Recurring concern

Unreliable searches and screening for drugs and prohibited items in controlled environments

First to latest report 6 Jun 2014 — 9 Sep 2024

Reports that mention this concern
9
Times this concern has been raised
13
Stated actions linked to this concern
12

What this concern includes

Includes entry, person, room and comparable searches or screening intended to detect, record and remove drugs, contraband or dangerous prohibited items in a controlled environment.

What is not included
  • Searches for missing people or investigative evidence unrelated to prohibited-item control
  • Physical perimeter controls where no search or screening process is involved
  • Drug testing intended to identify consumption rather than possession or entry

Reports and published responses 9 reports

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

  1. West Yorkshire Eastern

    AI-generated summary

    Amanda Richardson · 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

    Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.

    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 search patient rooms and hospital grounds after serious illicit-drug incidents

    Wider context from the report

    “4. Ms Richardson died some 9 days later. Despite the seriousness of the 19.4.23 incident, no searches were carried out in her room or the hospital grounds in the period following her return. The toxicology and pathological evidence indicated that she had taken heroin shortly before her death. Her room was not searched even after her death, as assumptions were wrongly made that her death was due to a cardiac event. ”

    Source location

    Amanda Richardson · Prevention of Future Deaths report
    Page 1 · 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 record the nature, duration and responsible person for searches of returning patients

    Wider context from the report

    “3. On 19.4.23, Ms Richardson was permitted unescorted leave in the community under S.17 MHA 1983. She did not return. She did, however, voluntarily reappear at the hospital the following day, albeit under the influence of illicit drugs and alcohol. Evidence was given that nurses reported having searched Ms Richardson on her return, but no adequate written record was made to confirm the nature or duration of the search, nor by whom it was conducted, in breach of hospital policies. ”

    Source location

    Amanda Richardson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.

    Verbatim wording from the response

    “Inmind Healthcare remain committed to learning and improving service but given the assurances given to the Coroner at the Inquest, Inmind Healthcare consider that actions have been taken to fully address the issues identified by the Serious Incident Report and to prevent future deaths in similar circumstances.”

    Source location

    Response from InMind
    Page 2 · response
    Published 10 September 2024

    Open published response

  2. Manchester North

    AI-generated summary

    Ania Sohail · 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

    Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.

    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

    Ineffective searches of patients’ rooms for stockpiled medication

    Wider context from the report

    “(5) Searches undertaken on Ania’s room following the overdoses on 10 March and 5 June 2021 were ineffective and did not uncover the Propranolol that Ania had been stockpiling. ”

    Source location

    Ania Sohail · 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

    Deliver training for ward staff on effective room and personal searches and record compliance.

    Verbatim wording from the response

    “In respect of searches, a Trust Risk & Safety Advisor has facilitated training sessions regarding how to conduct both room and personal searches effectively. All ward staff have completed this training and the ward manager keeps a record of staff compliance.”

    Source location

    Response from Greater Manchester Mental Health
    Page 2 · response
    Published 22 February 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

    Update the Trust search policy to incorporate learning about contraband and reinforce search procedures.

    Verbatim wording from the response

    “The Trust policy HS13 Search of service users, visitors and belonging policy was reviewed and updated to include the learning from Ania’s death. This included a review of contraband items and reinforcement of search procedures.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 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

    Room searches were conducted and found no medication; intimate searches were not indicated at the time.

    Verbatim wording from the response

    “(5) Searches undertaken of Ania’s room following the overdoses on 10 March and 5 June 2021 were ineffective and did not uncover the Propranolol that Ania had been stockpiling.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 2023

    Open published response

  3. Buckinghamshire

    AI-generated summary

    Amanda Gibbens · 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

    Amanda Gibbens died on 13 July 2020 at Stoke Mandeville Hospital after suffering a cardiac arrest while detained under Section 2 of the Mental Health Act at Ruby Ward. The concerns included the use of a monitor rather than continuous direct observation during Level 3 observations and ineffective bedroom searches for prohibited items that could be used for self-harm.

