Recurring concern

Insufficient inpatient detoxification capacity

First to latest report 2 Aug 2017 — 18 Dec 2017

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
2

What this concern includes

Includes shortages, unavailable facilities, insufficient beds or stabilisation places, and resulting access delays or out-of-area placement for people requiring inpatient detoxification, including detoxification capacity in custodial or community-linked settings.

What is not included
  • Excludes general substance-misuse treatment, outpatient detoxification or recovery-support deficiencies where inpatient detoxification capacity is not the unsafe condition.
  • Excludes generic prison staffing, healthcare access or bed-capacity concerns unless they directly limit inpatient detoxification places or stabilisation capacity.
  • Excludes psychiatric inpatient capacity and mental-health placement shortages where detoxification capacity is not materially involved.
  • Excludes delays or poor treatment after an appropriate inpatient detoxification place has been secured.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Exeter and Greater Devon

    AI-generated summary

    Stephen Mark SHAYLOR · 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

    Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.

    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

    Insufficient stabilisation-wing capacity for inmates needing detoxification

    Wider context from the report

    “(1) There were 38 places available on a corridor in C4 wing as a stabilisation wing for dealing with inmates subject to Healthcare night welfare checks. Head of Residence and Safety told the Court that the Prison received between 60 – 80 inmates per week needing detox and requiring placement in C4 cells which had doors with larger windows for checking patients at night. ”

    Source location

    Stephen Mark SHAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Thomas Christall · 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

    Thomas Christall’s inquest concluded that he took his own life. Concerns included the lack of a local inpatient detoxification facility, long waiting times, and insufficiently collaborative treatment for people with dual diagnosis, with delays and refusals increasing distress and despair.

    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 local in-patient detoxification facility availability

    Wider context from the report

    “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK? ”

    Source location

    Thomas Christall · Prevention of Future Deaths report
    Page 2 · 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

    Delays in access to in-patient detoxification

    Wider context from the report

    “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK? ”

    Source location

    Thomas Christall · Prevention of Future Deaths report
    Page 2 · 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

    Provide out-of-city inpatient detoxification through City Roads, supported by service-user consultation, pathway planning and visits to establish the replacement service.

    Verbatim wording from the response

    “In December 2015 Sussex Partnership NHS Foundation Trust gave notice that they would be terminating their substance misuse in-patient detoxification service from the 31st March 2016. The in-patient detoxification services at Mill View Hospital were no longer financially or clinically viable, following the withdrawal of a number of London Boroughs from their contract with Sussex Partnership NHS Foundation Trust. There was no alternative equivalent service in Brighton and Hove. The public health department elected to work with Cranston, the lead provider in the Pavilions Community Substance Misuse Services partnership, and to refer patients to their inpatient detoxification unit in London. Cranston have been providing this service from the City Roads location in London for a significant period of time, and patients come from many areas of the country.”

    Source location

    2017-0321-Response-by-Brighton-Hove-City-Council
    Page 1 · response
    Published 3 December 2017

    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

    Review City Roads referrals through a multidisciplinary meeting, complete a pre-admission checklist, prepare patients for admission, and develop aftercare plans before detoxification.

    Verbatim wording from the response

    “In general patients are admitted to City Roads within ten days of having their assessment by the Pavilions doctor. All referrals to City Roads are reviewed at a multidisciplinary team meeting where a pre-admission checklist is completed. This includes service preparation work to ensure that an individual understands what will be required of them once they are in residence at the unit. This preparation work aims to ensure that people are referred at a point in their recovery journey where they are most likely to be successful. The aftercare support plan for once a person has successfully completed detoxification is also developed before the individual goes to City Road. This helps to ensure that the ongoing support a person will need to continue their recovery is in place.”

    Source location

    2017-0321-Response-by-Brighton-Hove-City-Council
    Page 2 · response
    Published 3 December 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Brighton and Hove City Council is responsible for commissioning local substance misuse services.

    Verbatim wording from the response

    “The commissioning of local substance misuse services is undertaken by Brighton and Hove City Council. The local substance misuse services in Brighton and Hove were being provided by Sussex Partnership NHS Foundation Trust. In 2014 the service was put out to a tendering process by Brighton and Hove City Council. Sussex Partnership put in a full proposal and bid to keep the local substance misuse services as we recognise the value for patients and their families for services to be local to their homes, and the high number of service users who have mental health needs and substance misuse needs. Unfortunately, Sussex Partnership NHS Foundation Trust were not chosen by the commissioners of the service, Brighton and Hove City Council, to continue to provide this service. Sadly, it is not within our gift to provide these services if we are not commissioned to provide them by the commissioners.”

    Source location

    2017-0321-Response-by-Susssex-Partnership-NHS-Trust
    Page 1 · response
    Published 3 December 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Trust cannot provide local substance misuse services without being commissioned by Brighton and Hove City Council.

    Verbatim wording from the response

    “The commissioning of local substance misuse services is undertaken by Brighton and Hove City Council. The local substance misuse services in Brighton and Hove were being provided by Sussex Partnership NHS Foundation Trust. In 2014 the service was put out to a tendering process by Brighton and Hove City Council. Sussex Partnership put in a full proposal and bid to keep the local substance misuse services as we recognise the value for patients and their families for services to be local to their homes, and the high number of service users who have mental health needs and substance misuse needs. Unfortunately, Sussex Partnership NHS Foundation Trust were not chosen by the commissioners of the service, Brighton and Hove City Council, to continue to provide this service. Sadly, it is not within our gift to provide these services if we are not commissioned to provide them by the commissioners.”

    Source location

    2017-0321-Response-by-Susssex-Partnership-NHS-Trust
    Page 1 · response
    Published 3 December 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Out-of-city inpatient detoxification is not necessarily inadequate; limited local availability and separation from home may support successful detoxification.

    Verbatim wording from the response

    “In December 2015 Sussex Partnership NHS Foundation Trust gave notice that they would be terminating their substance misuse in-patient detoxification service from the 31st March 2016. The in-patient detoxification services at Mill View Hospital were no longer financially or clinically viable, following the withdrawal of a number of London Boroughs from their contract with Sussex Partnership NHS Foundation Trust. There was no alternative equivalent service in Brighton and Hove. The public health department elected to work with Cranston, the lead provider in the Pavilions Community Substance Misuse Services partnership, and to refer patients to their inpatient detoxification unit in London. Cranston have been providing this service from the City Roads location in London for a significant period of time, and patients come from many areas of the country.”

    Source location

    2017-0321-Response-by-Brighton-Hove-City-Council
    Page 1 · response
    Published 3 December 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Brighton & Hove City Council’s Public Health department is responsible for commissioning adult and substance misuse inpatient detoxification beds.

    Verbatim wording from the response

    “As a CCG we are very keen to reflect on the services we commission with a view to making improvements and avoiding future patient harm. Brighton & Hove City Council’s Public Health department is the responsible commissioner for the adult and substance misuse in-patient detoxification beds. ████████ Interim Director of Public Health has therefore provided a reply although he and his team were not named in the report.”

    Source location

    2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
    Page 1 · response
    Published 3 December 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026