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.

24 Mar2026
Milton Keynes
Concerns raised3
1. Failure to maintain a clear and current drug under the influence policy
2. Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response
3. Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
This report raised 13 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 7
1. Action
  Develop and implement the SPICE policy and local operating procedure for assessing and managing intoxication.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Provide structured assessment tools, escalation expectations and clinical leadership to improve recognition and response to synthetic-cannabinoid deterioration.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Train clinical staff to recognise deterioration using NEWS2 and reinforce escalation pathways across services.
  Stated by Central and North West London NHS Foundation TrustStated completed
1. Action
  Participate in joint simulation exercises and prison-led first-aid and emergency-response training.
  Stated by Central and North West London NHS Foundation TrustStated in progress
2. Action
  Clarify clinical roles and expectations and strengthen addictions-team governance through additional referral-timeliness and escalation audits.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Introduce risk-based triage to prioritise prisoners at highest risk.
  Stated by Central and North West London NHS Foundation TrustStated completed
4. Action
  Refer intoxicated prisoners to the addictions team for review within 48 hours.
  Stated by Central and North West London NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Healthcare services alone cannot mitigate all risks within custody.
  Stated by Central and North West London NHS Foundation TrustUnable to act
AI-generated summary

Ronald William MEIKLE · 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

Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at 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 maintain a clear and current drug under the influence policy
Wider context from the report
“Concern 2: Failure consistently to identify, record and respond to prisoners under the influence The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention. ”
Source location
Ronald William MEIKLE · 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 recognise suspected synthetic cannabinoid intoxication promptly during collapse response
Wider context from the report
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause. Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment. ”
Source location
Ronald William MEIKLE · 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
Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
Wider context from the report
“Concern 2: Failure consistently to identify, record and respond to prisoners under the influence The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention. ”
Source location
Ronald William MEIKLE · 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
Develop and implement the SPICE policy and local operating procedure for assessing and managing intoxication.

Verbatim wording from the response
“Concern 2: Identification, recording and response to prisoners under the influence: We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that”

Source location
Response from Central & North West London NHS Foundation Trust
Page 1 · response
Published 26 March 2026
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 structured assessment tools, escalation expectations and clinical leadership to improve recognition and response to synthetic-cannabinoid deterioration.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 2026
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
Train clinical staff to recognise deterioration using NEWS2 and reinforce escalation pathways across services.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 2026
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
Participate in joint simulation exercises and prison-led first-aid and emergency-response training.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 2026
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
Clarify clinical roles and expectations and strengthen addictions-team governance through additional referral-timeliness and escalation audits.

Verbatim wording from the response
“Concern 2: Identification, recording and response to prisoners under the influence: We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that”

Source location
Response from Central & North West London NHS Foundation Trust
Page 1 · response
Published 26 March 2026
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
Introduce risk-based triage to prioritise prisoners at highest risk.

Verbatim wording from the response
“Concern 2: Identification, recording and response to prisoners under the influence: We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that”

Source location
Response from Central & North West London NHS Foundation Trust
Page 1 · response
Published 26 March 2026
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
Refer intoxicated prisoners to the addictions team for review within 48 hours.

Verbatim wording from the response
“identifies and prioritises individuals at highest risk. Intoxicated prisoners are being immediately referred to the addictions team for review within 48 hours.”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 2026
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 services alone cannot mitigate all risks within custody.

Verbatim wording from the response
“Thank you for bringing your concerns to our attention. While healthcare services alone cannot mitigate all risks within custody, the Trust is committed to learning from Mr Meikle’s death and to strengthening how vulnerability is identified and responded to across Health and Justice services. Should you have any questions or comments, please do not hesitate to contact me.”

Source location
Response from Central & North West London NHS Foundation Trust
Page 3 · response
Published 26 March 2026
Open published response
17 Feb2026
Bedfordshire and Luton
Concerns raised3
1. Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence
2. Failure to observe and monitor prisoners suspected to be under the influence of illicit substances
3. Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances
This report raised 2 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 7
1. Action
  Agree and implement a common local protocol, including a flowchart, defining healthcare and prison staff roles, responsibilities, escalation and management of suspected illicit-substance influence.
  Stated by Northamptonshire Healthcare NHS Foundation TrustStated completed
2. Action
  Circulate the UTI protocol and amended UTI recording log to healthcare and prison staff.
  Stated by Northamptonshire Healthcare NHS Foundation TrustStated completed
3. Action
  Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Issue the updated UTI protocol to prison and healthcare staff through briefings, written notices, meeting updates and daily checks.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Appoint a substance misuse lead to conduct daily assurance and visit suspected UTI cases to support consistent protocol adherence.
  Stated by HM Prison and Probation ServiceStated completed
4. Action
  Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Edward James HANDS · 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

Edward James Hands, known as Eddie, died in his cell at HMP Bedford on 16 February 2024 after consuming methadone and developing aspiration pneumonitis. The inquest identified failures in follow-up care, monitoring, escalation, and the implementation of the Under the Influence protocol, with confusion between prison and healthcare staff about their responsibilities.

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 frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence
Wider context from the report
“The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
Source location
Edward James HANDS · 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 observe and monitor prisoners suspected to be under the influence of illicit substances
Wider context from the report
“The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
Source location
Edward James HANDS · 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 align policies and protocols for managing prisoners suspected to be under the influence of illicit substances
Wider context from the report
“The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
Source location
Edward James HANDS · 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
Agree and implement a common local protocol, including a flowchart, defining healthcare and prison staff roles, responsibilities, escalation and management of suspected illicit-substance influence.

Verbatim wording from the response
“We have worked with the Prison Governor and Head of Safety to agree and implement a common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford. I have enclosed a copy of the protocol with this letter for your information.”

Source location
Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 23 February 2026
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
Circulate the UTI protocol and amended UTI recording log to healthcare and prison staff.

Verbatim wording from the response
“The healthcare and prison service leadership teams circulated the UTI protocol and an amended UTI recording log to staff late last year. Mandatory training for healthcare staff on UTI detection and management is being facilitated by the Trust’s Resuscitation Lead and is part of our induction programme. An ‘Airways Champion’ has also been identified. The Airways Champion supports our leadership team in maintaining competence in airway management and suction machine use. They will also help deliver future UTI simulation training sessions.”

Source location
Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 23 February 2026
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
Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.

Verbatim wording from the response
“Following the conclusion of the inquest HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place. This review resulted in the removal of any previous conflicting guidance and implementation of a single UTI protocol with standardisation of responsibilities, including observation requirements, escalation routes, and handover expectations. This protocol has been agreed by both parties and is to be followed by both operational and healthcare staff at HMP Bedford.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 23 February 2026
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
Issue the updated UTI protocol to prison and healthcare staff through briefings, written notices, meeting updates and daily checks.

Verbatim wording from the response
“The updated protocol has been issued to all prison and healthcare staff through structured briefings, written notices, daily meeting updates, and daily checks.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 23 February 2026
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 staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.

Verbatim wording from the response
“• Staff have been given guidance on recognising signs of being UTI, initiating the protocol, completing observations, and ensuring follow up checks are undertaken.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 23 February 2026
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
Appoint a substance misuse lead to conduct daily assurance and visit suspected UTI cases to support consistent protocol adherence.

