Recurring concern

Unsafe access to and application of Naloxone guidance

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First reported 5 Aug 2014•Latest report 10 Apr 2026

Definition

What this concern includes

Includes failures of dedicated Naloxone guidance and decision-making controls, including guidance that is difficult to locate, insufficiently accessible, misunderstood, or not applied to appropriate clinical indications.

Not included

  • Excludes generic difficulties with accessing clinical information that are not specifically tied to Naloxone guidance or administration.
  • Excludes failures concerning other medicines, drug interactions, or emergency treatments unless the report directly links them to Naloxone guidance or its indications.
  • Excludes general training, documentation, staffing, or equipment deficiencies that are not specifically dedicated to safe Naloxone access or administration.
Reports
6

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
4

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
Central and North West London NHS Foundation Trust1
General Medical Council1
HM Prison and Probation Service1
Home Office1
Joint Royal Colleges Ambulance Liaison Committee1
Langley Health Centre1
London Ambulance Service NHS Trust1
Mitie1
Mitie Care And Custody Limited1
NHS England1
Nursing and Midwifery Council1
Recipient name withheld1
South Western Ambulance Service NHS Foundation Trust1
the Hillingdon Hospitals 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. Shropshire, Telford and Wrekin

    AI-generated summary

    Wayne AUSTIN · 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

    Wayne Austin became unwell and collapsed at Shrewsbury Probation office on 10 October 2024 after reporting that he had consumed cider; paramedics were subsequently informed that he had consumed crack cocaine. He was treated with CPR, advanced life support and Naloxone, transferred to hospital, and died as a result of combined buprenorphine and alcohol toxicity. Concerns included difficulty locating and applying the appropriate Naloxone guidance, the practical difficulty of complying with dosing guidelines during cardiac arrest, and the number of Naloxone vials carried by ambulances.

    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

    Difficulties in locating the appropriate cardiac-arrest Naloxone guidance on the JRCALC app

    Wider context from the report

    “(1) Difficulties in locating the appropriate tab for cardiac arrest (where opioid toxicity is the likely cause) on the JRCALC app for Naloxone meant it was missed and not applied ”

    Source location

    Wayne AUSTIN · Prevention of Future Deaths report
    Page 2 · 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

    JRCALC and Class Publishing are responsible for resolving the app’s format, navigation and usability issues.

    Verbatim wording from the response

    “The Naloxone Hydrochloride guidance within the JRCALC PLUS App is authored by JRCALC and digitally formatted and published by Class Publishing. WMAS do not have the ability to customise the format, layout, or navigation structure of the JRCALC PLUS App. This includes the location of drugs, the tabs used to access them, and the presentation of reference tables. These design and structural elements are determined centrally by JRCALC and Class Publishing and are applied consistently across all subscribing ambulance services.”

    Source location

    Response from West Midlands Ambulance Service
    Page 2 · response
    Published 17 April 2026

    Open published response

  2. Inner North London

    AI-generated summary

    Frances Ann NEWBURY · 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

    Frances Ann Newbury was found unconscious and not breathing at home on 20 May 2023 after reportedly taking drugs the previous evening; the inquest recorded acute poly drug toxicity, substance misuse disorder and chronic lung disease as the medical causes of death. The principal concern was that paramedics did not administer Naloxone despite being informed of illicit drug use and observing signs associated with drug use, which may affect outcomes in other cases.

    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 administer Naloxone to patients with an opiate misuse history when other potential reversible causes have been treated

    Wider context from the report

    “Despite paramedics being informed that Ms Newbury had taken illicit drugs the previous evening (albeit the report being of ████████) and obvious signs of ‘popping’ scars on her legs from ████████, Naloxone was not administered. Although in Ms Newbury’s case, it would have made no difference, I am concerned that in another case it may. This is not the first inquest in which I have queried why Naloxone has not been administered to patients (with a opiate misuse history) when all other potential reversible causes have been treated. ”

    Source location

    Frances Ann NEWBURY · 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

    Request a review of current JRCALC guidance on naloxone use in opioid-related cardiac arrest.

    Verbatim wording from the response

    “Overall the evidence base suggests that where cardiac arrest is established and confirmed from opioid use, naloxone has limited efficacy in reversing the cardiac arrest. The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Practice Guidance advise the use of naloxone in cardiac arrest, noting that this has been unchanged and more recently the empirical reviews of the clinical evidence have been undertaken. I have asked that our Consultant Paramedics and Associate Clinical Directors who both are members of the JRCALC resuscitation group, request that a review is undertaken of JRCALC current guidance in light of the emerging clinical evidence, in respect of opioids.”

    Source location

    Response from London Ambulance Service
    Page 3 · response
    Published 14 November 2023

    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

    Provide high-concentration naloxone on specialist Trust resources for cases involving potentially potent synthetic opioids.

    Verbatim wording from the response

    “That said, the LAS is absolutely of the view that naloxone should be administered where a patient presents with respiratory depression and/or is peri (near) arrest, in this instance it is recognised to be lifesaving and we absolutely support its administration. In March 2022, the London Ambulance Service initiated the availability of high concentration naloxone on specialist resources utilised by the Trust. This was in recognition of the potential for highly potent synthetic opioids where stronger doses of naloxone may be required. We are also highly supportive of naloxone in community programs, for those where there is a high risk of overdose.”