    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 conduct effective bedroom searches for prohibited self-harm items

    Wider context from the report

    “2. Searching bedrooms on Ruby ward for prohibited items The evidence in this case demonstrated that the deceased had prohibited items in her bedroom on Ruby Ward, including a ████████ ████████ The search of the patient environment in July 2020 was not effective in identifying and removing items which could be used for self-harm by a detainee patient under the Mental Health Act, who was at risk of self harm. The evidence heard at the time of the inquest in February 2022 was that the bedroom searching process does not always include looking into or underneath a patient’s property in their room for concealed items, although some changes to the method and recording of searches are intended. A previous Report to Prevent Future Deaths to the Trust dated April 2019 also identified that the search process on Ruby ward was not effective. ”

    Source location

    Amanda Gibbens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester North

    AI-generated summary

    Liam Kenyon · 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

    Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.

    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 procedure for requesting a drug check of a resident’s room

    Wider context from the report

    “3. The Court heard following the incident on the 17th July the procedure of asking Liam if a drug check of his room could be conducted was not done. ”

    Source location

    Liam Kenyon · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. East London

    AI-generated summary

    Rohan Dayal Singh · 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

    Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.

    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 searches to detect and remove dangerous contraband

    Wider context from the report

    “1. Rohan Singh died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, Rohan had been subject to a personal search by police officers when the bracelet was seized. During Rohan’s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband. ”

    Source location

    Rohan Dayal Singh · 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

    Revise the search policy to govern search-information handover and review, and the disposal or storage of seized items, then disseminate the changes.

    Verbatim wording from the response

    “In order to address the issue of contraband being handed back to Mr Dayal Singh, the Trust is revising its search policy to explicitly include guidance on:”

    Source location

    2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 5 May 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

    Create and deliver a search training course, record completion in ESR, provide it at induction and every two years, and monitor compliance.

    Verbatim wording from the response

    “To ensure that nursing staff are equipped to carry out robust searches the Trust’s Director of Nursing and the Learning and Development Team are creating a ‘search’ training course. The course will reflect the Trust’s updated policy. Completion of the course will be monitored using the Trust’s Electronic Staff Record (ESR) data base.”

    Source location

    2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 5 May 2021

    Open published response

  6. Brighton and Hove

    AI-generated summary

    Bethany Tengquist · 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

    Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.

    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 an effective searching system for patients and visitors

    Wider context from the report

    “1. The search policy and Beth’s access to alcohol on a frequent basis Given Beth’s extremely high risk of self-harm or suicide (described by the her Responsible Clinician, a highly experienced psychologist, as one of the very highest risk patients she had encountered in her lengthy career) and characterised by high levels of impulsivity, I have grave concerns that Beth had frequent access to alcohol whilst detained under section 3 of the MHA on an acute ward. It was, or should have been, widely recognised by all staff that an even greater elevation of the already exceptionally high risk of self-harm or suicide would be occasioned by Beth’s access to alcohol; the jury have confirmed that, notwithstanding this clear danger to her safety, there was a persistent and on-going failure to ensure all reasonable steps were taken to ensure that alcohol was not available on the ward. It has been conceded by the Trust that searching policy was inconsistent and ineffective. Whilst I have received evidence with respect to a more robust approach to daily environmental checks having now been introduced, I remain concerned that there is an insufficiently robust and effective system in place for the effective searching of voluntary patients, those detained patients returning from section 17 leave and all visitors to Caburn Ward. The continued absence of dedicated security staff at the entrance to Caburn Ward, during the hours that patients and visitors may arrive, gives rise to a risk of future deaths should alcohol continue to find a route onto the ward. ”

    Source location

    Bethany Tengquist · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Incomplete and flawed checks and removal of dangerous items from patient rooms

    Wider context from the report

    “During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm. The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed. The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself. Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them. Please tell me precisely how you are going to put this right. ”

    Source location

    Bethany Tengquist · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Birmingham and Solihull

    AI-generated summary

    Stephen Keith Harte · 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

    Stephen Keith Harte was found unresponsive in his room at the Tamarind Centre on 18 August 2018 and could not be resuscitated. A post-mortem found a fatal dose of heroin, and the medical cause of death was recorded as heroin toxicity. The principal concern was that drugs could too easily enter the medium secure unit through routes including unsupervised takeaway deliveries, residents returning from leave, and staff bringing in unscreened food.