Verbatim wording from the response
“• A newly appointed substance misuse lead carries out daily assurance and visits all suspected UTI cases, ensuring consistency between operational and healthcare colleagues and consistent adherence to the UTI protocol.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 23 February 2026
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
Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.

Verbatim wording from the response
“• Assurance of documentation and observations is completed to ensure compliance of timescales and escalation procedures. Where this identifies areas requiring improvement a record is made and the issue escalated to both prison and healthcare senior leaders to be addressed as appropriate.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 23 February 2026
Open published response
19 Jul2024
Mid Kent and Medway
Concerns raised4
1. Lack of guidance for escalating and monitoring suspected intoxication
2. Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication
3. Failure to promptly notify the prison orderly and document suspected intoxication
1. Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence
This report raised 3 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 5
1. Action
  Review out-of-hours GP calls to assess their frequency and effectiveness.
  Stated by Oxleas NHS Foundation TrustStated planned
2. Action
  Update guidance to clarify that required patient monitoring cannot occur without on-site healthcare and requires hospital transfer.
  Stated by Oxleas NHS Foundation TrustStated planned
3. Action
  Issue and implement a night-state process for escalating suspected illicit-substance cases, conducting welfare checks, deciding on medical escalation, and recording follow-up requirements.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Develop national guidance for staff managing prisoners suspected to be under the influence of illicit substances and complete stakeholder consultation.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Roll out agreed national guidance through regional and local leads, support local guidance development, and conduct assurance checks on its development and embedding.
  Stated by HM Prison and Probation ServiceStated planned
Respondent positions 3
1. Position
  Existing night arrangements, including trained officers, personal management plans, on-call GP advice and emergency services, are relied upon to manage healthcare concerns.
  Stated by Oxleas NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  Patient monitoring cannot be undertaken at night without healthcare staff on site; patients requiring monitoring must instead be transferred to hospital.
  Stated by Oxleas NHS Foundation TrustUnable to act
2. Position
  NHS England is responsible for explaining whether 24-hour healthcare should be commissioned in Category C prisons because of drug-related patient safety risks.
  Stated by Oxleas NHS Foundation TrustRedirects responsibility
AI-generated summary

Benjamin Noah Frances Harrison · 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

Benjamin Harrison died in HMP Rochester on 9 May 2022 after inhaling fumes from a medication heated with a vape pen. The inquest identified concerns including insufficient overnight healthcare cover, failure to inform the night orderly that he appeared to be under the influence, inadequate guidance for monitoring and escalation, and weaknesses in medication briefing and information sharing.

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 guidance for escalating and monitoring suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
Source location
Benjamin Noah Frances Harrison · 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
Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
Source location
Benjamin Noah Frances Harrison · 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
Failure to promptly notify the prison orderly and document suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
Source location
Benjamin Noah Frances Harrison · 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
Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
Source location
Benjamin Noah Frances Harrison · 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
Review out-of-hours GP calls to assess their frequency and effectiveness.

Verbatim wording from the response
“The agreed arrangements between the hours of 21:00 – 07:30 when there is no commissioned healthcare provision on site, is that all higher risk prisoners have an agreed personal management plan in accordance with the Personal Management Plan Local Operating Procedure, and that in the event that officers have any healthcare concerns regarding a prisoner the Custodial Manager in charge of the prison should call the On-Call GP for further advice and guidance, and in an emergency they should dial 999 for emergency services. A review of out of hours calls to the out of hours GP service will be carried out in Autumn 2024 to ascertain frequency and effectiveness of use. Any calls to out of hours GP are discussed in the Governor’s morning briefing each day and followed up by the healthcare team.”

Source location
Response from Oxleas NHS Foundation Trust
Page 3 · response
Published 1 August 2024
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 guidance to clarify that required patient monitoring cannot occur without on-site healthcare and requires hospital transfer.

Verbatim wording from the response
“We will ensure that this guidance is updated and that it also includes the relevant information to manage the expectations of HMPPS colleagues – for example if any patient monitoring is required then this cannot be undertaken at HMP Rochester when there are no healthcare staff on site and in any circumstances where a patient requires monitoring then they would need to be transferred to hospital.”

Source location
Response from Oxleas NHS Foundation Trust
Page 4 · response
Published 1 August 2024
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
Issue and implement a night-state process for escalating suspected illicit-substance cases, conducting welfare checks, deciding on medical escalation, and recording follow-up requirements.

Verbatim wording from the response
“You have expressed concern that there does not appear to be a clear process at HMP Rochester for escalating concerns when prisoners appear to be under the influence of an illicit substance outside of the hours in which healthcare staff are present. I have received assurance from the Governor of HMP Rochester that following the inquest an order has been issued to all staff setting out that at times when there is no on-site healthcare team, such as during the night state, prison staff must escalate concerns about prisoners suspected to be under the influence of illicit substances to the Orderly Officer. The Orderly Officer will then attend to conduct a welfare check on the prisoner.”

Source location
Response from HMPPS
Page 1 · response
Published 1 August 2024
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 national guidance for staff managing prisoners suspected to be under the influence of illicit substances and complete stakeholder consultation.

Verbatim wording from the response
“HMPPS is currently developing national guidance for all staff managing prisoners who are under the influence of illicit substances. The guidance has been developed by the national Substance Misuse Group with contributions from internal and external stakeholders, including from areas such as health and safety. Its purpose is to provide structured guidance for prisons to support the development of local under the influence guidance that will ensure that there is a consistent and safe response to the management of prisoners. It is important to note that this guidance does not replace healthcare advice and in a medical emergency instructions and advice from healthcare colleagues must be followed as a priority.”

Source location
Response from HMPPS
Page 2 · response
Published 1 August 2024
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
Roll out agreed national guidance through regional and local leads, support local guidance development, and conduct assurance checks on its development and embedding.

Verbatim wording from the response
“Once agreed, the guidance document will be rolled out via the regional and local drug strategy leads who will be responsible for developing local guidance. The Substance Misuse Group will deliver additional training and support if necessary, and through their rolling programme of support assurance checks will be conducted to ensure that under the influence guidance has been developed and embedded at each prison.”

Source location
Response from HMPPS
Page 2 · response
Published 1 August 2024
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
Existing night arrangements, including trained officers, personal management plans, on-call GP advice and emergency services, are relied upon to manage healthcare concerns.

Verbatim wording from the response
“OSG officers have undergone basic first aid training during their induction to the standard deemed by HMPPS appropriate for their roles, including being in service during night patrols without healthcare staff on site, and managing any situation which may occur. HMPPS colleagues will be able to give further details regarding this training. The OSGs work together with Orderly Officers who have additional training and experience, and they have operational procedures to follow in the event of prisoners who present as requiring medical support during night state.”

Source location
Response from Oxleas NHS Foundation Trust
Page 3 · response
Published 1 August 2024
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
Patient monitoring cannot be undertaken at night without healthcare staff on site; patients requiring monitoring must instead be transferred to hospital.

Verbatim wording from the response
“As stated, there is no in-house healthcare in HMP Rochester after 9pm. There are arrangements for GP on-call provision arranged by providers which we have in place at HMP Rochester. GPs on an on-call rota have access to SystmOne records and therefore access to past medical history, past and current medical problems and any future appointments is in place to provide medical advice to prison staff, prevent unnecessary transfers to hospital and ensure patient safety by providing guidance on next steps when hospital transfer is required.”