    Source location

    Response from London Ambulance Service
    Page 3 · response
    Published 14 November 2023

    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

    Work with agencies regularly contacting opioid users to improve naloxone availability.

    Verbatim wording from the response

    “increasing the accessibility to public access defibrillators and trained responders and we are working with our agencies who have regular contact with opioid users around utility of naloxone to be available to them.”

    Source location

    Response from London Ambulance Service
    Page 4 · response
    Published 14 November 2023

    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

    Established cardiac arrest and absent immediate opioid-use evidence meant naloxone was not mandated and would not have changed the outcome.

    Verbatim wording from the response

    “Whilst it is recognised that Ms Newbury had a long term history of opioid use, naloxone was not considered at the time of the cardiac arrest as there was no immediate history of opioid use and a clinically feasible cause of the arrest was identified, which was a current infection. The resuscitation attempt focused on high quality chest compressions and effective ventilation. It was recognised by the clinicians that naloxone would not have reversed the effects of ████████. The information reported to the clinicians at the time of attendance was that Ms Newbury had taken ████████ the previous evening.”

    Source location

    Response from London Ambulance Service
    Page 1 · response
    Published 14 November 2023

    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

    For confirmed cardiac arrest, standard resuscitation with high-quality compressions and ventilation should take priority over naloxone.

    Verbatim wording from the response

    “Asphyxia (deprivation of oxygen), through the respiratory depression (reduction in an individual’s breathing), develops and this leads to further cerebral hypoxia. Ultimately it is the hypoxia/hypercarbia which cause a diminishing cardiac output and may finally sadly result in a patient’s cardiac arrest. Where a patient is in cardiac arrest, there is immediate and ongoing artificial ventilation in an attempt to correct any ventilatory failure. Naloxone is a competitive antagonist (receptor site blocker) for the opioid and its administration aims to diminish the effects of the opioid, however, once a patient is in cardiac arrest (as opposed to respiratory arrest) the focus should be on high quality standard life support including artificial ventilation, chest compressions and adrenaline administration.”

    Source location

    Response from London Ambulance Service
    Page 2 · response
    Published 14 November 2023

    Open published response

  3. East Sussex

    AI-generated summary

    Neville Lewis MCNAIR · 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

    Neville Lewis MCNAIR was found unresponsive in his cell at HMP Lewes on 16 June 2018 and could not be revived after extensive CPR. The inquest concluded that the cause involved heroin toxicity with aspiration, and raised concerns about the availability of Naloxone in prison wings and prison officers’ training and awareness of its use.

    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 a local protocol for accessing and administering Naloxone

    Wider context from the report

    “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally. ”

    Source location

    Neville Lewis MCNAIR · 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

    Determine how prison staff could identify opioid overdoses and administer naloxone, including the training required.

    Verbatim wording from the response

    “I am committed to working with NHSE&I to make naloxone more readily available across the prison estate. This is not straightforward, and there are risks to both staff and prisoners that need to be managed. For this reason, the current position is that it is being administered only by healthcare professionals. There are a number of issues that require further consideration before we can move forward to involve prison staff more widely. Identifying a potential opioid overdose and administering treatment for it has not previously been a part of the role of prison officers and other non-clinical staff in prisons, and we will need to consider precisely how this will work in practice, and what training we will need to provide to equip staff to take it on. We will also need to consult trade unions as we develop our approach.”

    Source location

    Response from HM Prisons and Probation Service
    Page 1 · response
    Published 27 December 2019

    Open published response

  4. London (West)

    AI-generated summary

    Amir Siman-Tov · 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

    Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

    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 administer naloxone in suspected opiate overdose

    Wider context from the report

    “14. An emergency bag was brought containing adrenaline autoinjector and also naloxone which Dr Harris said was a temporary antidote to opiates. A nurse gave an injection of adrenaline into the thigh “because he thought it might help”. Naloxone was not given, even though ████████ had required emergency admission the day prior because of an opiate overdose. This puts detainees at risk. ”

    Source location

    Amir Siman-Tov · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Inner South London

    AI-generated summary

    Laurence Boyens · 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

    Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.

    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 recognise appropriate indications for Naloxone administration

    Wider context from the report

    “4. ████████ ████████ was represented at the inquest and the following evidence gave rise to concerns: • He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison. • When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam. • He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing. • He said that he did not know whether he should stop Methadone if the BP was low. • Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy. • At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered. • At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered. • He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives. ”

    Source location

    Laurence Boyens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Exeter and Greater Devon

    AI-generated summary

    Clare Louise BAIN · 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

    Clare Louise BAIN, who was prescribed Methadone and Valium, was found collapsed after ingesting a fatal quantity of prescribed and non-prescribed Methadone and Valium. She initially responded to Naloxone but later suffered cardiac arrest and died. The concerns were that paramedics may have treated the incident as a heroin overdose and that insufficient repeat Naloxone could fail to counteract the longer respiratory-depressant effects of Methadone.

    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 provide repeat naloxone treatment doses while opiates remain active

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) That given Deceased had declined to go to hospital the paramedics were under the impression that this was a heroin overdose and the use of one dose Naloxone was sufficient to counteract the effects of the opiate. (2) If paramedics are unaware that the respiratory depressive effects of Methadone last longer that the antagonism afforded by Naloxone there is a danger of further deaths because lack of repeat treatment doses of Naloxone when opiates are still active. ”

    Source location

    Clare Louise BAIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026