Recurring concern

Unreliable access to drug test results

First to latest report 25 Nov 2015 — 29 Aug 2019

Reports that mention this concern
2
Times this concern has been raised
4
Stated actions linked to this concern
2

What this concern includes

Includes failures of arrangements for authorised staff to access, retrieve, view or use drug test results, including inadequate training or local procedures, unavailable system access and login failures, where the deficiency can leave relevant results unavailable for safety decisions.

What is not included
  • Excludes failures to collect, analyse or perform drug tests when access to completed results is not the deficient condition.
  • Excludes failures to interpret or act on drug test results after authorised staff have reliably accessed them.
  • Excludes generic IT, staffing, training or documentation deficiencies unless they directly prevent authorised staff from accessing drug test results.
  • Excludes access to clinical results unrelated to drug testing unless the assertion explicitly concerns the same drug-test-results access process.

Reports and published responses 2 reports

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

  1. Manchester North

    AI-generated summary

    Michael Hoolickin · 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

    Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.

    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 training on accessing drug test results

    Wider context from the report

    “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results. As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices. ”

    Source location

    Michael Hoolickin · Prevention of Future Deaths report
    Page 5 · 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

    N-Delius failing to provide timely access to current offender information

    Wider context from the report

    “Numerous witnesses gave evidence as to the difficulties in accessing this system, its design and the time it takes to access the different parts which hold pertinent information about an offender, describing this as prohibitive. For example for Offender managers trying to read through the file to obtain current information there is nowhere which would easily show the most up to date curfew or the most up to date position as to how often drug testing is being conducted. ”

    Source location

    Michael Hoolickin · Prevention of Future Deaths report
    Page 5 · 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 induction training and office procedures on local drug-testing practices

    Wider context from the report

    “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results. As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices. ”

    Source location

    Michael Hoolickin · 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

    Modernise probation case-management tools by assessing issues raised, identifying rapid improvements and consulting frontline practitioners on solutions.

    Verbatim wording from the response

    “The Court was extremely concerned as to whether the N Delius case management system is fit for purpose, particularly when attempting to capture all relevant, recent information about a high-risk offender in order to reach an informed decision such as recalling them to prison”

    Source location

    2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
    Page 2 · response
    Published 25 October 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

    Update the National Induction Pack to require local-practice induction for new and transferring staff.

    Verbatim wording from the response

    “There is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices. This is particularly pertinent if staff transfer from other offices.”

    Source location

    2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
    Page 2 · response
    Published 25 October 2019

    Open published response

  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

    Unavailability of compact drug results to DART workers

    Wider context from the report

    “7. DART workers are currently unable to access compact drug results as workers are unable to log onto the computer. ”

    Source location

    Dean Ronald Edmund BOLAND · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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