Source location
Response from Oxleas NHS Foundation Trust
Page 4 · response
Published 1 August 2024
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
NHS England is responsible for explaining whether 24-hour healthcare should be commissioned in Category C prisons because of drug-related patient safety risks.

Verbatim wording from the response
“such as psychoactive substances ‘spice’ are explored. Change, Grow, Live (CGL) are subcontracted by Oxleas to provide psychosocial substance misuse and they have a large caseload at HMP Rochester who undertake group and 1:1 work to address substance misuse issues including the use of psychoactive substances, and encourage harm minimisation and ultimately recovery. Healthcare attend to those suspected to be under the influence of substances during the day until 21:00 as contracted by NHS England. As a Category C prison, Rochester, in accordance with most Category C prisons does not have 24-hour healthcare provision. The contracts for Category C prisons do not normally make provision for healthcare services at night if there is no Inpatient department, and therefore no prisoners requiring 24-hour healthcare provision.”

Source location
Response from Oxleas NHS Foundation Trust
Page 3 · response
Published 1 August 2024
Open published response
27 Mar2024
South Yorkshire (Western)
Concerns raised1
1. Lack of police officer training in recognising drug intoxication and determining when hospital treatment is required
This report raised 8 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
  Introduce poisoning, acute alcohol intoxication and intentional overdose content into the year-three First Aid module.
  Stated by South Yorkshire PoliceStated completed
2. Action
  Introduce the poisoning module into the MOD 2 initial First Aid course.
  Stated by South Yorkshire PoliceStated planned
3. Action
  Deliver Acute Behavioural Disturbance training through Personal Safety and First Aid courses, including recognition, clinical escalation and treatment principles.
  Stated by South Yorkshire PoliceStated completed
AI-generated summary

Matthew Terrill · 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

Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.

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 police officer training in recognising drug intoxication and determining when hospital treatment is required
Wider context from the report
“1. Lack of training in the First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of drug intoxication. Specifically, how to recognise a drug overdose or the ill-effects of drug intoxication, and when it is appropriate for a detainee to be taken to hospital. I have been told that officers routinely come across persons who are intoxicated through drugs, and that officers are routinely expected to risk assess these persons and decide whether to transport to hospital or custody. Without proper guidance in place for the officers, I am concerned about the risk of future death to persons who are intoxicated by drugs and requiring hospital treatment. I note the circulation of the ‘Patient or Prisoner’ cards, but these do not include reference to intoxication by drugs. I note also that some training is given to trainee officers, but this does not specifically cover intoxication by drugs, and even if it did, I am concerned that training an officer once, at the beginning of their career, leaves the door open to the development of bad practice and the fallibility of human memory. ”
Source location
Matthew Terrill · 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
Introduce poisoning, acute alcohol intoxication and intentional overdose content into the year-three First Aid module.

Verbatim wording from the response
“A change to the First Aid learning program for next year introduces poison which covers:”

Source location
Response from South Yorkshire Police and Humberside Police
Page 3 · response
Published 4 April 2024
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
Introduce the poisoning module into the MOD 2 initial First Aid course.

Verbatim wording from the response
“7.7 How to manage a casualty who has been poisoned. What it is perm/temp What can Causes alcohol? Recognise some signs and symptoms. And treatments going to give.”

Source location
Response from South Yorkshire Police and Humberside Police
Page 3 · response
Published 4 April 2024
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
Deliver Acute Behavioural Disturbance training through Personal Safety and First Aid courses, including recognition, clinical escalation and treatment principles.

Verbatim wording from the response
“However, in both Personal Safety Training (PST) and First Aid training since 2014 officers have received an input on Acute Behavioural Disturbance (ABD) and on how to recognise signs and symptoms in both theory and practice.”

Source location
Response from South Yorkshire Police and Humberside Police
Page 4 · response
Published 4 April 2024
Open published response
4 Mar2024
Inner West London
Concerns raised1
1. Unavailability of near-patient illicit-drug testing for assessing intoxication
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
  Stock and mandate near-patient urine drug testing for patients presenting with sedation of unknown cause, making tests available to clinicians.
  Stated by Oxleas NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing urine testing is considered sufficient to inform clinical reviews and substance misuse prescribing decisions.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Mr Lee Martin Hughes, also known as Martin Lee Hughes · 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 Martin Hughes was found deceased in his cell at HMP Wandsworth on 25 December 2021 while remanded in custody. The medical cause of death was methadone and benzodiazepine intoxication, and the jury concluded that drug-related misadventure was contributed to by neglect. Concerns included the assessment and prescribing of methadone, failure to respond appropriately to signs of sedation and impaired consciousness, and inadequate communication and escalation between healthcare disciplines.

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 near-patient illicit-drug testing for assessing intoxication
Wider context from the report
“6. That there should be tests available for illicit drugs from near patient testing to allow a clinician to better assess a patient showing signs of intoxication. ”
Source location
Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report
Page 4 · 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
Stock and mandate near-patient urine drug testing for patients presenting with sedation of unknown cause, making tests available to clinicians.

Verbatim wording from the response
“6. HMP Wandsworth has investigated the commercially available near patient urine tests for drugs, including psychoactive substances (‘spice’). HMP Wandsworth now stock a test which detects a wider variety of prescribed and illicit drugs. These tests are now mandated for patients who present with sedation of unknown cause. The limitations of these tests, particularly false negatives, are well known to substance misuse practitioners. However, they are a useful aid to the management of patients whose urine test suggests continuing illicit drug use on a prison wing. These tests are currently being used and are available to all clinicians.”

Source location
Response from Oxleas NHS Foundation Trust
Page 3 · response
Published 6 March 2024
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
Existing urine testing is considered sufficient to inform clinical reviews and substance misuse prescribing decisions.

Verbatim wording from the response
“6. There should be tests available for illicit drugs for near patient testing to allow clinicians to better assess a patient showing signs of intoxication.”

Source location
Response from NHS England
Page 2 · response
Published 6 March 2024
Open published response
17 Jan2024
Nottinghamshire
Concerns raised1
1. Failure to follow the Under the Influence Policy
This report raised 9 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
  Change senior managers and officers as part of ongoing efforts to address failures in observations and compliance with the Under the Influence Policy.
  Stated by SodexoStated in progress
AI-generated summary

Kane Christopher Boyce · 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

Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.

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 follow the Under the Influence Policy
Wider context from the report
“3. Failure to follow the local Under the Influence Policy Three members of staff suspected Kane was under the influence of something in the hours before his death, yet none opened an under the influence log or sought any medical advice about how frequently to check on him, what signs of deterioration to look out for, and when to seek further assistance. ”
Source location
Kane Christopher Boyce · 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
Change senior managers and officers as part of ongoing efforts to address failures in observations and compliance with the Under the Influence Policy.

Verbatim wording from the response
“Sodexo have concerns about the practices of the staff that transferred to Sodexo with HMP Lowdham Grange. These include failures of staff to conduct observations and follow the Under the Influence Policy. This is part of an ongoing culture change that we are trying to address but one that takes time and has to date involved changes to Senior Managers and Officers at the prison.”

