Recurring concern

Inadequate control of illicit substance use and supply in secure institutions

First to latest report 28 Oct 2015 — 24 Mar 2026

Reports that mention this concern
23
Times this concern has been raised
30
Stated actions linked to this concern
61

What this concern includes

Includes failures of controls specifically dedicated to preventing, detecting, investigating or responding to illicit substance entry, supply, distribution or use in secure hospitals, prisons and comparable secure institutional settings, including searches, testing, intelligence, supply-reduction strategies, risk investigation, warnings and safeguarding or clinical response where directly tied to the illicit-substance concern.

What is not included
  • Excludes ordinary medication-security, prescribing, dispensing or administration failures where illicit substances are not the material concern.
  • Excludes generic staffing, communication, training or governance deficiencies unless they directly impair control of illicit substance entry, supply, distribution or use in a secure institution.
  • Excludes substance-use treatment or withdrawal-management failures where the issue is not control of illicit substances entering, circulating or being used in the secure institution.
  • Excludes general violence, self-harm, overdose or prisoner-safety concerns without a specific illicit-substance control failure.
  • Excludes community or public illicit-drug supply concerns without a secure-institution setting.

Reports and published responses 23 reports

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

  1. Hertfordshire

    AI-generated summary

    KRISTOPHER COREY JAMIE LEE TILBURY · 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

    Kristopher Corey Jamie Lee Tilbury died in his prison cell at HMP The Mount after smoking a synthetic cannabinoid and consuming alcohol, causing respiratory depression. The report raised concerns that illicit drugs and alcohol remained widely available at the prison, including on a wing for prisoners with substance misuse issues, creating a significant risk of future deaths.

    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

    Weak and unembedded illicit drug supply reduction work

    Wider context from the report

    “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors found that levels of violence were comparatively high and mostly related to drugs and debt. They found that less than half of required intelligence led searches were completed and most suspicion drugs tests were missed. They reported that mandatory drug testing indicated that nearly a third of prisoners were using illicit drugs, and that this undermined the prison’s ability to remain safe. The inspectors found that drug supply reduction work was weak and not embedded in the wider strategy, and that half of the prisoners said it was easy to access illicit drugs. The proportion of positive mandatory drug tests, including for psychoactive substances (████████), was high at 32%. (2) In the report of the Independent Monitoring Board for the year to February 2019 it was noted that drugs were widely available in the prison. (3) Mr Tilbury died on 24th September 2019 and was found dead in his cell. The medical cause of his death was established by the pathologist at the inquest as respiratory depression caused by the combined use synthetic cannabinoids and alcohol. (4) The Prisons and Probation Ombudsman carried out an independent investigation into the death of Mr Tilbury on 24th September 2019 at the Mount. The report was produced, as a result of this investigation, in March 2020. The report concluded that it was extremely troubling that Mr Tilbury was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues. The report concluded that much more needed to be done to tackle the issue of illicit substances at the prison, and the Governor should ensure that key drug issues at the Mount are identified and that the prison’s local drug strategy be appropriately revised to address them. (5) Since the death of Mr Tilbury, and the Prisons and Probation Ombudsman’s, report four other prisoners have died at HMP The Mount as a result of taking ████████, namely: a. Prisoner X ████████ – died on 14th July 2022 b. Prisoner Y ████████ – died on 25th July 2022 c. Prisoner Z ████████ – died on 6th January 2023 d. Prisoner W ████████ – died on 26th January 2023 (6) At the inquest the court heard evidence from prison officers that they encountered ‘spice’ every day in the prison and the problem of drugs in the prison in seems to be the same as it was in 2019. (7) At the inquest the Head of Safety at HMP The Mount advised the court that the percentage of positive Mandatory Drug Tests in 2023 (at the date of the inquest) was 26.21% (compared to 32% in 2018). ████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████ (9) Four years after the death of Mr Tilbury, drugs and alcohol are still widely available in HMP The Mount, and continue to create a significant risk of future deaths. ”

    Source location

    KRISTOPHER COREY JAMIE LEE TILBURY · Prevention of Future Deaths report
    Page 2 · concerns

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  2. Buckinghamshire

    AI-generated summary

    Haik Patrick NIKOLYAN · 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

    Haik Patrick NIKOLYAN committed suicide and was found unresponsive in his cell at HMYOI Aylesbury in the early hours of 11 March 2019. The inquest identified concerns including failures to protect him from harm, withdrawal of depression medication without documented risk assessment or enhanced monitoring, bullying and exploitation, ineffective safeguarding and communication, and inadequate consideration of his Autism Spectrum Disorder.

