Recurring concern

Inadequate engagement with prisoners at risk from drug use

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First reported 18 Sep 2015•Latest report 11 Mar 2026

Definition

What this concern includes

Includes failures in dedicated prison healthcare or drug-recovery arrangements to provide meaningful, safety-focused interaction with prisoners at risk from drug use, including discussing drug use and associated risks, reviewing relevant concerns, identifying warning signs and returning or adapting engagement when initial contact is ineffective.

Not included

  • Excludes generic prison supervision, therapeutic engagement or communication failures where drug-use-related health risk is not a material part of the asserted concern.
  • Excludes failures of medication, drug testing, contraband control or withdrawal treatment where meaningful safety-focused engagement is not the deficient control.
  • Excludes general substance-misuse service capacity or staffing shortages unless they directly result in inadequate engagement with a prisoner at risk from drug use.
  • Excludes failures occurring after relevant drug-use risks have been reliably identified and engaged with, where the remaining issue is treatment or escalation.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
2

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.

Herefordshire and Worcestershire Health and Care NHS Trust1
Hewell Prison1
HM Prison and Probation Service1
Pentonville Prison1
Phoenix Futures1
Practice Plus Group1

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 North London

    AI-generated summary

    Peter Asher CAMPBELL · 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

    Peter Asher Campbell collapsed in his prison cell at Pentonville after smoking a drug and died five days later. The principal concerns were the failure to prevent drugs entering the prison and shortcomings in the prison drug service’s response, including inadequate engagement, harm-minimisation advice, staff training, supervision and auditing.

    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 follow up when recovery-worker engagement is ineffective

    Wider context from the report

    “For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

    Source location

    Peter Asher CAMPBELL · Prevention of Future Deaths report
    Page 3 · 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

    Failure to have meaningful discussions about prisoners’ drug use

    Wider context from the report

    “For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

    Source location

    Peter Asher CAMPBELL · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.

    Verbatim wording from the response

    “Likewise, the points raised under the heading for Phoenix and PPG mainly relate to Phoenix Futures and the steps taken by one of their employees. Whilst we work closely with Phoenix as one of our subcontractors at Pentonville and work together to improve services and continue our strong working partnership, we do not propose to comment on their service or individual employees. We understand that Phoenix will be responding to the points raised separately.”

    Source location

    Response from Practice Plus Group (1)
    Page 3 · response
    Published 17 April 2026

    Open published response

  2. Worcestershire

    AI-generated summary

    Liam SMITH · 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

    Liam Smith was admitted to HMP Hewell on 7 August 2014 and died after taking a combination of prescribed and illicitly obtained medication in his cell. The concerns included possible failures to follow mandatory ACCT procedures, inadequate dissemination and recording of medical information, and limited healthcare interaction with high-risk drug users, potentially resulting in warning signs being missed.

    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

    Limited healthcare staff interaction with prisoners at high risk from drug use

    Wider context from the report

    “(4) Evidence suggested only limited interaction between members of Healthcare Staff and prisoners who were deemed as "high risk drug users" with a concern that warning signs are missed ”

    Source location

    Liam SMITH · Prevention of Future Deaths report
    Page 1 · 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

    Change high-risk drug-user detoxification practices by providing next-day caseworker contact and introducing a follow-up SystmOne ledger within three working days of programme completion.

    Verbatim wording from the response

    “The Trust has confirmed that they have now changed their practices relating to high risk drug users. The initial contact for those undergoing any type of detoxification is from the caseworker who has contact the day after the person is received into the prison. Additionally, a follow up ledger to SystmOne has been introduced within three working days of the detoxification programme ending. An audit will be undertaken within the first quarter of 2016 to check that the processes are working effectively.”

    Source location

    2015-0382-Response-by-NOMS
    Page 2 · response
    Published 18 September 2015

    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

    Audit high-risk drug-user detoxification processes during the first quarter of 2016.

    Verbatim wording from the response

    “The Trust has confirmed that they have now changed their practices relating to high risk drug users. The initial contact for those undergoing any type of detoxification is from the caseworker who has contact the day after the person is received into the prison. Additionally, a follow up ledger to SystmOne has been introduced within three working days of the detoxification programme ending. An audit will be undertaken within the first quarter of 2016 to check that the processes are working effectively.”

    Source location

    2015-0382-Response-by-NOMS
    Page 2 · response
    Published 18 September 2015

    Open published response
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Data last updated 7 September 2026