Recurring concern

Unreliable access to drug test results

Get email alerts

Request correction

First reported 25 Nov 2015•Latest report 29 Aug 2019

Definition

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.

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: 2
Individual concerns: 4
Date range: 2015–2019
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Justice2

Birmingham Community Healthcare NHS Foundation Trust1

Birmingham Prison1

Greater Manchester Police1

HM Prison and Probation Service1

Lancashire Constabulary1

National Police Chiefs’ Council1

National Probation Service1

Probation Service1

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.

29 Aug2019
Manchester North
Concerns raised3
1. Lack of training on accessing drug test results
2. N-Delius failing to provide timely access to current offender information
3. Lack of induction training and office procedures on local drug-testing practices
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Modernise probation case-management tools by assessing issues raised, identifying rapid improvements and consulting frontline practitioners on solutions.
  Stated by HM Prison and Probation Service and Ministry of Justice and Probation ServiceStated in progress
2. Action
  Update the National Induction Pack to require local-practice induction for new and transferring staff.
  Stated by HM Prison and Probation Service and Ministry of Justice and Probation ServiceStated completed
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
25 Nov2015
Birmingham and Solihull
Concerns raised1
1. Unavailability of compact drug results to DART workers
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Lack of training on accessing drug test results

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

Lack of induction training and office procedures on local drug-testing practices

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Unavailability of compact drug results to DART workers

Actions described in response 2