Recurring concern

Failure to ensure naloxone is available and usable for opioid overdose emergencies

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First reported 28 Aug 2019•Latest report 31 Mar 2025

Definition

What this concern includes

Includes failures of dedicated arrangements to provide, position, access, authorise, train for or administer naloxone for opioid-overdose emergencies, including unavailable wing or area supplies and responders who lack the required training or authorisation.

Not included

Excludes general opioid-overdose recognition, treatment or clinical-guidance failures where naloxone availability or usability is not the deficient control.
Excludes general medication storage, supply or staff-training deficiencies unless they directly affect naloxone for opioid-overdose emergencies.
Excludes restricted access to naloxone caused solely by a person's non-engagement with substance-misuse services when no failure in the responsible access arrangement is identified.
Excludes the existing concern focused on access to and application of Naloxone guidance when the assertion concerns guidance accessibility or clinical indications rather than availability or usability of naloxone itself.

Reports: 4
Individual concerns: 7
Date range: 2019–2025
Stated actions: 7

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.

Central and North West London NHS Foundation Trust1

HM Prison and Probation Service1

Home Office1

Langley Health Centre1

Mitie1

Mitie Care And Custody Limited1

NHS England1

Recipient name withheld1

Royal Free Hospital1

St Mungo Community Housing Association1

the Hillingdon Hospitals NHS Foundation Trust1

Wife of the deceased1

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.

31 Mar2025
Inner North London
Concerns raised1
1. Failure to ensure timely availability of Naloxone
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Deliver two weeks of safety-huddle sessions on accessing and replenishing Naloxone, including out-of-hours arrangements.
  Stated by Royal Free London NHS Foundation TrustStated planned
2. Action
  Increase ward 8 North Naloxone stock from two to three boxes and audit stocking consistency.
  Stated by Royal Free London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Access to Naloxone on ward 8 North was not disrupted; unusually high usage caused the delay in administration.
  Stated by Royal Free London NHS Foundation TrustDisputes the concern
AI-generated summary

Abu RAHMAN · 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

Abu Rahman, aged 88, suffered a traumatic fall causing a fractured hip and underwent hemi-arthroplasty before deteriorating with pneumonia on a background of end stage renal failure. Concerns included delays in obtaining Naloxone when supplies ran out and limited awareness of opioid toxicity or accumulation in patients with kidney impairment or failure.

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 ensure timely availability of Naloxone
Wider context from the report
“Firstly, I heard evidence from the family that nursing staff were frequently unable to administer Naloxone as it had run out. They had to obtain more Naloxone from the pharmacy, which led to delays for “hours and hours” on multiple occasions. Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the risk of opioid toxicity / accumulation in patients with kidney impairment/failure, even where the “correct” dose may have been given. I am concerned that if there is no proper or properly implemented system for obtaining medication in a timely manner, and limited awareness of the matters canvassed above, then this gives rise to a risk of future deaths. ”
Source location
Abu RAHMAN · 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 two weeks of safety-huddle sessions on accessing and replenishing Naloxone, including out-of-hours arrangements.

Verbatim wording from the response
“Clarity on the process of accessing Naloxone, including out of hours, should stock need replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately available. Stock levels have been increased from 2 boxes to 3 boxes which under expected usage levels provides a sufficient supply for more than 24 hours.”

Source location
Response from Royal Free Hospital
Page 2 · response
Published 1 April 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase ward 8 North Naloxone stock from two to three boxes and audit stocking consistency.

Verbatim wording from the response
“Clarity on the process of accessing Naloxone, including out of hours, should stock need replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately available. Stock levels have been increased from 2 boxes to 3 boxes which under expected usage levels provides a sufficient supply for more than 24 hours.”

Source location
Response from Royal Free Hospital
Page 2 · response
Published 1 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Access to Naloxone on ward 8 North was not disrupted; unusually high usage caused the delay in administration.

Verbatim wording from the response
“Access to Naloxone during Dr Rahman’s time on 8 North was not reported to be disrupted and his medication chart records that it was administered to him between 24 minutes and 1 hour following the prescription being made, despite the significant quantity that was used. It was concluded that this was a highly unusual circumstance, in which Dr Rahman was receiving ongoing infusions, requiring an unusually large quantity of Naloxone, as a result impacting the time to administer.”

