Recurring concern

Unsafe controls for intoxication requiring medical attention

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First reported 28 Oct 2015•Latest report 24 Mar 2026

Definition

What this concern includes

Includes dedicated alcohol or drug intoxication policies, supervision, recognition guidance, assessment, monitoring, documentation, emergency action and referral where deficiencies expose a person to medically dangerous intoxication.

Not included

Illicit-substance supply controls where intoxication prevention or response is not deficient
Treatment after the person has reached appropriate medical care
Generic emergency-response failures with no intoxication context

Reports: 16
Individual concerns: 32
Date range: 2015–2026
Stated actions: 71

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.

College of Policing4

HM Prison and Probation Service3

Ministry of Justice2

National Police Chiefs’ Council2

Oxleas NHS Foundation Trust2

Avon and Somerset Constabulary1

Bedford Prison1

British Transport Police1

Central and North West London NHS Foundation Trust1

Cheshire Constabulary1

City of London Police1

Cumbria Constabulary1

Dyfed-Powys Police1

First Response Group1

G4S1

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.

26 Feb2021
Inner South London
Concerns raised2
1. Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable”
2. Failure to train officers on when to refer an intoxicated person for medical attention
This report raised 4 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 3
1. Action
  Review FALP learning outcomes to incorporate concerns about assessing intoxicated people, referral for medical attention, and monitoring breathing and symptoms.
  Stated by College of PolicingStated in progress
2. Action
  Provide officers with further training to assess intoxicated persons’ incapacity and need for medical attention.
  Stated by City of London PoliceStated completed
3. Action
  Develop and provide a vulnerability learning programme supporting consistent identification of hidden medical conditions and other risks requiring intervention.
  Stated by College of PolicingStated completed
Respondent positions 3
1. Position
  Chief Officers may add medical training where local force risk assessments identify a critical need, under local clinical governance advice.
  Stated by College of PolicingRedirects responsibility
1. Position
  Training clearly defines when intoxicated persons are drunk and incapable or require medical attention, contrary to the concern about insufficient clarity.
  Stated by City of London PoliceDisputes the concern
2. Position
  The programme cannot provide detailed training covering every medical emergency or policing context because officers attend a wide range of incidents.
  Stated by College of PolicingUnable to act
AI-generated summary

Mr Joseph Agnew · 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

Mr Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.

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 train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable”
Wider context from the report
“1. For the attention of CoLP and College of Policing: CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable”. A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention. ”
Source location
Mr Joseph Agnew · 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 train officers on when to refer an intoxicated person for medical attention
Wider context from the report
“1. For the attention of CoLP and College of Policing: CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable”. A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention. ”
Source location
Mr Joseph Agnew · 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 FALP learning outcomes to incorporate concerns about assessing intoxicated people, referral for medical attention, and monitoring breathing and symptoms.

Verbatim wording from the response
“In addition, a wider review of the high level learning outcomes for the FALP has already been initiated to ensure that they remain fit for purpose. We will ensure that your causes for concern will form part of this review. It is anticipated that this work will be completed towards the end of 2021 following the publication of updates expected from the UK Resuscitation Council this year.”

Source location
2021-0055-Response-from-College-of-Policing-Redacted
Page 3 · response
Published 1 March 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
Provide officers with further training to assess intoxicated persons’ incapacity and need for medical attention.

Verbatim wording from the response
“In relation to Concern (1); as you heard from DCI ████████ (the officer in charge of the City of London Police Learning and Organisational Development Unit), who testified remotely before you, since Mr. Agnew's passing, and as a result of the lessons learned from his death, City of London Police officers now receive further training on how to assess whether apparently intoxicated persons meet the definition of being drunk and incapable or otherwise require medical attention.”

Source location
2021-0055-Response-from-City-of-London-Police-Redacted
Page 1 · response
Published 1 March 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
Develop and provide a vulnerability learning programme supporting consistent identification of hidden medical conditions and other risks requiring intervention.

Verbatim wording from the response
“The PCDA places a high level of emphasis on the potential vulnerability of a person who, because of their situation or circumstances, is unable to take care or protect themself from harm or exploitation. This includes the importance of considering the possibility of hidden medical conditions or non-visible signs that may lead to a person being vulnerable. The College has developed a vulnerability learning programme which supports the PCDA programme and can also be used for officers who have not been trained through the PCDA to ensure consistency in learning.”

Source location
2021-0055-Response-from-College-of-Policing-Redacted
Page 4 · response
Published 1 March 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
Chief Officers may add medical training where local force risk assessments identify a critical need, under local clinical governance advice.

Verbatim wording from the response
“It is recognised that some areas of policing, such as working in custody environments, firearms operations or public order teams, require additional skills and knowledge. The relevant staff have additional FALP training modules available to ensure they are prepared for situations they are likely to encounter in their specialist roles. Additionally, where local force risk assessments identify a critical need, Chief Officers are able to add additional medical training provisions under the advice of local clinical governance.”