Source location
Response from Sodexo
Page 2 · response
Published 25 January 2024
Open published response
8 Dec2023
Manchester South
Concerns raised2
1. Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
2. Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 26
1. Action
  Implement and operate Joint Operating Protocols with four North West police forces covering information sharing, agency primacy, escalation, open lines, lead agency and clinical hub contact.
  Stated by NHS Cheshire and Merseyside ICBStated completed
2. Action
  Oversee progress updates on Joint Operating Protocol implementation through the Regional Clinical Quality Assurance Committee.
  Stated by NHS Cheshire and Merseyside ICBStated planned
3. Action
  Review the concerns with two other Northwest integrated care boards and coordinate steps to progress them.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
1. Action
  Implement the Joint Operating Protocol with Cheshire, Cumbria, Lancashire and Merseyside Police Forces.
  Stated by North West Ambulance Service NHS TrustStated completed
2. Action
  Complete sign-off and implement the updated Joint Operating Protocol with Greater Manchester Police across the North West.
  Stated by North West Ambulance Service NHS TrustStated planned
3. Action
  Review communication procedures and standards with blue-light partners, particularly North West Ambulance Service.
  Stated by Merseyside Fire and Rescue ServiceStated completed
4. Action
  Continue working with Northwest partners to agree and implement a Joint Operating Procedure aligned with Right Care, Right Person.
  Stated by Greater Manchester PoliceStated in progress
5. Action
  Develop a Greater Manchester partnership agreement defining police and ambulance roles and expectations for physical-health Concern for Welfare incidents.
  Stated by Greater Manchester PoliceStated in progress
6. Action
  Brief FCCO staff on the agreed Joint Operating Procedure before its implementation, including its purpose, relevance and required use.
  Stated by Greater Manchester PoliceStated planned
7. Action
  Continue adopting JESIP principles and operational guidance to promote collaborative working between blue-light partners.
  Stated by Lancashire Fire and Rescue ServiceStated completed
8. Action
  Apply JESIP principles and clear speech when coordinating with other emergency services.
  Stated by North West Fire ControlStated completed
9. Action
  Embed and assess compliance with NFCC National Operational Guidance and JESIP inter-agency operating standards.
  Stated by North West Fire ControlStated in progress
10. Action
  Operate the Multi-Agency Tactical Control Communications Group to improve interoperability through shared lessons, training and exercises.
  Stated by North West Fire ControlStated completed
11. Action
  Operate under a Joint Operating Procedure defining agency responsibilities, information sharing and incident escalation.
  Stated by Cumbria ConstabularyStated completed
12. Action
  Sign and endorse the revised joint operating protocol.
  Stated by Cheshire ConstabularyStated completed
13. Action
  Maintain direct inter-control-room communications with police, ambulance and fire services through ESICTRL talk groups.
  Stated by British Transport PoliceStated completed
14. Action
  Implement the regional Standard Operating Procedure on information sharing in relation to incident logs (Version 1.0).
  Stated by Lancashire ConstabularyStated completed
15. Action
  Brief Force Control Room Supervisors and Force Incident Managers on the Joint Operating Protocol.
  Stated by Lancashire ConstabularyStated completed
16. Action
  Continue monthly meetings with regional forces and ambulance services to agree the Joint Operating Protocol.
  Stated by Lancashire ConstabularyStated in progress
17. Action
  Sign off Lancashire Police’s version 1.3 Joint Operating Protocol document.
  Stated by Lancashire ConstabularyStated completed
18. Action
  Maintain agreed police–ambulance escalation processes for obtaining information, escalating delays, cancelling ambulances and resolving operational concerns.
  Stated by Greater Manchester PoliceStated completed
19. Action
  Provide frontline personnel with access to NWAS remote clinical support through SOPs and fallback telephones.
  Stated by Lancashire Fire and Rescue ServiceStated completed
20. Action
  Adopt Multi-Agency Incident Transfer as an early adopter and put the tool in place.
  Stated by North West Fire ControlStated planned
21. Action
  Provide feedback to NWAS and conduct a gap analysis of information-sharing procedures against NWFC operating arrangements.
  Stated by North West Fire ControlStated completed
22. Action
  Provide officers with clinical support through the “treat and hear” facility for direct updates from NWAS.
  Stated by Cumbria ConstabularyStated completed
23. Action
  Provide control-room briefings to support exchange of initial triage information with partner responder agencies.
  Stated by British Transport PoliceStated completed
Respondent positions 4
1. Position
  Ambiguous lead-agency wording prevents agreement to the Joint Operating Procedure until responsibilities and deployment expectations are clarified.
  Stated by Greater Manchester PoliceUnable to act
1. Position
  Existing LFRS guidance and processes are considered sufficient to address the recommendations.
  Stated by Lancashire Fire and Rescue ServiceExisting arrangements considered sufficient
2. Position
  Confirmation of the Joint Operating Protocol’s go-live rests with North-West Ambulance Service, pending sign-off from GMP and Fire and Rescue.
  Stated by Lancashire ConstabularyRedirects responsibility
3. Position
  Existing GMP-NWAS escalation processes are considered appropriate and sufficient while work continues to implement the Joint Operating Procedure.
  Stated by Greater Manchester PoliceExisting arrangements considered sufficient
AI-generated summary

Claire Nicole Briggs · 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

Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.

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 consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report
“The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses. ”
Source location
Claire Nicole Briggs · 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
Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report
“The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses. ”
Source location
Claire Nicole Briggs · 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
Implement and operate Joint Operating Protocols with four North West police forces covering information sharing, agency primacy, escalation, open lines, lead agency and clinical hub contact.

Verbatim wording from the response
“As mentioned in your concern during the time of the inquest NWAS had engaged with all the North West Police Forces and were advanced in the development of a Joint Operating Protocol (JOP) for the opening, updates, and closures of logs between NWAS and Police Forces. I can now confirm that four of the North West forces including Cheshire Constabulary and Merseyside Police and have now agreed and gone live with their JOPs.”

Source location
Response from Cheshire and Merseyside ICB
Page 1 · response
Published 12 December 2023
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
Oversee progress updates on Joint Operating Protocol implementation through the Regional Clinical Quality Assurance Committee.

Verbatim wording from the response
“The JOP should mitigate the gap in process that you highlighted and the learning from Claire’s tragic death and progress updates on the implementation of the Joint Operating Protocol will be overseen by the NWAS Regional Clinical Quality Assurance Committee which has representation from the Lancashire and South Cumbria Integrated Care Board (LSC ICB) as a commissioner of ambulance services.”

Source location
Response from Cheshire and Merseyside ICB
Page 1 · response
Published 12 December 2023
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
Review the concerns with two other Northwest integrated care boards and coordinate steps to progress them.

Verbatim wording from the response
“Following the inquest, you raised concerns in your Regulation 28 Report that there is a risk a future death will occur unless action is taken. We have worked with the 2 other ICBs in the Northwest who also use North West Ambulance Service particularly Lancashire ICB who act as a lead commissioner for the provider to review the concerns and ensure steps are taken to progress the concerns raised.”