Source location
Response from Royal Free Hospital
Page 2 · response
Published 1 April 2025
Open published response
12 Dec2024
Inner North London
Concerns raised1
1. Lack of naloxone-use training for night concierges
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 3
1. Action
  Arrange refresher Naloxone training for the Endell Street staff team.
  Stated by St Mungo’s Community Housing AssociationStated in progress
2. Action
  Provide regular Naloxone training for new staff and refresher training, supported by targeted communications to managers in first-stage hostels.
  Stated by St Mungo’s Community Housing AssociationStated planned
3. Action
  Review whether Overdose Prevention and Naloxone Training should become mandatory for first-stage hostels.
  Stated by St Mungo’s Community Housing AssociationStated planned
Respondent positions 1
1. Position
  Naloxone administration is not mandatory because non-clinical staff may not feel comfortable or confident administering an injection.
  Stated by St Mungo’s Community Housing AssociationUnable to act
AI-generated summary

Nonie Atshiki · 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

Nonie Atshiki, aged 35, was found dead in the stairwell of the hostel where she lived shortly after 4am on 13 July 2024. Her medical cause of death was acute cardiac failure associated with cocaine use and long-term alcohol excess. The report raised concerns that the hostel’s night concierge had no first aid training from St Mungo’s, there was no defibrillator, and no cardiopulmonary resuscitation was attempted after her discovery.

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 naloxone-use training for night concierges
Wider context from the report
“I heard evidence at inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not. Whilst not relevant in this case, I was told that the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use. The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki. There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation. ”
Source location
Nonie Atshiki · 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
Arrange refresher Naloxone training for the Endell Street staff team.

Verbatim wording from the response
“i. Immediate action: We understand that the night concierge may have not received training in using Naloxone, which we accept may affect how a person responds in the case of an overdose. The Service Manager at Endell Street is arranging for the staff team to refresh their Naloxone training. Training is available as an on-line video recommended by the St Mungo’s Complex Needs Team that staff can watch. However, whilst we strongly encourage staff to use Naloxone in overdose situations, we do not make this mandatory. We accept that not all our staff (who are non-clinical and recruited to provide housing-related support) would feel comfortable or confident in administering an injection.”

Source location
Response from St Mungo's
Page 11 · response
Published 18 December 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
Provide regular Naloxone training for new staff and refresher training, supported by targeted communications to managers in first-stage hostels.

Verbatim wording from the response
“ii. Short to Medium-term action: The Service Manager will ensure that regular Naloxone training is provided to all new staff, as well as refresher training either by the local drug”

Source location
Response from St Mungo's
Page 11 · response
Published 18 December 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
Review whether Overdose Prevention and Naloxone Training should become mandatory for first-stage hostels.

Verbatim wording from the response
“We will conduct a review to determine whether it would be appropriate to add Overdose Prevention and Naloxone Training to our mandatory training list for first-stage hostels, where there is a higher prevalence of clients using substances. This review will be completed by October 2025.”

Source location
Response from St Mungo's
Page 12 · response
Published 18 December 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
Naloxone administration is not mandatory because non-clinical staff may not feel comfortable or confident administering an injection.

Verbatim wording from the response
“i. Immediate action: We understand that the night concierge may have not received training in using Naloxone, which we accept may affect how a person responds in the case of an overdose. The Service Manager at Endell Street is arranging for the staff team to refresh their Naloxone training. Training is available as an on-line video recommended by the St Mungo’s Complex Needs Team that staff can watch. However, whilst we strongly encourage staff to use Naloxone in overdose situations, we do not make this mandatory. We accept that not all our staff (who are non-clinical and recruited to provide housing-related support) would feel comfortable or confident in administering an injection.”