Source location
2021-0055-Response-from-College-of-Policing-Redacted
Page 3 · response
Published 1 March 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
Training clearly defines when intoxicated persons are drunk and incapable or require medical attention, contrary to the concern about insufficient clarity.

Verbatim wording from the response
“Your concern is stated to be that there appears to be no clarity for officers from their training as to when to offer an intoxicated person for medical attention. DCI ████████ explained to you the training that officers are given.”

Source location
2021-0055-Response-from-City-of-London-Police-Redacted
Page 1 · response
Published 1 March 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
The programme cannot provide detailed training covering every medical emergency or policing context because officers attend a wide range of incidents.

Verbatim wording from the response
“The FALP has five modules and the national recommendation is that police officers receive a minimum of Module 2 training (the equivalent to the qualification of a HSE Emergency First Aider). While Module 2 does not seek to provide detailed coverage of all specific medical conditions it does allow officers and staff to make an assessment of the casualty, including the known factors that may present a risk to their health.”

Source location
2021-0055-Response-from-College-of-Policing-Redacted
Page 3 · response
Published 1 March 2021
Open published response
28 Aug2020
Lincolnshire
Concerns raised3
1. Lack of meaningful training in self-induced intoxication and new psychoactive substances
2. Inadequate knowledge and training in diagnosis, treatment and care of new psychoactive substance intoxication
3. Failure to challenge, test or verify presumed drug intoxication
This report raised 15 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

Carlington Maurice Spencer · 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

Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.

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 meaningful training in self-induced intoxication and new psychoactive substances
Wider context from the report
“1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely: a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel); b. Concerns of co-detainees are not appreciated or noted or actively sought; c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel; d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice"; e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident; f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency; g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory; ”
Source location
Carlington Maurice Spencer · Prevention of Future Deaths report
Page 4 · 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
Inadequate knowledge and training in diagnosis, treatment and care of new psychoactive substance intoxication
Wider context from the report
“2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely: a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room); b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities; c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency; d. Failure to consult information contained on the Illicit Substance Misuse Programme; e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption; f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident; g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances"; ”
Source location
Carlington Maurice Spencer · Prevention of Future Deaths report
Page 4 · 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 challenge, test or verify presumed drug intoxication
Wider context from the report
“1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely: a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel); b. Concerns of co-detainees are not appreciated or noted or actively sought; c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel; d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice"; e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident; f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency; g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory; ”
Source location
Carlington Maurice Spencer · Prevention of Future Deaths report
Page 4 · concerns
Open source report
25 Aug2020
Inner North London
Concerns raised1
1. Failure to detect drug or alcohol impairment
This report raised 5 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 1
1. Action
  Roll out the updated employee drug-testing regime.
  Stated by London Borough of CamdenStated planned
AI-generated summary

Daniel Richard COLEMAN · 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

Daniel Richard Coleman, a construction site manager living at a demolition site, died in an accidental fire associated with his production of crystal meth. The report raised concerns that his occupation of the site and frequent illicit drug use went unnoticed, that site security was ineffective, that records of his presence were incomplete, and that the drug and alcohol policy had not led to any drug testing.

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 detect drug or alcohol impairment
Wider context from the report
“7. I heard evidence that not one of Mr Coleman’s Camden managers or First Response colleagues noticed that he was in any way intoxicated or under the influence of drugs. ”
Source location
Daniel Richard COLEMAN · 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
Roll out the updated employee drug-testing regime.

Verbatim wording from the response
“Trade Unions are currently being consulted on the Policy and it is hoped that formal consultation will be complete before the end of the year, with the testing regime to be rolled out in the new year.”

Source location
2020-0166-Response-from-Camden-Council_Redacted.pdf
Page 4 · response
Published 26 October 2020
Open published response
10 Jul2018
Wiltshire and Swindon
Concerns raised2
1. Inadequate algorithm for assessing deterioration risk in intoxicated people
2. Insufficient training and knowledge for assessing alcohol intoxication
This report raised 6 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

Eugeniusz Niedziolko · 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

Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.