Source location
Response from Greater Manchester ICB
Page 1 · response
Published 12 December 2023
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
Implement the Joint Operating Protocol with Cheshire, Cumbria, Lancashire and Merseyside Police Forces.

Verbatim wording from the response
“As confirmed in the evidence provided by the Trust during the inquest, the JOP implementation process was recommenced with all Police partners on 6 July 2023 and involved fortnightly meetings with all parties. The aim of those meetings was to agree a standard format and wording for the JOP to be used across the North West.”

Source location
Response from NWAS
Page 2 · response
Published 12 December 2023
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 sign-off and implement the updated Joint Operating Protocol with Greater Manchester Police across the North West.

Verbatim wording from the response
“We have continued to work closely with Greater Manchester Police to overcome any remaining barriers and an updated version of the JOP has now been agreed with Greater Manchester Police who are in the final stages of sign off. It is anticipated the updated version of the JOP will be implemented and “go live” across the whole North West following the next meeting with police partners, scheduled for the latter part of February 2024.”

Source location
Response from NWAS
Page 2 · response
Published 12 December 2023
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
Review communication procedures and standards with blue-light partners, particularly North West Ambulance Service.

Verbatim wording from the response
“Upon receipt of the Regulation 28 referred to above Merseyside Fire and Rescue Service reviewed its current procedures and standards of communication with its blue light partners, in particular with North West Ambulance (‘NWAS’).”

Source location
Response from Merseyside Fire and Rescue Service
Page 1 · response
Published 12 December 2023
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
Continue working with Northwest partners to agree and implement a Joint Operating Procedure aligned with Right Care, Right Person.

Verbatim wording from the response
“Further progress has been made to finalise, agree, and implement the JOP since the inquest touching upon the death of Claire Briggs concluded. Version 1.0 of the JOP went live on 12 October 2023 with four of the five North West police forces, namely Cheshire Constabulary, Cumbria Constabulary, Lancashire Constabulary and Merseyside Police.”

Source location
Response from GMP
Page 2 · response
Published 12 December 2023
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 Greater Manchester partnership agreement defining police and ambulance roles and expectations for physical-health Concern for Welfare incidents.

Verbatim wording from the response
“GMP is currently working closely with NWAS in respect of the RCRP project. Work is ongoing in relation to the response to be provided by police and ambulance resources to incidents of a physical health concern. To ensure an appropriate response is provided by both blue light services, a partnership agreement specific to Greater Manchester is currently in development. This partnership agreement will formally outline each organisation’s roles and expectations at incidents of Concern for Welfare (‘CFW’) where the primary or sole nature of the incident relates to a physical health concern, and will ensure that GMP’s response to matters of physical health concern, in conjunction with NWAS, is aligned to the principles of RCRP and the regional JOP and that organisations meet their legal obligations under ECHR legislation.”

Source location
Response from GMP
Page 2 · response
Published 12 December 2023
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
Brief FCCO staff on the agreed Joint Operating Procedure before its implementation, including its purpose, relevance and required use.

Verbatim wording from the response
“Once the JOP has been agreed for launch in Greater Manchester, and before the implementation stage, there will be a process within the FCCO to ensure that all staff are made aware of the document and that they understand its purpose and aims, its relevance to GMP, and how it should be used by them. This message will be distributed by the senior leadership team within the FCCO to all supervisors within the branch for further cascading to all staff members.”

Source location
Response from GMP
Page 3 · response
Published 12 December 2023
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
Continue adopting JESIP principles and operational guidance to promote collaborative working between blue-light partners.

Verbatim wording from the response
“LFRS were not involved in this tragic incident but we are committed to a culture of improvement and learning from lessons identified. LFRS actively supports and works to the Joint Emergency Services Interoperability Programme (JESIP) doctrine, promoting effective interagency working through its principles of Co-Location, Communication, Co-ordination, Joint Understanding of Risk and Shared Situational Awareness. LFRS regularly review policies, procedures and training in line with JESIP. LFRS has adopted the National Fire Chiefs (NFCC) National Operational Guidance, which is considered good practice; this guidance has been incorporated into LFRS Standard Operating Procedures (SOP).”

Source location
Response from Lancashire Fire and Rescue Service
Page 1 · response
Published 12 December 2023
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
Apply JESIP principles and clear speech when coordinating with other emergency services.

Verbatim wording from the response
“2.1. NWFC supports the consistent and robust embedding of the Joint Emergency Services Interoperability Programme (JESIP), which promotes effective inter-agency working through its principles of Co-Location, Communication, Co-ordination, Joint Understanding of Risk, and Shared Situational Awareness. We ensure we follow the JESIP doctrine and use clear speech when liaising with other agencies and avoid using fire service terminology.”

Source location
Response from North West Fire Control
Page 2 · response
Published 12 December 2023
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
Embed and assess compliance with NFCC National Operational Guidance and JESIP inter-agency operating standards.

Verbatim wording from the response
“2.13. To ensure that operating standards set out in NFCC endorsed National Operational Guidance and JESIP related to inter-agency working are embedded and being met.”

Source location
Response from North West Fire Control
Page 4 · response
Published 12 December 2023
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
Operate the Multi-Agency Tactical Control Communications Group to improve interoperability through shared lessons, training and exercises.

Verbatim wording from the response
“2.16. The Inter-Agency Lead has successfully established the Multi-Agency Tactical Control Communications Group which has control room representation at senior level from NWFC, Merseyside Fire Control, all North West regional Police Services, NWAS, British Transport Police and the Coastguard.”

Source location
Response from North West Fire Control
Page 4 · response
Published 12 December 2023
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
Operate under a Joint Operating Procedure defining agency responsibilities, information sharing and incident escalation.

Verbatim wording from the response
“We have been working under this Joint Operating Procedure (JOP) since the 12th October 2023. The JOP outlines the roles and responsibilities of each agency, how we share information and how to escalate any incidents through the command structure.”

Source location
Response from Cumbria Constabulary
Page 1 · response
Published 12 December 2023
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
Sign and endorse the revised joint operating protocol.

Verbatim wording from the response
“1. Cheshire Constabulary has been in liaison with NWAS and throughout the development of the JOP has been supportive and keen to move this forward.”

Source location
Response from Cheshire Constabulary
Page 1 · response
Published 12 December 2023
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
Maintain direct inter-control-room communications with police, ambulance and fire services through ESICTRL talk groups.

Verbatim wording from the response
“Following the major incidents of MAI and Grenfell Tower, a recommendation was made to improve communications directly between the three Emergency Service Control Rooms (3ES -Police, Fire, Ambulance). This resulted in the creation of ESICTRL (Emergency Service Inter-Control) radio talk groups that provide 24/7, uninterrupted, radio communications directly between the 3ES control rooms.”

Source location
Response from BTP
Page 2 · response
Published 12 December 2023
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
Implement the regional Standard Operating Procedure on information sharing in relation to incident logs (Version 1.0).

Verbatim wording from the response
“Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This was initially agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs went live on Thursday 12th October 2023. It was also agreed with the regional Forces and NWAS that monthly meetings will continue until North-West Fire and GMP were able to proceed with the agreement.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Brief Force Control Room Supervisors and Force Incident Managers on the Joint Operating Protocol.

