Recurring concern

Unreliable prison response to positive drug tests

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First reported 25 Nov 2015•Latest report 28 May 2025

Definition

What this concern includes

Includes failures in the dedicated prison process for responding to positive drug tests, including result notification to responsible prison and healthcare staff, defined action pathways, assessment of the person's needs and risks, discussion or support, documentation, escalation and follow-up.

Not included

  • Excludes general prison psychoactive-substance risk controls, drug intelligence or warning systems where no positive-test response process is deficient.
  • Excludes drug testing itself, including failures to perform or schedule a test, when the test result and subsequent response process are not the concern.
  • Excludes generic information-sharing, staffing, training or policy deficiencies unless they directly impair the prison response to a positive drug test.
  • Excludes medication or substance-use treatment failures outside a prison positive-drug-test response pathway.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
4

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.

Ministry of Justice2
Birmingham Community Healthcare NHS Foundation Trust1
Birmingham Prison1
HM Prison and Probation Service1
North London NHS Foundation Trust1
Practice Plus Group1
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

    Samuel Anthony Donald STEWART · 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

    Samuel Stewart was found deceased in his cell at HMP Wormwood Scrubs on 15 July 2023, with drugs paraphernalia in the cell. His death was due to drugs in combination with long-term cardiac damage. A positive drug test on 6 March 2023 was not followed by discussion, support, or a multidisciplinary meeting, and the pathways after a positive result were unclear or not followed.

    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 support and discuss positive drug test results with prisoners

    Wider context from the report

    “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him ”

    Source location

    Samuel Anthony Donald STEWART · 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 ensure clear and followed pathways for action after a positive drug test

    Wider context from the report

    “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him ”

    Source location

    Samuel Anthony Donald STEWART · 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 clinical pathway for communicated positive drug tests, including medication checks, clinical substance-misuse review, confirmatory screening, assessment, incident reporting and an individual care plan.

    Verbatim wording from the response

    “However, Practice Plus Group, and the wider healthcare team at HMP Wormwood Scrubs, do have a process in place when positive results are communicated to us. For context, whilst Practice Plus Group provide the primary healthcare services and clinical substance misuse services, Forward Trust provide non-clinical substance misuse (Psychosocial) services and North London NHS Foundation Trust (formally Barnet, Enfield and Haringey NHS Trust) provide secondary mental health services. We have outlined the steps which would be taken below:”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 14 November 2025

    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

    Remind all ISFL wing managers in writing of the requirements following a positive drug test.

    Verbatim wording from the response

    “Governor of HMP Wormwood Scrubs that she has reminded all managers on the ISFL wing, in writing, of the requirements following a positive test. The managers have and will continue to remind staff working in the ISFL of their duties during briefings.”

    Source location

    Response from HM Prison and Probation Service and MOJ
    Page 2 · response
    Published 14 November 2025

    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

    Remind ISFL wing staff of their duties during staff briefings.

    Verbatim wording from the response

    “Governor of HMP Wormwood Scrubs that she has reminded all managers on the ISFL wing, in writing, of the requirements following a positive test. The managers have and will continue to remind staff working in the ISFL of their duties during briefings.”

    Source location

    Response from HM Prison and Probation Service and MOJ
    Page 2 · response
    Published 14 November 2025

    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

    Healthcare staff are responsible for subsequent actions after prison staff refer a prisoner who tests positive for illicit substances.

    Verbatim wording from the response

    “Following a positive test prison staff are required to complete a referral to the Forward Trust. It is then the responsibility of healthcare staff to take the subsequent actions, such as discussing the positive result with the prisoner. I have received assurances from the”

    Source location

    Response from HM Prison and Probation Service and MOJ
    Page 1 · response
    Published 14 November 2025

    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

    Healthcare was not aware of the positive test because prison staff did not communicate it, so healthcare was not in a position to act.

    Verbatim wording from the response

    “Response: We consider it is important to outline at the outset that in this case healthcare was unfortunately not made aware of the positive test and therefore were not in a position to take”

    Source location

    Response from Practice Plus Group
    Page 1 · response
    Published 14 November 2025

    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

    Failure to inform prison officers of positive drug test results

    Wider context from the report

    “8. Prison officers are unaware of positive drug test results and therefore unable to take any action in response. ”

    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
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Data last updated 7 September 2026