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 algorithm for assessing deterioration risk in intoxicated people
Wider context from the report
“g) 2017 AGREEMENT – I raised with Consultant Paramedic ████████, and he is aware of my concern, that given the evidence of ████████ Consultant in Accident & Emergency who gave evidence that even if the observations had been carried out which to the greatest sense and purpose includes the checks in algorithm on page 10 of 12 of the 2017 Agreement, I am not convinced that if another Eugeniusz was to crop up that this risk of significant deterioration and death would have been picked up and avoided using this algorithm. Sometimes you have to spell it out and there was no questioning in this case as to when the person last consumed alcohol and over what period and what quantity they had consumed relative to this decision-making process. I queried whether especially with somebody who is not being cooperative as to whether the use of a breathalyser (if they were to consent) would aid in the intelligence gathering. There is also no mention of physical presentation. In Eugeniusz’s case, he had become incontinent of urine in respect of which I asked all relevant witnesses as to how many people they knew who were deliberately incontinent of urine. The answer, not unsurprisingly, was no-one. That factor from the common-sense point of view either is suggestive of physical issue whereby Eugeniusz was incontinent or that it was related to the degree of his intoxication in that he could no longer control and had no awareness of bodily function in that respect. The algorithm needs to be reviewed and considered in the light of this case specifically so that it would pick up another “Eugeniusz”. ”
Source location
Eugeniusz Niedziolko · 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
Insufficient training and knowledge for assessing alcohol intoxication
Wider context from the report
“b) TRAINING AND GENERAL LIFE SKILLS - It was quite clear during the evidence that both police officers had a very limited knowledge in relation to the effects alcohol has on the body. Neither officer asked, nor even attempted to ask, what I would term were obvious questions at the time, namely how much had the individual had to drink and when was the last drink was consumed and over what period the alcohol was consumed. Considering the Courts regard Police Officers as experts in relation to drunkenness (officers tend to provide evidence in relation to drink related offences) neither offered to provide any idea as regards the link between alcoholism and mental health issues; that sex, age and build being all variables can affect how the body processes alcohol; the fact that alcoholics can be quite difficult to judge having regard to tolerance levels (how much they have consumed becoming essential information so as to factor that relevant information to enable a decision to be reached, not just as to what the risk to that individual was at that stage but also in the foreseeable immediate future (in terms of the next few hours or so). The evidence from the Consultant A & E Specialist, ████████ was that there was a poor correlation between visual presentation and the amount of alcohol that might actually be in that individual’s system. I am concerned here that a blinkered approach adopted by officers attending somebody who is intoxicated can easily lead to the wrong decision being taken and one which is based on assumptions. I have been made aware of changes to training programmes but I am concerned that the training does not provide sufficient awareness and that there may be still a significant number of officers who simply do not have the life experience and general knowledge to factor that experience into professional judgement making. It would not surprise me if your officers in Swindon, more likely than not, have a better awareness of these issues and perhaps they could look to improve the training and share their experiences to officers elsewhere in the County. ”
Source location
Eugeniusz Niedziolko · Prevention of Future Deaths report
Page 3 · concerns
Open source report
29 Jun2016
South Wales Central
Concerns raised1
1. Lack of staff training and guidance on responding to residents suspected of illicit drug use
This report raised 1 other concern. 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 3
1. Action
  Deliver overdose instruction and guidance to all frontline hostel staff through presentations, team meetings and one-to-one instruction.
  Stated by The WallichStated planned
2. Action
  Revise the drug policy to include Cymorth Cymru guidance for support workers working with drug users.
  Stated by The WallichStated planned
3. Action
  Revise the e-learning module with updated guidance and roll it out across the organisation.
  Stated by The WallichStated planned
AI-generated summary

Lee Colin DAVIES · 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

Lee Colin DAVIES, who was residing at a hostel for homeless people and was known to use illicit drugs intravenously, was found unresponsive in his room the morning after he had been found with a needle in his groin. He was declared deceased by attending paramedics; the inquest conclusion was “Drug Related” and the medical cause of death was recorded as combined drug toxicity and bronchopneumonia. The report raised concern that hostel staff lacked guidance and training on monitoring and safeguarding residents found in circumstances suggesting illicit drug use, creating a risk that residents might be put to bed without ongoing monitoring.

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 staff training and guidance on responding to residents suspected of illicit drug use
Wider context from the report
“(1) The evidence revealed that staff, including night staff at the hostel, have no direct training or guidance on what steps should be taken when a resident is found in circumstances which suggest that they may have injected or otherwise take illicit drugs. The training which they are given, known as a Harm Reduction Course, has some focus on recognising the signs of an overdose and, in appropriate cases, administering opiate drug antidotes, but does not give any guidance or training on monitoring and safeguarding a resident in this situation. Given that many of the residents in this hostel are likely to have alcohol or drug issues, a lack of guidance or training is likely to lead to future deaths in circumstances in which residents are simply put to bed and left without any form of ongoing monitoring. ”
Source location
Lee Colin DAVIES · 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
Deliver overdose instruction and guidance to all frontline hostel staff through presentations, team meetings and one-to-one instruction.

Verbatim wording from the response
“1. Frontline hostel staff to receive instruction and guidance by hostel management via team meetings and one to one instruction. – PowerPoint point presentation ‘Dealing with Overdose’ to be presented and discussed with all staff members by the end of August 2016.”