    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 effectively search staff entering the unit

    Wider context from the report

    “3) I also heard evidence that staff are not typically searched upon entering the unit. They also walk thought the scanner, but this is unlikely to reveal small quantities of drugs on their person. Further, whilst they are required to leave personal belongings in lockers, they are allowed to take their own food on to the unit which is also not searched. ”

    Source location

    Stephen Keith Harte · Prevention of Future Deaths report
    Page 1 · 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 effectively search residents returning from unsupervised leave

    Wider context from the report

    “1) I heard evidence about the potential routes for drugs to enter the medium secure unit. This included: (a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of their choice and the food is not searched upon arrival. Historically, residents were only allowed to order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was unclear whether the CQC had similarly asked other units to relax their rules. (b) Those residents allowed unsupervised leave are not typically searched upon their return. They walk thought a scanner, but this is unlikely to reveal small quantities of drugs on their person. ”

    Source location

    Stephen Keith Harte · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conducted a comprehensive inspection of the trust and published the inspection reports.

    Verbatim wording from the response

    “The Care Quality Commission commenced a comprehensive inspection of Birmingham and Solihull Mental Health Foundation NHS trust 27th–31st March 2017 and published the reports 2nd August 2017. At that inspection we found the trust had implemented blanket restrictions with regards to the ordering of food from takeaways and in relation to patient searches. We informed the trust that it was appropriate for them to provide patients with information on hygienic ratings and to explain the benefits. However, patients with mental capacity had the right to order takeaways from the shop of their choice, and the policy did not promote an individualised approach to patient’s choice or risk. We”

    Source location

    2019-0077-Response-by-CQC
    Page 1 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conducted a comprehensive follow-up inspection of the trust and assessed its search and security arrangements.

    Verbatim wording from the response

    “We visited the trust in November and December 2018 and carried out a comprehensive inspection as part of our regular inspection programme. At that inspection we found the trust had reviewed and implemented a new search and security policy based on risk assessment. We did not find any breaches related to blanket restrictions.”

    Source location

    2019-0077-Response-by-CQC
    Page 2 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Search service users returning from unescorted leave, in addition to scanner screening.

    Verbatim wording from the response

    “The Trust Policy on the searching of service users in our secure care inpatient wards states that a search will be conducted on all service users returning from unescorted leave. This is in addition to service users walking through the scanner. We recognise that service users may at times secrete drugs in body cavities and that our regular search approach may not identify these. In addition to this, we have therefore implemented a wide range of additional controls to detect any drugs entering the unit. These include:-”

    Source location

    2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 2 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide each service user with at least one random monthly drug screen, varied according to individual risk and care plans.

    Verbatim wording from the response

    “• Service users have at least one random monthly drug screen, but may vary dependent on individualised risk and care plans”

    Source location

    2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 2 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct random clothing searches after unescorted community leave when individual concerns are identified.

    Verbatim wording from the response

    “• Random change of clothes search following service users returning from unescorted community leave if particular concerns are noted about individualised patients”

    Source location

    2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 2 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Directed the trust to assess individually the risks posed by patients returning from leave.

    Verbatim wording from the response

    “Because of our findings we told the trust that they must ensure that it undertakes active individual assessment of risks posed by patients returning from leave. We told the trust that they should review practice of not allowing patients to buy food from a takeaway shop of their choice.”

    Source location

    2019-0077-Response-by-CQC
    Page 2 · response
    Published 9 June 2019

    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

    Staff are not routinely searched; scanning, drug-dog detection and risk-based searches are relied upon to address drug-entry concerns.

    Verbatim wording from the response

    “Our current arrangement within our inpatient facilities is that staff are not typically searched upon entering the unit and that this would only occur if we had clear grounds for concern that particular staff members were facilitating access to drugs on the unit. We do however have the drug dog which visits our secure care and acute care wards and would detect any traces of drugs or illicit substances on members of staff.”

    Source location

    2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 4 · response
    Published 9 June 2019

    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

    Decisions about searching staff entering units are assigned to each individual organisation, not made by the CQC.