Source location
Response from St Mungo's
Page 11 · response
Published 18 December 2024
Open published response
5 Nov2019
East Sussex
Concerns raised4
1. Unavailability of Naloxone on prison wings outside the healthcare wing
2. Lack of a local protocol for accessing and administering Naloxone
3. Lack of prison officer training in Naloxone use
1. Failure of prison staff to know the Naloxone requirement and availability
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
  Determine how prison staff could identify opioid overdoses and administer naloxone, including the training required.
  Stated by HM Prison and Probation ServiceStated planned
2. Action
  Prepare a pilot to train prison staff in selected prisons in northern England.
  Stated by HM Prison and Probation ServiceStated in progress
Respondent positions 1
1. Position
  Broader prison staff administration of naloxone cannot yet proceed because risks, role requirements, training needs and trade union consultation require further consideration.
  Stated by HM Prison and Probation ServiceUnable to act
AI-generated summary

Neville Lewis MCNAIR · 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

Neville Lewis MCNAIR was found unresponsive in his cell at HMP Lewes on 16 June 2018 and could not be revived after extensive CPR. The inquest concluded that the cause involved heroin toxicity with aspiration, and raised concerns about the availability of Naloxone in prison wings and prison officers’ training and awareness of its use.

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 Naloxone on prison wings outside the healthcare wing
Wider context from the report
“In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally. ”
Source location
Neville Lewis MCNAIR · 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
Lack of a local protocol for accessing and administering Naloxone
Wider context from the report
“In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally. ”
Source location
Neville Lewis MCNAIR · 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
Lack of prison officer training in Naloxone use
Wider context from the report
“In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally. ”
Source location
Neville Lewis MCNAIR · 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 of prison staff to know the Naloxone requirement and availability
Wider context from the report
“In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally. ”
Source location
Neville Lewis MCNAIR · 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
Determine how prison staff could identify opioid overdoses and administer naloxone, including the training required.

Verbatim wording from the response
“I am committed to working with NHSE&I to make naloxone more readily available across the prison estate. This is not straightforward, and there are risks to both staff and prisoners that need to be managed. For this reason, the current position is that it is being administered only by healthcare professionals. There are a number of issues that require further consideration before we can move forward to involve prison staff more widely. Identifying a potential opioid overdose and administering treatment for it has not previously been a part of the role of prison officers and other non-clinical staff in prisons, and we will need to consider precisely how this will work in practice, and what training we will need to provide to equip staff to take it on. We will also need to consult trade unions as we develop our approach.”

Source location
Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 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
Prepare a pilot to train prison staff in selected prisons in northern England.

Verbatim wording from the response
“We are working to determine the best way of managing the risks. Consideration is being given to the use of alternatives to intramuscular naloxone, such as nyxoid, a nasal form of naloxone. We are also preparing a pilot project to train prison staff in a number of prisons in”

Source location
Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 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
Broader prison staff administration of naloxone cannot yet proceed because risks, role requirements, training needs and trade union consultation require further consideration.

Verbatim wording from the response
“I am committed to working with NHSE&I to make naloxone more readily available across the prison estate. This is not straightforward, and there are risks to both staff and prisoners that need to be managed. For this reason, the current position is that it is being administered only by healthcare professionals. There are a number of issues that require further consideration before we can move forward to involve prison staff more widely. Identifying a potential opioid overdose and administering treatment for it has not previously been a part of the role of prison officers and other non-clinical staff in prisons, and we will need to consider precisely how this will work in practice, and what training we will need to provide to equip staff to take it on. We will also need to consult trade unions as we develop our approach.”

Source location
Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 2019
Open published response
28 Aug2019
London (West)
Concerns raised1
1. Failure to administer naloxone in suspected opiate overdose
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.

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

Amir Siman-Tov · 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

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

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 administer naloxone in suspected opiate overdose
Wider context from the report
“14. An emergency bag was brought containing adrenaline autoinjector and also naloxone which Dr Harris said was a temporary antidote to opiates. A nurse gave an injection of adrenaline into the thigh “because he thought it might help”. Naloxone was not given, even though ████████ had required emergency admission the day prior because of an opiate overdose. This puts detainees at risk. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure timely availability of Naloxone

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

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

Concerns raised1

Lack of naloxone-use training for night concierges

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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

Concerns raised4

Unavailability of Naloxone on prison wings outside the healthcare wing

Lack of a local protocol for accessing and administering Naloxone

Lack of prison officer training in Naloxone use

Failure of prison staff to know the Naloxone requirement and availability

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

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

Concerns raised1

Failure to administer naloxone in suspected opiate overdose

Actions described in response 2

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 2

Respondent positions 1