Recurring concern

Insufficient dedicated substance-misuse support in custody

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First reported 17 Jan 2014•Latest report 21 Oct 2019

Definition

What this concern includes

Includes failures of dedicated substance-misuse support in custodial settings, including unavailable or insufficient substance-misuse teams, dedicated officers, staffing, cover or specialist support where the deficiency leaves detainees without the support needed to manage substance-related risks.

Not included

  • Excludes generic prison, police-custody or healthcare staffing shortages where dedicated substance-misuse support is not the identified unsafe condition.
  • Excludes general substance-misuse treatment or service-access failures outside custody settings.
  • Excludes clinical treatment, withdrawal management or drug-testing failures where dedicated custodial substance-misuse support is not deficient.
  • Excludes ordinary supervision or security staffing unrelated to supporting detainees with substance-misuse needs.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2019

First to latest report issue date

Stated actions
0

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.

Department of Health and Social Care1
G4S Forensic & Medical Services (UK) Ltd1
HM Prison and Probation Service1
National Police Chiefs’ Council1
NHS England1
Nottingham Prison1
Nottinghamshire Healthcare NHS Foundation Trust1
Recipient name withheld1
Serco Wincanton Court Services1
Wormwood Scrubs Prison1

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. West London

    AI-generated summary

    Harold Chukwudemu Uzomechina · 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

    Harold Chukwudemu Uzomechina died in prison on 24 April 2016 after being found unresponsive in his cell and not responding to CPR. The inquest concluded that he died a drug-related death, with failure to recognise signs of cardio-respiratory depression contributing. Concerns included inadequate overnight physical monitoring and differing levels of care and attention for detainees in the substance misuse unit compared with those formerly on an ACCT.

    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

    Unavailability of dedicated prison officers for substance misuse unit detainees at night

    Wider context from the report

    “1. There appeared to be differential treatment of detainees on the substance misuse unit at night compared to treatment they received during the day – specifically, detainees had the benefit of dedicated prison officers during the day time but not during the night. ”

    Source location

    Harold Chukwudemu Uzomechina · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Nottinghamshire

    AI-generated summary

    Shalan Blackwood · 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

    Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.

    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 staffing of the Substance Misuse Team

    Wider context from the report

    “3. That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr Blackwood’s are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future. ”

    Source location

    Shalan Blackwood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. North London

    AI-generated summary

    Wayne Spencer Malcolm Broad · 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 Spencer Malcolm Broad was arrested while under the influence of alcohol and became unwell during transfer between police custody, court and hospital. He later developed delirium tremens, collapsed despite resuscitation and died after suffering a hypoxic injury. Concerns included the lack of a dedicated substance misuse team in police custody, the need for alignment of handcuffing procedures with guidance for seriously ill detainees, and the availability of specially trained nursing staff for patients with substance misuse.

    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

    Unavailability of a dedicated substance misuse team in police custody suites

    Wider context from the report

    “(1) That was no dedicated substance misuse team available to look after Mr Broad when he was in the custody suite at Hatfield Police Station, as there would have been had Mr Broad been detained in prison. ”

    Source location

    Wayne Spencer Malcolm Broad · 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

    The current contract does not provide for dedicated substance misuse teams at police stations.

    Verbatim wording from the response

    “G4S Forensic and Medical Service are responsible for the provision of medical services to Hertfordshire Police as defined in a specific contract written by Hertfordshire Police (“the Contract”), which does not at this time, provide for putting a dedicated substance misuse team into each of the police stations served by the Contract. Rather, the Contract requires us to provide medical staff to deal with a wide range of issues from the confirmation of death, intimate examinations of victims of sexual assault, advice on medical issues across a wide spectrum of circumstances and the provision of face to face clinical treatment of those detained in custody.”

    Source location

    2014-0020R2_Redacted
    Page 1 · response
    Published 17 January 2014

    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

    A dedicated substance misuse team in police custody is not viable because police forces lack the facility and detention costs and timescales are prohibitive.

    Verbatim wording from the response

    “I note your recommendation that Hertfordshire ought to have a substance misuse team available at the police station, similar to that which would be provided within the Prison Service. Unfortunately this is not a facility that police forces have available; the cost and relatively short timescales of police detention mean this is not a viable or cost effective option for forces. We do however take our duty of care for the welfare of detainees very seriously and provide medical care in custody which effectively triages our detainees to assess that they are fit to be detained and are kept safe.”

    Source location

    2014-0020R3_Redacted
    Page 1 · response
    Published 17 January 2014

    Open published response
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Data last updated 7 September 2026