Verbatim wording from the response
“Lancashire Police are already working closely with North-West Regional Forces and North-West Ambulance Service in relation to agreed processes in the Joint Operating Protocol. The document will provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays. It will also give operational officers at the scene of an incident guidance and information to obtain direct clinical advice from North-west Ambulance Service prior to them arriving on the scene of an incident. Implementation was initially via email/briefing to all Force Control Room Supervisors and Force Incident Managers.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Continue monthly meetings with regional forces and ambulance services to agree the Joint Operating Protocol.

Verbatim wording from the response
“Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This was initially agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs went live on Thursday 12th October 2023. It was also agreed with the regional Forces and NWAS that monthly meetings will continue until North-West Fire and GMP were able to proceed with the agreement.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Sign off Lancashire Police’s version 1.3 Joint Operating Protocol document.

Verbatim wording from the response
“Rollout via email briefing was due to take place to operational officers and Control Room staff to be made aware of the purpose and aims of the JOP, how it applies to that agency and how it should be used by staff. However, this has been delayed due to GMP having issues with the wording in the document about the responsibilities of the lead agency. Further meetings have now taken place with all regional forces to agree the wording. Version 1.3 was due to go live on 31/01/2024, however this is still waiting sign off from GMP and Fire and Rescue. Lancashire Police are happy and have signed off with the Version 1.3 document, and we are just waiting for confirmation of go live from North-west Ambulance Service who are leading on the document.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Maintain agreed police–ambulance escalation processes for obtaining information, escalating delays, cancelling ambulances and resolving operational concerns.

Verbatim wording from the response
“In November 2022, communication was distributed throughout the FCCO outlining the escalation process between GMP and NWAS. This message was reinforced in June 2023 via internal messaging and is recirculated, as necessary, to ensure consistent compliance. What was initially introduced as an interim measure in 2022 is now considered “business as usual” and, through regular liaison with NWAS, is regarded as appropriate practice for both organisations. These escalation processes are outlined below:”

Source location
Response from GMP
Page 3 · response
Published 12 December 2023
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 frontline personnel with access to NWAS remote clinical support through SOPs and fallback telephones.

Verbatim wording from the response
“Within numerous SOP’s (Communications, Gaining Entry, Immediate Emergency Care), guidance is provided for personnel to access remote clinical support. If there is a delay in NWAS response, or if the casualties condition appears to be deteriorating, personnel are directed to utilise the clinical support lines provided by NWAS Clinical Support Hub or Trauma Cell. All frontline fire appliances and officers have access to these numbers via fallback telephones. Clinical advice and guidance will be provided over the phone with the potential for the NWAS response to be upgraded.”

Source location
Response from Lancashire Fire and Rescue Service
Page 1 · response
Published 12 December 2023
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
Adopt Multi-Agency Incident Transfer as an early adopter and put the tool in place.

Verbatim wording from the response
“6.1. Multi-Agency Incident Transfer (MAIT) is an electronic means of sharing information with other agencies subscribed to the MAIT hub.”

Source location
Response from North West Fire Control
Page 6 · response
Published 12 December 2023
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 feedback to NWAS and conduct a gap analysis of information-sharing procedures against NWFC operating arrangements.

Verbatim wording from the response
“7.1. In July 2023, The Multi-Agency Tactical Control Communications Group was presented with a draft version of an information sharing document produced by NWAS to enable collaboration between NWAS and the Police.”

Source location
Response from North West Fire Control
Page 7 · response
Published 12 December 2023
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 clinical support through the “treat and hear” facility for direct updates from NWAS.

Verbatim wording from the response
“We also have clinical support within Cumbria through our “treat and hear” facility which allows officers on the front line to provide updates direct to a member of NWAS.”

Source location
Response from Cumbria Constabulary
Page 1 · response
Published 12 December 2023
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 control-room briefings to support exchange of initial triage information with partner responder agencies.

Verbatim wording from the response
“BTP are also adopting this model that improves the identification of incidents/ patients requiring escalation. Actions currently underway to ensure BTP officers and staff are adequately aware of this approach include:”

Source location
Response from BTP
Page 1 · response
Published 12 December 2023
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
Ambiguous lead-agency wording prevents agreement to the Joint Operating Procedure until responsibilities and deployment expectations are clarified.

Verbatim wording from the response
“Other partner organisations, including GMP, have yet to agree to the JOP. GMP considers the wording contained within the section on ‘Identifying the Lead Agency’ creates ambiguity and could cause confusion. The current wording is not clear as to which organisation would be the lead agency in certain circumstances, particularly in instances when there may be scene safety concerns, and what such a designation would mean in practical terms. This section of the JOP also suggests that two organisations could be considered the lead agency at the same incident for different purposes (“the lead for the policing purpose would be the Police, NWAS would remain the Lead Agency for the health matter”).”

Source location
Response from GMP
Page 2 · response
Published 12 December 2023
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
Existing LFRS guidance and processes are considered sufficient to address the recommendations.

Verbatim wording from the response
“In response to the recommendations made, LFRS believes that appropriate guidance and processes are available and in place, and I trust this response addresses the matters raised. LFRS will continue to adopt existing JESIP principles and operational guidance, promoting collaborative working between blue-light partners, whilst striving to develop guidance and process to ensure the most effective response is delivered.”

Source location
Response from Lancashire Fire and Rescue Service
Page 2 · response
Published 12 December 2023
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
Confirmation of the Joint Operating Protocol’s go-live rests with North-West Ambulance Service, pending sign-off from GMP and Fire and Rescue.

Verbatim wording from the response
“Rollout via email briefing was due to take place to operational officers and Control Room staff to be made aware of the purpose and aims of the JOP, how it applies to that agency and how it should be used by staff. However, this has been delayed due to GMP having issues with the wording in the document about the responsibilities of the lead agency. Further meetings have now taken place with all regional forces to agree the wording. Version 1.3 was due to go live on 31/01/2024, however this is still waiting sign off from GMP and Fire and Rescue. Lancashire Police are happy and have signed off with the Version 1.3 document, and we are just waiting for confirmation of go live from North-west Ambulance Service who are leading on the document.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Existing GMP-NWAS escalation processes are considered appropriate and sufficient while work continues to implement the Joint Operating Procedure.

Verbatim wording from the response
“In November 2022, communication was distributed throughout the FCCO outlining the escalation process between GMP and NWAS. This message was reinforced in June 2023 via internal messaging and is recirculated, as necessary, to ensure consistent compliance. What was initially introduced as an interim measure in 2022 is now considered “business as usual” and, through regular liaison with NWAS, is regarded as appropriate practice for both organisations. These escalation processes are outlined below:”

Source location
Response from GMP
Page 3 · response
Published 12 December 2023
Open published response
25 Oct2023
Cheshire
Concerns raised1
1. Failure of ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks
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 2
1. Action
  Publish the revised First Aid Learning Programme outcome requiring officers to recognise signs and symptoms of acute behavioural disturbance.
  Stated by College of Policing and National Police Chiefs’ CouncilStated completed
2. Action
  Develop and update Public and Personal Safety Training to cover ABD presentation and causes, de-escalation, restraint risks, medical assistance, monitoring, and scenario-based decision-making.
  Stated by College of Policing and National Police Chiefs’ CouncilStated completed
AI-generated summary

Carl FULLALOVE · 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

Carl Fullalove was arrested after being observed jumping on cars, behaving bizarrely and appearing to be under the influence of a substance. He was placed in prone restraint during a search in custody, became non-responsive and suffered cardiac arrest, and subsequently died in hospital. The principal concerns were that signs of acute behavioural disturbance or illness were not recognised, the risks of prone restraint and stimulant drugs were not sufficiently considered, and training did not adequately address calming intervention in an upright position.