    Verbatim wording from the response

    “The Care Quality Commission did tell the trust that it must ensure that active and individual assessment of risks posed to patients who return from leave and use this to base decision on searches. The trust carried out a comprehensive review of its search policy and implemented a security policy and a new search policy in response to our requirement notice. During our inspections we do not review the searching of staff entering units although for some services we would review the security arrangement. Any decisions to search staff would be a decision taken by each individual organisation. The Care Quality Commission would review what action an organisation was taking if they informed us they had a problem of drugs entering their units and would comment on them within our reports.”

    Source location

    2019-0077-Response-by-CQC
    Page 2 · response
    Published 9 June 2019

    Open published response

  8. Birmingham and Solihull

    AI-generated summary

    Dean Ronald Edmund BOLAND · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dean Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient drug-dog coverage for screening prisoners and visitors

    Wider context from the report

    “12. Birmingham prison has 2 drug dogs who work on a shift pattern. This means not every area in the prison can be covered as only one dog is on duty at any one time. Given that these dogs are the only current mechanism for identifying certain drugs consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened. ”

    Source location

    Dean Ronald Edmund BOLAND · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of capability to screen incoming prisoners and visitors for concealed drugs

    Wider context from the report

    “11. At present there is no ability to search or screen prisoners or visitors for drugs concealed on their person when they come into prison. Given that this is a major source of drugs coming into the prison further consideration need to be given, on a national level, as to how concealed drugs can be identified for example with the use of a full body scanner. The current scanner can only identify metal objects. ”

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train specialist dogs to search for and detect new psychoactive substances in prisons.

    Verbatim wording from the response

    “substances. It includes a new offence of possession of a psychoactive substance in a custodial institution, which will tackle the dangerous and pervasive use of new psychoactive substances in prisons. The Government recently commenced a clause in the Serious Crime Act, which introduces a new offence of throwing any item over a prison wall, including psychoactive substances. Plans are in place to provide widespread testing for psychoactive substances as part of the MDT process by April 2016, and NOMS has trained more than 300 specialist dogs to search and detect new psychoactive substances in prisons. NOMS is also evaluating the effectiveness of body scanners to tackle further the threat posed by drugs being smuggled into prisons.”

    Source location

    2015-0468-Response-by-NOMS
    Page 5 · response
    Published 25 November 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Evaluate body-scanner effectiveness for tackling drugs smuggled into prisons.

    Verbatim wording from the response

    “substances. It includes a new offence of possession of a psychoactive substance in a custodial institution, which will tackle the dangerous and pervasive use of new psychoactive substances in prisons. The Government recently commenced a clause in the Serious Crime Act, which introduces a new offence of throwing any item over a prison wall, including psychoactive substances. Plans are in place to provide widespread testing for psychoactive substances as part of the MDT process by April 2016, and NOMS has trained more than 300 specialist dogs to search and detect new psychoactive substances in prisons. NOMS is also evaluating the effectiveness of body scanners to tackle further the threat posed by drugs being smuggled into prisons.”

    Source location

    2015-0468-Response-by-NOMS
    Page 5 · response
    Published 25 November 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Four drug dogs are deployed strategically according to intelligence and risk, including searches of prisoners, visitors, cells and targeted areas.

    Verbatim wording from the response

    “Consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened HMP Birmingham has four operational drug dogs at its disposal. There are two dog handlers each of whom has two drug dogs: a passive drug dog (trained to search people) and an active drug dog (trained to search areas).”

    Source location

    2015-0468-Response-by-NOMS
    Page 5 · response
    Published 25 November 2015

    Open published response

  9. South and East Cumbria

    AI-generated summary

    James Edward Boylan · 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

    James Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.

    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

    Insufficient searching of patients’ property for concealed dangerous items

    Wider context from the report

    “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion, and so again Mr Boylan had access to something which he could use to hang himself with. ”

    Source location

    James Edward Boylan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.

    Verbatim wording from the response

    “I note that you have also addressed your report to the Cumbria Partnership NHS Foundation Trust and I would expect them to properly address the four concerns relating to events during Mr Boylan’s time on the Dova Unit at Furness General Hospital.”

    Source location

    2014-0253-Response-by-Department-of-Health
    Page 2 · response
    Published 6 June 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026