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. 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

    Rife use of New Psychoactive Substances within the prison

    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

  2. Birmingham and Solihull

    AI-generated summary

    Dean Ronald Edmund BOLAND · 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

    Dean Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.

    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, health and DART workers to share drug issue information adequately

    Wider context from the report

    “2. There is a lack of multi-disciplinary approach to drug issues within the prison. The evidence heard at the inquest confirmed that prison officers, health workers and DART workers do not adequately discuss trends and general drugs issues to ensure all staff are up to date and aware of the problems. It is accepted that patient’s confidentiality needs to be maintained but it is essential to discuss trends and significant events in a multi-disciplinary way. ”

    Source location

    Dean Ronald Edmund BOLAND · 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

    Lack of prison officer awareness and understanding of drug issues

    Wider context from the report

    “1. There was a general lack of awareness and understanding of the drugs issues in the prison by prison officers. Two prison officers who worked on B wing said they were unaware of any problems with prisoners using illicit drugs including general medications. Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners come by those drugs. ”

    Source location

    Dean Ronald Edmund BOLAND · 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

    Hold monthly drug-strategy meetings, require B-Wing officers to attend, and require detox and recovery staff to confirm they have read the minutes.

    Verbatim wording from the response

    “Drug strategy meetings are being held monthly and the purpose of these meetings is to discuss current issues and trends around drug misuse within the prison and to agree actions and strategies going forward. These meetings are attended by a cross-functional group of interested parties including clinical staff, residential managers and DART workers. From 9 December 2015 there has been mandatory attendance at these meetings from prison officers who work on B Wing. All staff on the detox and recovery unit will be required to sign a document indicating that they have read the minutes of the meeting each month. Also included in this meeting is discussion of those prisoners receiving opiate substitution medications who have failed both mandatory and compliance based drugs tests.”

    Source location

    2015-0468-Response-by-NOMS
    Page 1 · response
    Published 25 November 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

    Discuss drug-misuse trends in monthly drug-strategy and security meetings and identify and implement risk-reduction actions.

    Verbatim wording from the response

    “Issues around the misuse of illicit drugs and prescribed medication are discussed during monthly drug strategy and security meetings. During the meeting trends and issues around drug misuse of all kinds are discussed and actions to reduce the risk and likelihood of these occurrences are identified and put in place. Due consideration is given to confidentiality, but this does not prevent discussion around these issues.”

    Source location

    2015-0468-Response-by-NOMS
    Page 2 · response
    Published 25 November 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

    Complete drug-awareness training for prison staff by 31 January 2016.

    Verbatim wording from the response

    “Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners consume them Following the inquest, training on supervising the administration of opiate substitution medication has been completed with detox unit staff and drug awareness training is scheduled for completion by 31 January 2016.”

    Source location

    2015-0468-Response-by-NOMS
    Page 1 · response
    Published 25 November 2015

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Kevin Anthony Forster · 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

    Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.

    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

    Complacency about prisoners presenting under the influence of drugs

    Wider context from the report

    “9. As mentioned earlier the evidence indicated that there was a degree of complacency about prisoners presenting under the influence of drugs and the risks associated therewith (at handover one officer said to another “there are some prisoners sleeping it off”). Due to the scale of the issue, the potential risk to health of prisoners is such that there needs to be absolute clarity of response and care for prisoners who so present. The evidence indicated that a more integrated approach between healthcare staff and discipline staff would be beneficial notwithstanding there were good lines of communication between the two. ”

    Source location

    Kevin Anthony Forster · Prevention of Future Deaths report
    Page 1 · 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

    Complacency and acceptance by staff of the prison drug problem

    Wider context from the report

    “1. It was clear from evidence that there is a serious drug problem in HMP Durham. This has led to a degree of complacency and acceptance by staff of that situation. ”

    Source location

    Kevin Anthony Forster · 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

    Introduce monthly multidisciplinary substance misuse training for healthcare, discipline and other prison staff.

    Verbatim wording from the response

    “2. We have introduced, under the leadership of Dr Bray, a monthly training event specific to all aspects of substance misuse issues which is held monthly on a Friday afternoon in the Prison Training Centre. The training event is open to all staff at the prison from all disciplines of the various organisations within the prison and wider region, both healthcare staff and discipline staff. Each session usually lasts for a couple of hours. The training is a mixture of white board training, discussion, group work, multi-disciplinary discussions, sharing information and experiences and clinical reviews. This training reinforces the seriousness of substance misuse and overdose issues and emphasises the inappropriateness and unacceptability of attitudes of complacency and acceptance towards the issues.”

    Source location

    2015-0453-Response
    Page 3 · response
    Published 28 October 2015

    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