    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

    Access to illicit substances within the prison

    Wider context from the report

    “The evidence heard at this Inquest in July 2023 indicates that general staffing levels are likely to impact upon the operation of the daily regime, training and reaction to individual incidents, against a background of increasing levels of violence and access to illicit substances, resulting from the changing cohort of longer-term and older prisoners within this Category C institution. ”

    Source location

    Haik Patrick NIKOLYAN · 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

    Review the adjudication tariff and process for drug-related incidents, county lines and criminal exploitation.

    Verbatim wording from the response

    “Considerable work continues to be undertaken to reduce the availability and use of drugs within HMP Aylesbury. A National and Group Drug Strategy support visit has included a review of the adjudication tariff and process for drug related incidents including positive MDT results, and a review of county lines and criminal exploitation. Conversations are additionally underway with Public Health and Commissioners to support the strategy of improving staff and prisoner”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

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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

    Work with Public Health and Commissioners to improve substance-misuse awareness and support drug-supply reduction, demand reduction and recovery.

    Verbatim wording from the response

    “Considerable work continues to be undertaken to reduce the availability and use of drugs within HMP Aylesbury. A National and Group Drug Strategy support visit has included a review of the adjudication tariff and process for drug related incidents including positive MDT results, and a review of county lines and criminal exploitation. Conversations are additionally underway with Public Health and Commissioners to support the strategy of improving staff and prisoner”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

    Open published response

  3. Dorset

    AI-generated summary

    Jason Anthony Williams · 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

    Jason Anthony Williams was found unresponsive in his cell at HMP Guys Marsh on 31 July 2020, and his death was confirmed by paramedics. The report states that synthetic cannabinoid intoxication was the medical cause of death and that he had deliberately taken drugs without intending fatal consequences. Concerns included inadequate guidance on vulnerable prisoners, shortcomings in the keyworker programme and NOMIS record keeping, and the absence of a Governor notice about increased psychoactive-substance risks.

    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 issue Governor notices in response to increased psychoactive substance risks

    Wider context from the report

    “iv. A Governor notice was not issued in the time leading up to Jason’s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances. I request that consideration is given to a review being undertaken by HMP Guys Marsh as to when such notices should be issued, particularly in relation to increased risks to prisoners around drug use. ”

    Source location

    Jason Anthony Williams · 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

    Operate a weekly multidisciplinary Restrict Supply Tasking Group to share drug-ingress information and identify potentially dangerous substances.

    Verbatim wording from the response

    “In respect of your last concern, HMP Guys Marsh have introduced a new weekly meeting (Restrict Supply Tasking Group) which is attended by a multi-disciplinary team. The purpose of this meeting is to discuss and share information regarding the drug ingress into the prison, and to identify any specific strains and substances that are potentially dangerous. If the risks identified require further action, a Governor’s Notice To Staff and a prisoners’ notice highlighting the risks and concerns will be issued. Further to this, known prolific substance misuse users will be issued with harm minimisation guidance and support.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 13 February 2023

    Open published response

  4. Dorset

    AI-generated summary

    Kyle Nel · 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

    Kyle Nel, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell on 9 June 2018 and was subsequently declared dead after resuscitation attempts. The inquest recorded the medical cause of death as aspiration of gastric contents associated with synthetic cannabinoid (5F-ADB), also known as “Spice”, use, with a conclusion of misadventure. Concerns included the prison’s handling and recording of welfare concerns raised by families and the ability to pass drugs and other prohibited items between prison units through security fences.

    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 of prison security fences to prevent the transfer of drugs and other prohibited materials between prisoners

    Wider context from the report

    “ii) The security fences within the prison estate need to be reviewed and consideration urgently given to prevent drugs and other prohibited materials being passed between prisoners through the fences. ”

    Source location

    Kyle Nel · Prevention of Future Deaths report
    Page 3 · 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

    Conduct diagnostic checks of internal and external perimeters, including fences and gates, to identify drug-supply vulnerabilities and report findings to establishments.

    Verbatim wording from the response

    “The national Drug Strategy and Delivery team conduct diagnostic visits, checking internal and external perimeters (including fences and gates), to identify any vulnerabilities relating to drug dealing which are reported back to establishments to take action. HMP Guys Marsh has also been included in the accelerator project, where selected prisons have received additional resources in certain areas. At HMP Guys Marsh this includes a dedicated drug strategy manager who has been in place since Autumn 2021 and is making a positive impact on the local drug strategy processes. The project has now received additional funding and will be extended for three years to further support efforts to tackle the problem of drugs in prisons.”

    Source location

    2021-0426-Response-from-HMPPS_Published
    Page 2 · response
    Published 23 December 2021

    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

    Existing security fences at HMP Guys Marsh meet agreed national requirements, so further review is not identified as necessary.

