Recurring concern

Unreliable recording of drug-related deaths and casualties

First to latest report 21 Aug 2023 — 8 Dec 2025

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

What this concern includes

Includes failures to identify, record, collate or maintain data on drug-related deaths or casualties across defined public-safety settings, including music festivals and prisons, where the information is needed to quantify harm, compare risks or assess preventive controls.

What is not included
  • Excludes drug availability, possession, supply, screening or treatment failures where no deficiency in recording drug-related deaths or casualties is identified.
  • Excludes general prevalence data about drug use or disorders when it does not concern deaths or casualties.
  • Excludes individual clinical, coronial or incident records where the shared concern is not a continuing system for recording drug-related deaths or casualties.
  • Excludes unrelated safety data, including general collision, infection or service-activity statistics without a drug-related death or casualty context.

Reports and published responses 2 reports

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

  1. Surrey

    AI-generated summary

    OLIVER MULANGALA · 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

    Oliver Mulangala was in custody at HMP High Down, had epilepsy and a history of serious seizures, and was found dead in his cell on 13 July 2024 after suffering a drug-induced seizure. The report identifies concerns about the easy availability and use of illicit new psychoactive substances in HMP High Down, including their contribution to drug-related deaths, coercion and risks to prisoners. It also raises concerns about the availability of mobile phones and the use of drones to facilitate the delivery of drugs and other contraband into prisons.

    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 hold statistics on drug-related deaths in prisons

    Wider context from the report

    “It is of grave concern that: (1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison (2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales (3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security a. ███ facilitate the delivery of drugs into prison to precise locations at specified times b. ███ can be used to bring in other contraband including weapons and even firearms c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life (4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure. ”

    Source location

    OLIVER MULANGALA · Prevention of Future Deaths report
    Page 5 · concerns

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    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

    Examine all drug-related deaths through the early learning review process and use findings and recommendations to address safety concerns.

    Verbatim wording from the response

    “However, we do monitor such deaths closely and ensure that lessons are learned from them. All drug-related deaths are examined through our early learning review process, in which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the national Safety Group and Drug and Alcohol Group. And we study the outcomes of Prisons and Probation Ombudsman’s reports and ingests in these cases very carefully and take action to address any recommendations and matters of concern that are reported.”

    Source location

    Response from HM Prison and Probation Service
    Page 3 · response
    Published 8 December 2025

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    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

    HMPPS cannot publish a specific drug-related deaths category because such cases cannot be identified accurately within required publication timescales.

    Verbatim wording from the response

    “With regard to the reporting of deaths in custody, we publish Official Safety in Custody Statistics quarterly, but do not have a specific category of ‘drug-related’ in those statistics. For administrative and statistical purposes our classification is by apparent cause of death. This has evolved specifically to help place reliable numbers of deaths in prison custody in the public domain without undue delay, and we do not use the category of ‘drug-related’ in published statistics because it is difficult to identify such cases accurately within the timescale required for our publications.”

    Source location

    Response from HM Prison and Probation Service
    Page 3 · response
    Published 8 December 2025

    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

    More definitive drug-related deaths statistics cannot currently cover later years because incomplete coroner data would reduce result quality.

    Verbatim wording from the response

    “There is inevitably a considerable time lag before more definitive statistics of this type can be produced: the decision was taken for the 2023 publication to stop at 2019 because at the time the Coroner’s data for later years was far from complete, reducing the quality of the results. We hope to collaborate with ONS again to provide a further version of this publication in the future. We also keep the contents of our Official Statistics under continuous review, to ensure their compliance with the three pillars of the Code of Practice for Statistics; trustworthiness, quality and value.”

    Source location

    Response from HM Prison and Probation Service
    Page 3 · response
    Published 8 December 2025

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    David Joseph Celino · 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

    David Joseph Celino, aged 16, took tablets sold as an illicit drug at Leeds Festival in August 2022, developed an adverse reaction, and died after being treated at the festival field hospital and in hospital. The concerns included inadequate information about the number of under-18 attendees, the absence of national oversight and reliable data on drug-related casualties at music festivals, insufficient action to deter drug supply, and a failure by festival staff to identify and assist David as his condition deteriorated.

    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 reliable records of drug-related festival casualties

    Wider context from the report

    “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem. (3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites. ”

    Source location

    David Joseph Celino · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Write to the Secretary of State supporting a national music-festival oversight body and the availability of national drug-related casualty data.

    Verbatim wording from the response

    “The Licensing Committee draws upon available specialist expertise from the multi-agency SAG in its consideration of the EMP for the Leeds Festival. The Council agrees that guidance, oversight and data from a national governing body for music festivals would be extremely valuable in this process and would welcome such a body being introduced. The Licensing Committee chair will write to the Secretary of State to support the introduction of such a body.”

    Source location

    Response from Leeds City Council
    Page 2 · response
    Published 6 September 2023

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    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

    National festival statistics are considered unlikely to assist in reducing drug-related casualties, which are best addressed locally.

    Verbatim wording from the response

    “I do not object to supplying data to a National Database (subject to Data Protection Regulations) but doubt that this will assist in fighting drug related casualties at festivals, concerts or other events. I consider the fight against drugs and the peddling of drugs at festivals is best addressed at a local level.”

    Source location

    Response from Festival Republic 1
    Page 9 · response
    Published 6 September 2023

    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