Source location
2016-0239-Response-by-The-Wallich
Page 1 · response
Published 29 June 2016
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
Revise the drug policy to include Cymorth Cymru guidance for support workers working with drug users.

Verbatim wording from the response
“3. The Wallich Drug policy to be revised to include guidance from Cymorth Cymru’s specifically designed for support workers working with drug users. Completion August 2016.”

Source location
2016-0239-Response-by-The-Wallich
Page 1 · response
Published 29 June 2016
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
Revise the e-learning module with updated guidance and roll it out across the organisation.

Verbatim wording from the response
“4. The Wallich e-learning module to be revised to include updated guidance and rolled out across the organisation. September onwards”

Source location
2016-0239-Response-by-The-Wallich
Page 1 · response
Published 29 June 2016
Open published response
28 Oct2015
County Durham and Darlington
Concerns raised1
1. Lack of operational guidance for responding to suspected overdoses
This report raised 10 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 3
1. Action
  Develop clinical guidelines covering substance misuse treatment and care, including patients presenting under the influence of illicit drugs.
  Stated by Eric StephensStated in progress
2. Action
  Develop and consult on the Drugs and Alcohol Recovery Teams pathway and brief key leaders before wider circulation.
  Stated by Eric StephensStated in progress
3. Action
  Develop a substance misuse treatment-plan template for SystmOne covering care plans, regular observations and relevant care options.
  Stated by Eric StephensStated planned
Respondent positions 1
1. Position
  A formal substance misuse policy is not preferred; flexible clinical guidelines are considered better suited to varying patient circumstances.
  Stated by Eric StephensNo action considered necessary
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
Lack of operational guidance for responding to suspected overdoses
Wider context from the report
“4. The evidence indicated that there was a lack of guidance as to how staff should react when faced with a person who had overdosed; no local procedures as envisaged by the policy were disclosed, what should be done where there is no indicator as to what substance had been ingested and what would be the appropriate level of observations recognising that (Policy paragraph 8.1) symptoms may develop later. ”
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
Develop clinical guidelines covering substance misuse treatment and care, including patients presenting under the influence of illicit drugs.

Verbatim wording from the response
“Spectrum Community Health and G4S, in liaison with NHS England, therefore began a joint project, working together to update the procedures in operation at the prison.”

Source location
2015-0453-Response
Page 2 · response
Published 28 October 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
Develop and consult on the Drugs and Alcohol Recovery Teams pathway and brief key leaders before wider circulation.

Verbatim wording from the response
“A draft report and overarching pathway for Drugs and Alcohol Recovery Teams was produced at the end of November 2015. Following consultation between all contributors, including NHS England, the pathway is not designed to be a weighty document, but one that all practitioners and prison staff can use to understand the Drugs and Alcohol Recovery Team pathway, guidance, protocols and interventions. It is proposed the pathway features space to embed documents and hyperlinks to guidance.”

Source location
2015-0453-Response
Page 2 · response
Published 28 October 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
Develop a substance misuse treatment-plan template for SystmOne covering care plans, regular observations and relevant care options.

Verbatim wording from the response
“4. The clinical guidelines being developed for substance misuse issues will include a treatment plan template to be included on SystmOne for use in substance misuse cases. The treatment plan will include all relevant care options, including the requirement for a care plan and regular observations.”

Source location
2015-0453-Response
Page 3 · response
Published 28 October 2015
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
A formal substance misuse policy is not preferred; flexible clinical guidelines are considered better suited to varying patient circumstances.

Verbatim wording from the response
“Some months after the introduction of the new Substance Misuse Policy, however, towards the beginning of September 2015, I was made aware there had been changes in clinical practice which meant the Policy was outdated in some respects. It was felt at this stage that clinical guidelines would be a preferable, more flexible “policy”, preferable to a formal Policy document, because clinical guidelines envisage all different situations and respond accordingly.”

Source location
2015-0453-Response
Page 2 · response
Published 28 October 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable”

Failure to train officers on when to refer an intoxicated person for medical attention

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised3

Lack of meaningful training in self-induced intoxication and new psychoactive substances

Inadequate knowledge and training in diagnosis, treatment and care of new psychoactive substance intoxication

Failure to challenge, test or verify presumed drug intoxication

Concerns raised1

Failure to detect drug or alcohol impairment

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.1

Concerns raised2

Inadequate algorithm for assessing deterioration risk in intoxicated people

Insufficient training and knowledge for assessing alcohol intoxication

Concerns raised1

Lack of staff training and guidance on responding to residents suspected of illicit drug use

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.3

Concerns raised1

Lack of operational guidance for responding to suspected overdoses

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Respondent positions 3

Actions described in response 1

Actions described in response 3

Actions described in response 3

Respondent positions 1