    Verbatim wording from the response

    “The second concern you raise recommends that consideration should be given to reviewing the security fences used within the prison estate to prevent drugs and other prohibited items from being passed between prisoners. As a category C prison, the security fences in place at HMP Guys Marsh meet the current agreed national requirements necessary to keep prisoners safe and secure. I wish to assure you that the work being carried out nationally by the Drug Strategy Team and filtered down into each establishment is focused on restricting the supply of drugs in prisons, supporting prisoners to reduce and avoid substance misuse, and providing the help and treatment they need to maintain their recovery.”

    Source location

    2021-0426-Response-from-HMPPS_Published
    Page 2 · response
    Published 23 December 2021

    Open published response

  5. Dorset

    AI-generated summary

    Anthony John Larcher · 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

    On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.

    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 observations and welfare checks for prisoners found under the influence of psychoactive substances

    Wider context from the report

    “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS). ”

    Source location

    Anthony John Larcher · Prevention of Future Deaths report
    Page 5 · 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

    Gather information from regional prison safety groups about local initiatives for observations and welfare checks.

    Verbatim wording from the response

    “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.”

    Source location

    2021-0356-Response-from-HMPPS_Published
    Page 1 · response
    Published 22 October 2021

    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

    Discuss nationally rolling out local drug-related safety initiatives with the NHSE/I national team.

    Verbatim wording from the response

    “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.”

    Source location

    2021-0356-Response-from-HMPPS_Published
    Page 1 · response
    Published 22 October 2021

    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

    HMPPS is responsible for deciding whether local welfare, substance intervention and life-support processes should be rolled out nationally.

    Verbatim wording from the response

    “1. Consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP), and the Custodial Officer Intermediate Life Support initiatives (COILS).”

    Source location

    2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 1 · response
    Published 22 October 2021

    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

    Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.

    Verbatim wording from the response

    “We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these.”

    Source location

    2021-0356-Response-from-NHS-Digital_Published
    Page 1 · response
    Published 22 October 2021

    Open published response

  6. North Wales (East and Central)

    AI-generated summary

    Luke Morris Jones · 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

    Luke Morris Jones, a prisoner at HMP Berwyn, was found unresponsive after smoking a novel psychoactive substance and died on 31 March 2018 despite medical intervention. The report identified concerns about the accessibility and continuing availability of novel psychoactive substances in the prison and the associated risks to health.

    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

    Inadequate control of access to novel psychoactive substances within the prison

    Wider context from the report

    “The report of the Prisons and Probation Ombudsman highlighted that there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken at HMP Berwyn (namely in relation to the installation of a Rapiscan to test some of the incoming mail), evidence at the inquest confirmed that the continuing availability and use of novel psychoactive substances. By way of example, the evidence of the prison GP indicated that at least one instance of a prisoner being intoxicated was reported to him each day which he worked and as a result I consider it highly probable that the combination of the accessibility of NPS and the significant risks which they pose to health will be the cause of future deaths at the prison. ”

    Source location

    Luke Morris Jones · 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

    Revise Berwyn’s prison Drug Strategy to restrict illicit items, apply consequences for possession, and support dependent users.

    Verbatim wording from the response

    “At a local level, in recognition of the dangers posed by the use of psychoactive substances, the Governor of Berwyn and the Regional Substance Misuse lead for HMPPS Wales have revised the prison’s Drug Strategy. This primarily focuses on restricting the availability of illicit items, ensuring that there are appropriate consequences for those found in possession, and offering appropriate support for dependent users.”

    Source location

    2019-0409-Response-from-HM-Prison-and-Probation-Service-Redacted
    Page 1 · response
    Published 29 December 2019

    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

    Operate a Rapiscan machine to improve detection of contraband items.

    Verbatim wording from the response

    “Sophisticated intelligence systems that are designed to reduce the supply of illicit substances into the prison involve collaboration with a range of HMPPS and Police colleagues. As you know, a Rapiscan machine is now in place which has vastly improved the detection of contraband items. The introduction of improved gate searching, changes in the supervision of domestic visits and support for”

    Source location

    2019-0409-Response-from-HM-Prison-and-Probation-Service-Redacted
    Page 1 · response
    Published 29 December 2019

    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

    Introduce improved gate searching to limit the availability of drugs.

    Verbatim wording from the response

    “Sophisticated intelligence systems that are designed to reduce the supply of illicit substances into the prison involve collaboration with a range of HMPPS and Police colleagues. As you know, a Rapiscan machine is now in place which has vastly improved the detection of contraband items. The introduction of improved gate searching, changes in the supervision of domestic visits and support for”

    Source location

    2019-0409-Response-from-HM-Prison-and-Probation-Service-Redacted
    Page 1 · response
    Published 29 December 2019

    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

    Change supervision of domestic visits to limit the availability of drugs.

