alcohol and Drug Recovery Services work within, and are committed to, a recovery oriented system of care, supporting people through a recovery journey appropriate to their needs.”
A Scottish Government spokesperson said: “No one should die as a result of alcohol consumption, and my thoughts go out to all family and loved ones affected.”
The government is working on a series of “initiatives that will support communities across Scotland to address harmful and hazardous alcohol consumption,” they said.
“We also recognise that families affected by alcohol and drug use should often be involved in their loved one’s treatment and recovery,” the spokesperson added. They cited the government’s Whole Family Approach strategy, launched in December 2021, which aims to ensure “support and treatment is tailored for the whole family unit”.
“We have established an expert working group to support the implementation of this framework in local areas, with a focus on significantly improving the way services work with families,” they said.
Photo Credit: Angela Catlin