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 ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks
Wider context from the report
“(1)Whilst the jury did not make any finding of acute behavioural disturbance (ABD) in this case, much evidence was heard about the training in identification of the signs and symptoms. National training of police officers on the identification of ABD is focused on a triad of warning flags being, hot to touch, exhibiting constant or near constant activity and extreme agitation or aggression. Some evidence identified that Carl Fullalove did not exhibit these triad symptoms but did exhibit other nuanced symptoms in the long list delivered in training. It was evident that his symptoms were not recognised as ABD due to drug intoxication, and that the consequential risks associated with prone restraint were not therefore considered. Prone restraint ultimately led to his death. There were six experts providing evidence to the inquest two of whom identified that Carl would not have died had he been recognised as unwell at the point of arrest and assessed by a health care practitioner. Such attention would have provided a calming intervention for his heart rate and breathing prior to being placed in prone restraint, which exerted additional pressure on his ability to breath freely. ”
Source location
Carl FULLALOVE · 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
Publish the revised First Aid Learning Programme outcome requiring officers to recognise signs and symptoms of acute behavioural disturbance.

Verbatim wording from the response
“In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and”

Source location
Response from College of Policing
Page 1 · response
Published 28 November 2023
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 update Public and Personal Safety Training to cover ABD presentation and causes, de-escalation, restraint risks, medical assistance, monitoring, and scenario-based decision-making.

Verbatim wording from the response
“The College of Policing have designed and developed a new Public and Personal Safety Training (PPST) package for all police officers with the emphasis on de-escalation. It is twelve hours, scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. Some forces have already implemented the new training package, and all forces are to go live with this training in April 2024. From the evaluation of the training pilot, early, statistically significant data shows a reduction in police use of force incidents. The updated training will include a recently updated training package for ABD.”

Source location
Response from College of Policing
Page 2 · response
Published 28 November 2023
Open published response
16 Sep2022
Newcastle and North Tyneside
Concerns raised2
1. Lack of training for hostel workers to recognise the need for urgent medical intervention in intoxication
2. Lack of structured training for hostel workers to identify alcohol intoxication risks and signs
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

Colin Andrew Mark SMITH · 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

Colin Andrew Mark SMITH, aged 39, died at a hostel after consuming an excessive quantity of alcohol and returning highly intoxicated. The principal concerns were the absence of structured training for hostel workers to identify the risks and signs of alcohol intoxication and when urgent medical intervention was needed.

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 for hostel workers to recognise the need for urgent medical intervention in intoxication
Wider context from the report
“Evidence was given which confirmed the absence of any training policy/programme for all hostel workers in respect of identifying the risks and signs of alcohol intoxication and circumstances indicating the need for urgent medical intervention. (1) Lack of structured training policy/programme for ALL Hostel workers in respect of identifying risks of Alcohol intoxication and indicators/signs of those risks. (2) Lack of training policy /programme for ALL Hostel workers re signs/indicators of need for urgent medical Intervention in Intoxication. ”
Source location
Colin Andrew Mark SMITH · 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
Lack of structured training for hostel workers to identify alcohol intoxication risks and signs
Wider context from the report
“Evidence was given which confirmed the absence of any training policy/programme for all hostel workers in respect of identifying the risks and signs of alcohol intoxication and circumstances indicating the need for urgent medical intervention. (1) Lack of structured training policy/programme for ALL Hostel workers in respect of identifying risks of Alcohol intoxication and indicators/signs of those risks. (2) Lack of training policy /programme for ALL Hostel workers re signs/indicators of need for urgent medical Intervention in Intoxication. ”
Source location
Colin Andrew Mark SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Sep2021
West Sussex
Concerns raised4
1. Absence of directives in police training material and national policy on referral of apparently intoxicated injured people
2. Alcohol-appearing effects masking serious underlying medical conditions
3. Insufficient police training to identify and refer apparently intoxicated people complaining of injury
1. Failure to recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Circulate essential head-injury guidance to all officers, requiring medical assistance to be requested or facilitated where a head injury is suspected.
  Stated by Avon and Somerset ConstabularyStated completed
2. Action
  Send essential head-injury guidance to all first-aid trainers.
  Stated by Avon and Somerset ConstabularyStated completed
3. Action
  Add essential head-injury guidance to Modules 1, 2 and 4 casualty-assessment training.
  Stated by Avon and Somerset ConstabularyStated completed
1. Action
  Add essential head-injury guidance to Modules 3 and 4 head-injury training.
  Stated by Avon and Somerset ConstabularyStated completed
2. Action
  Incorporate head-injury response guidance into Taser, Personal Safety and Public Order training programmes.
  Stated by Avon and Somerset ConstabularyStated completed
3. Action
  Update first-aid training, policy or guidance when revised CoP or NPCC requirements are received.
  Stated by Avon and Somerset ConstabularyStated planned
4. Action
  Send this response and relevant updated force guidance and training documents to the CoP and NPCC for consideration in national guidance and training decisions.
  Stated by Avon and Somerset ConstabularyStated planned
5. Action
  Continue reviewing the concerns and working with the CoP and NPCC to implement recommended changes to training, policy and guidance.
  Stated by Avon and Somerset ConstabularyStated in progress
6. Action
  Review FALP learning outcomes with clinical leads and assess adding stronger coverage of alcohol, intentional overdoses, and head injuries to Module 2.
  Stated by College of Policing and National Police Chiefs’ CouncilStated in progress
Respondent positions 4
1. Position
  Existing first-aid training and formal governance routes will address the concerns about police responses to injured or vulnerable people.
  Stated by Home OfficeExisting arrangements considered sufficient
1. Position
  The range of incidents makes it impracticable to train all officers for every medical emergency or specify a response for every context.
  Stated by College of Policing and National Police Chiefs’ CouncilUnable to act
2. Position
  CoP and NPCC are responsible for determining national FALP training and policy changes; the Constabulary will follow their updated guidance.
  Stated by Avon and Somerset ConstabularyRedirects responsibility
3. Position
  Officers cannot always require members of the public to remain or engage with medical intervention.
  Stated by Avon and Somerset ConstabularyUnable to act
AI-generated summary

Hamish John Cameron HOWITT · 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

Hamish John Cameron HOWITT, a 20-year-old university student, died unexpectedly overnight in Frome on 1 July 2016 after an evening involving alcohol, a traumatic brain injury and self-administered ketamine. The concerns were that police did not recommend hospital assessment after he reported being injured, and that police training and national policy should address the risk of serious underlying conditions being masked by apparent intoxication.

