Recurring concern

Unreliable response to Spice-related incidents in prisons

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First reported 28 Aug 2020•Latest report 15 Dec 2025

Definition

What this concern includes

Includes prison processes for recognising, communicating, escalating, medically assessing, monitoring and taking formal protective action in response to presumed or identified Spice-related incidents.

Not included

  • Excludes generic prison illicit-substance supply, access or use concerns where no deficient response to a Spice-related incident is identified.
  • Excludes generic prison violence, healthcare communication or emergency-response failures without a material Spice-related incident context.
  • Excludes clinical treatment after the incident has been reliably escalated and assessed.
  • Excludes unrelated synthetic-substance or intoxication concerns unless the assertion explicitly concerns Spice-related incidents.
Reports
2

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2020–2025

First to latest report issue date

Stated actions
5

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Belmarsh Prison1
Ministry of Justice1
Morton Hall Prison1
Nottinghamshire Healthcare NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Sundeep Ghuman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sundeep Ghuman was a prisoner at HMP Belmarsh who was placed in a triple cell with a prisoner known to have racist and violent behaviour. On 18 February 2020, that prisoner violently assaulted Mr Ghuman with a table leg, and Mr Ghuman died in hospital on 19 February 2020 from a head injury. The principal concerns included failures in the CSRA process and training, inadequate treatment of racism alerts and other risk information, insufficient consideration of risks when allocating cellmates, and wider concerns about violence and drug use at HMP Belmarsh.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to take robust action and formal measures in response to widespread Spice use

    Wider context from the report

    “The evidence overall was that HMP Belmarsh has widespread levels of violence by prisoners against other prisoners, and seemingly ubiquitous levels of Spice use in the prison. This seems to be at a level where staff do not consider that they can always take robust action and formal measures when this occurs. In those circumstances, I have a concern that the Prison may not currently be capable of providing a safe and secure environment for prisoners accommodated there, and that there is a risk of future deaths from drug use or violence. ”

    Source location

    Sundeep Ghuman · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement Incentivised Substance Free Living Units across 88 prisons, including behavioural compacts, testing, and enhanced recovery opportunities.

    Verbatim wording from the response

    “We also continue to work closely with health partners to address substance misuse. This includes the implementation of Incentivised Substance Free Living Units in 88 prisons, including HMP Belmarsh, where prisoners commit to behavioural compacts, regular drug testing, and access to enhanced opportunities. We have embedded 54 Drug Strategy Leads in key establishments, and appointed 17 Group Drug and Alcohol Leads who are now embedded to provide strategic oversight. The Adult Health, Care and Wellbeing Core Capabilities Framework was introduced in May 2025, and through the Enable Programme, MoJ, HMPPS, and NHS England are accelerating specialist training on drugs, alcohol dependency, and trauma-informed care. Additionally, a comprehensive redesign of Foundation Training for new prison officers is underway, including mandatory modules on drug and alcohol misuse for all staff.”

    Source location

    Response from HM Prison & Probation Service
    Page 5 · response
    Published 18 December 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed Drug Strategy Leads and Group Drug and Alcohol Leads to provide establishment-level coordination and strategic oversight.

    Verbatim wording from the response

    “We also continue to work closely with health partners to address substance misuse. This includes the implementation of Incentivised Substance Free Living Units in 88 prisons, including HMP Belmarsh, where prisoners commit to behavioural compacts, regular drug testing, and access to enhanced opportunities. We have embedded 54 Drug Strategy Leads in key establishments, and appointed 17 Group Drug and Alcohol Leads who are now embedded to provide strategic oversight. The Adult Health, Care and Wellbeing Core Capabilities Framework was introduced in May 2025, and through the Enable Programme, MoJ, HMPPS, and NHS England are accelerating specialist training on drugs, alcohol dependency, and trauma-informed care. Additionally, a comprehensive redesign of Foundation Training for new prison officers is underway, including mandatory modules on drug and alcohol misuse for all staff.”

    Source location

    Response from HM Prison & Probation Service
    Page 5 · response
    Published 18 December 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement an HMP Belmarsh Drug Strategy covering illicit-substance supply, demand, detoxification, recovery, and safety.

    Verbatim wording from the response

    “Supported by these national initiatives, HMP Belmarsh has reviewed and implemented a number of measures to strengthen drug-misuse management, recovery support and overall safety within the establishment. A comprehensive Drug Strategy is embedded across the”

    Source location

    Response from HM Prison & Probation Service
    Page 5 · response
    Published 18 December 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate incentivised substance-free living, mandatory drug testing, disciplinary enforcement, structured support, and monthly multidisciplinary recovery-plan reviews at HMP Belmarsh.

    Verbatim wording from the response

    “A key development is the implementation of an Incentivised Substance-Free Living (ISFL) unit. This dedicated wing is designed to promote recovery and abstinence, with prisoners signing a formal compact committing to monthly drug testing. Those engaging with the ISFL scheme are able to access additional incentives, including extended domestic periods, increased gym access, and enhanced wing-level provisions. This approach has had a positive impact on stability across the prison and has contributed to reductions in drug misuse.”

    Source location

    Response from HM Prison & Probation Service
    Page 6 · response
    Published 18 December 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen drug-risk governance through a dedicated lead, monthly multidisciplinary meetings, recovery provision, lived-experience courses, and staff training.

    Verbatim wording from the response

    “Governance arrangements have also been strengthened. A dedicated Drug Strategy Lead oversees the coordination of activity across security, healthcare, residential units, and external partners. Monthly multi-disciplinary meetings are held to monitor trends, review incidents, and manage emerging risks. In addition, recovery and rehabilitation provision remains a central focus. The partnership with Phoenix Futures continues to deliver treatment and harm-reduction support. Lived Experience courses and staff training are in place to improve prisoner engagement and ensure continuity of care on release. These measures have supported high levels of community recovery engagement post-custody.”

    Source location

    Response from HM Prison & Probation Service
    Page 6 · response
    Published 18 December 2025

    Open published response

  2. Lincolnshire

    AI-generated summary

    Carlington Maurice Spencer · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clear escalation pathways for presumed Spice-related incidents

    Wider context from the report

    “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely: a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel); b. Concerns of co-detainees are not appreciated or noted or actively sought; c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel; d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice"; e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident; f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency; g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory; ”

    Source location

    Carlington Maurice Spencer · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of instructions on duration of conservative observation for presumed Spice consumption

    Wider context from the report

    “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely: a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room); b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities; c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency; d. Failure to consult information contained on the Illicit Substance Misuse Programme; e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption; f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident; g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances"; ”

    Source location

    Carlington Maurice Spencer · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of escalation protocols recognising healthcare primacy in ongoing detainee care

    Wider context from the report

    “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely: a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room); b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities; c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency; d. Failure to consult information contained on the Illicit Substance Misuse Programme; e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption; f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident; g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances"; ”

    Source location

    Carlington Maurice Spencer · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
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Data last updated 7 September 2026