    Verbatim wording from the response

    “Sophisticated intelligence systems that are designed to reduce the supply of illicit substances into the prison involve collaboration with a range of HMPPS and Police colleagues. As you know, a Rapiscan machine is now in place which has vastly improved the detection of contraband items. The introduction of improved gate searching, changes in the supervision of domestic visits and support for”

    Source location

    2019-0409-Response-from-HM-Prison-and-Probation-Service-Redacted
    Page 1 · response
    Published 29 December 2019

    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

    Use intelligence systems and collaborate with HMPPS and police colleagues to restrict illicit-substance supply.

    Verbatim wording from the response

    “Sophisticated intelligence systems that are designed to reduce the supply of illicit substances into the prison involve collaboration with a range of HMPPS and Police colleagues. As you know, a Rapiscan machine is now in place which has vastly improved the detection of contraband items. The introduction of improved gate searching, changes in the supervision of domestic visits and support for”

    Source location

    2019-0409-Response-from-HM-Prison-and-Probation-Service-Redacted
    Page 1 · response
    Published 29 December 2019

    Open published response

  7. 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

  8. Birmingham and Solihull

    AI-generated summary

    Andrew Stephen Carr · 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

    Andrew Stephen Carr, a prisoner, was found unresponsive in his cell on 29 March 2018 and was pronounced dead at 22:53 after attempts to revive him were unsuccessful. The medical cause of death was recorded as the effects of a synthetic cannabinoid. Concerns included failures to identify and record information about his prior substance use, the known use of the prison plumbing system to pass drugs, and the role of contraband mobile phones in 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

    Failure to record information about prisoner substance misuse and drug-related intelligence

    Wider context from the report

    “1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information. The inquest heard that there was no time to review information of prisoners coming into the prison. This is a major concern as key information may not be identified and this poses a risk to the individual and other prisoners. ”

    Source location

    Andrew Stephen Carr · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Birmingham and Solihull

    AI-generated summary

    Ricardo Wayne Holgate · 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

    Ricardo Wayne Holgate was found dead in his cell at Birmingham Prison on the morning of 26 March 2018. The post-mortem recorded coronary artery thrombosis and atherosclerosis, with the combined effects of synthetic cannabinoid and codeine. The inquest identified significant concerns about the supply and use of illicit substances, staffing levels, staff training and experience, and inconsistent management and reporting of prisoners affected by such substances.

    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 adequately manage illicit substance misuse in the prison

    Wider context from the report

    “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area. ”

    Source location

    Ricardo Wayne Holgate · 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

    Failure to prevent the use and supply of illicit substances in the prison

    Wider context from the report

    “2. Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe. ”

    Source location

    Ricardo Wayne Holgate · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. London (West)

    AI-generated summary

    John Kevin O’MEARA · 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

    John Kevin O’MEARA suffered respiratory failure and died on 29 March 2016 in a cell at HM Prison Wormwood Scrubs. The report identifies insufficient staffing, inadequate medical monitoring, and a missed opportunity to raise concerns about his health. It also raises concerns about delays in activating emergency codes and the availability of trained passive dogs to help control novel psychoactive substances in 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

    Insufficient availability of trained passive dogs for controlling Novel Psychoactive Substance use in prisons

    Wider context from the report

    “Passive Dog Use The Prison GP expert in this inquest was emphatic that Novel Psychoactive Substance played a part in the death. I understand that these drugs can be brought into the prison in a number of ways and one is NPS contaminated paper or even childrens’ photographs, arriving into Prisons in the post. I appreciate how challenging it is to control the use of Novel Psychoactive Substances in prisons. So, the use of trained passive dogs is particularly helpful In fact it appears to be one of the only failsafe ways to controlling NPS use in prisons. There are only two at HMP Wormwood Scrubs whereas HMP Highdown has eight. Although dogs can be ‘borrowed’ from other London prisons when handlers are away, I wish to put on record my support for funding for more of these dogs at this current challenging time. ”

    Source location

    John Kevin O’MEARA · 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

    Recruit additional dog handlers to increase regional search capacity and provide Wormwood Scrubs with seven passive and active search and patrol dogs.

    Verbatim wording from the response

    “I agree that we need to improve our capacity to address this issue, and I am pleased to report that the London and Thames Valley regional search team is currently recruiting additional dog handlers to increase the service provided to prisons in the region. This includes HMP Wormwood Scrubs, which will be provided with a total of seven dog hands, with both passive and active search and patrol dogs.”

    Source location

    2018-0012-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 7 March 2018

    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