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
Absence of directives in police training material and national policy on referral of apparently intoxicated injured people
Wider context from the report
“(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action. (2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used). (3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services. (4) Police training material and national policy setting should include directives to this effect. ”
Source location
Hamish John Cameron HOWITT · 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
Alcohol-appearing effects masking serious underlying medical conditions
Wider context from the report
“(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action. (2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used). (3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services. (4) Police training material and national policy setting should include directives to this effect. ”
Source location
Hamish John Cameron HOWITT · 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
Insufficient police training to identify and refer apparently intoxicated people complaining of injury
Wider context from the report
“(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action. (2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used). (3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services. (4) Police training material and national policy setting should include directives to this effect. ”
Source location
Hamish John Cameron HOWITT · 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 recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury
Wider context from the report
“(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action. (2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used). (3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services. (4) Police training material and national policy setting should include directives to this effect. ”
Source location
Hamish John Cameron HOWITT · 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
Circulate essential head-injury guidance to all officers, requiring medical assistance to be requested or facilitated where a head injury is suspected.

Verbatim wording from the response
“i. An internal communications bulletin has been sent to all officers which identified head injuries as a matter of concern, and provided a link to “essential guidance” on head injuries. This was included in the “Must know” section of the bulletin, which all officers are required to read. The linked guidance states that if an officer or staff member has any suspicion, or is told in good faith, that a person may have a head injury, they should treat the person as such in the absence of clear evidence to dispel that suspicion. The guidance makes clear that no visible marking is not an acceptable level of evidence that a head injury has not been sustained.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 3 · response
Published 5 October 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
Send essential head-injury guidance to all first-aid trainers.

Verbatim wording from the response
“ii. All first aid trainers have been sent the essential guidance on head injuries.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 3 · response
Published 5 October 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
Add essential head-injury guidance to Modules 1, 2 and 4 casualty-assessment training.

Verbatim wording from the response
“iii. The lesson plan for Modules 1, 2 and 4 for “Assess a Casualty (Primary and Secondary survey)” has been amended to require this training to provide the same essential guidance on head injuries.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 3 · response
Published 5 October 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
Add essential head-injury guidance to Modules 3 and 4 head-injury training.

Verbatim wording from the response
“iv. The Module 3 and 4 first aid training on head injuries has been amended to incorporate the same essential guidance on head injuries.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 3 · response
Published 5 October 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
Incorporate head-injury response guidance into Taser, Personal Safety and Public Order training programmes.

Verbatim wording from the response
“v. Avon and Somerset Constabulary officers with responsibility for leading force training in relation to Taser, Personal Safety Training and Public Order training have also been made aware of the Report and of the first aid guidance on head injuries, which have been incorporated into their training programmes.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 3 · response
Published 5 October 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
Update first-aid training, policy or guidance when revised CoP or NPCC requirements are received.

Verbatim wording from the response
“18. Avon and Somerset Constabulary will update its training provision immediately on receipt of any updated guidance from the CoP and / or NPCC.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 4 · response
Published 5 October 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
Send this response and relevant updated force guidance and training documents to the CoP and NPCC for consideration in national guidance and training decisions.

Verbatim wording from the response
“19. A copy of this response, and relevant updated force guidance and training documents, will also be sent to the CoP and the NPCC so that they are aware of all of the changes that have been made internally by Avon and Somerset Constabulary, and can take these into consideration when determining whether any additional national guidance, or amendments to training provision are required.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 4 · response
Published 5 October 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
Continue reviewing the concerns and working with the CoP and NPCC to implement recommended changes to training, policy and guidance.

Verbatim wording from the response
“17. It is understood that all matters of concern identified at Part 5 of your Report will be reviewed by the NPCC and CoP, including provision of training on head injury, the potential impact of alcohol in masking other underlying conditions, and your recommendations in relation to training material and national policy setting.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 4 · response
Published 5 October 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
Review FALP learning outcomes with clinical leads and assess adding stronger coverage of alcohol, intentional overdoses, and head injuries to Module 2.

Verbatim wording from the response
“As a matter of course, all coroner reports and requests related to the provision of first aid by police officers are reviewed by the NPCC First Aid Forum as a standing agenda item. The College is also working with clinical leads to review the high-level learning outcomes within the FALP with the aim of placing greater emphasis on the training elements that preserve life. The review is already considering addressing the issue of acute alcohol intoxication and intentional overdoses within Module 2. It is also considering extending the learning in relation to head injuries to Module 2. The matters of concern you raise with relation to the impact of alcohol and the assessment of head injuries will be raised formally at the next meeting (13th December) to assess whether it is feasible and practicable to address these concerns within the scope of the licence.”

Source location
2021-0320-Joint-response-from-College-of-Policing-and-National-Police-Chiefs-Council_Published
Page 2 · response
Published 5 October 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
Existing first-aid training and formal governance routes will address the concerns about police responses to injured or vulnerable people.

Verbatim wording from the response
“My officials have consulted College of Policing and National Police Chiefs Council (NPCC) on their response to your report. As mentioned in their joint letter, front line response police officers receive training at least equivalent to HSE Emergency First Aider level. Our police are required to deal with a wide range of situations on a daily basis and this includes working closely with ambulance services and other medical colleagues when responding to certain medical incidents, where appropriate.”

Source location
2021-0320-Response-from-Home-Office_Published
Page 1 · response
Published 5 October 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 range of incidents makes it impracticable to train all officers for every medical emergency or specify a response for every context.

Verbatim wording from the response
“Officers are called on to provide first aid in a wide range of incidents as part of their role. The range of incidents they attend mean it is not possible or viable for all officers to be trained for all types of medical emergencies, or for the FALP to explicitly outline the appropriate medical response in every context. That said, as detailed in this response, we acknowledge there is more that we can do to standardise our training and I trust that we have provided you with assurances that the matters of concern you have raised will be addressed.”

Source location
2021-0320-Joint-response-from-College-of-Policing-and-National-Police-Chiefs-Council_Published
Page 2 · response
Published 5 October 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
CoP and NPCC are responsible for determining national FALP training and policy changes; the Constabulary will follow their updated guidance.

Verbatim wording from the response
“ii. The CoP is working with clinical leads to review the high level learning outcomes with the aim of placing greater emphasis on the training elements that preserve life, and is presently considering:”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 4 · response
Published 5 October 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
Officers cannot always require members of the public to remain or engage with medical intervention.

Verbatim wording from the response
“i. An internal communications bulletin has been sent to all officers which identified head injuries as a matter of concern, and provided a link to “essential guidance” on head injuries. This was included in the “Must know” section of the bulletin, which all officers are required to read. The linked guidance states that if an officer or staff member has any suspicion, or is told in good faith, that a person may have a head injury, they should treat the person as such in the absence of clear evidence to dispel that suspicion. The guidance makes clear that no visible marking is not an acceptable level of evidence that a head injury has not been sustained.”

Source location
2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Page 3 · response
Published 5 October 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to maintain a clear and current drug under the influence policy

Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response

Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances

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.7

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

Concerns raised3

Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence

Failure to observe and monitor prisoners suspected to be under the influence of illicit substances

Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances

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.7

Concerns raised4

Lack of guidance for escalating and monitoring suspected intoxication

Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication

Failure to promptly notify the prison orderly and document suspected intoxication

Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence

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.5

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

Actions described in response 7

Respondent positions 1

Actions described in response 7

Actions described in response 5

Respondent positions 3