24 Mar 2026 Ronald William MEIKLE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1
Availability of illicit substances in custody View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Central and North West London NHS Foundation Trust
×
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 Availability of illicit substances in custody
Wider context from the report “Concern 1: Availability of illicit substances in custody
The evidence indicated that illicit drugs ████████ were readily available within HMP Woodhill . Material before the court showed this was not an isolated issue but part of a wider and continuing prison safety problem at HMP Woodhill and likely other prisons . The availability of synthetic cannabinoids in custody creates a foreseeable risk of sudden collapse, respiratory compromise, cardiac arrest, psychosis, violence, self-harm and death.
” Source location Ronald William MEIKLE · Prevention of Future Deaths report
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 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
Open published response
11 Mar 2026 Peter Asher CAMPBELL · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to prevent drugs from entering the prison View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service Practice Plus Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
HM Prison and Probation Service
Equip adult male closed prisons with X-ray body scanners to detect and deter internally concealed illicit items.
View source
HM Prison and Probation Service
Provide trace detection equipment to public sector prisons to identify drugs on physical items.
View source
HM Prison and Probation Service
Maintain dedicated search teams equipped with specialist tools to detect and retrieve illicit items, including mobile phones.
View source
HM Prison and Probation Service
Operate a dedicated counter-corruption unit providing staff training, support and guidance while pursuing corruption cases.
View source
HM Prison and Probation Service
Provide airport-style enhanced gate security at 54 priority establishments to screen staff and visitors.
View source See 2 more actions
×
AI-generated summary
Peter Asher CAMPBELL · 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
Peter Asher Campbell collapsed in his prison cell at Pentonville after smoking a drug and died five days later. The principal concerns were the failure to prevent drugs entering the prison and shortcomings in the prison drug service’s response, including inadequate engagement, harm-minimisation advice, staff training, supervision and auditing.
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 prevent drugs from entering the prison
Wider context from the report “For HMPPS and Pentonville
In the narrative conclusion, the jury recorded a failure to prevent drugs from entering the prison .
Every witness at inquest who expressed a view gave evidence that drugs are rife within Pentonville, as they are across the prison estate. They enter attached to drones and in throw overs; via prison officers, visitors and prisoners; and, to a lesser extent these days, in the post. ████████, a drug many times more potent and dangerous than cannabis, ████████ It has infiltrated the prison population with enormous reach and with potentially devastating consequences for the prisoners themselves and for others - there is a risk of prisoners leaving prison in a worse state than when they went in, a state that may of course be reflected in violent reoffending.
Initially, I was not going to include that failure within my prevention of future deaths report, because the availability of drugs in prison seems such a huge and intractable problem. However, on reflection it seems to me that it would be complacent to view the size of the problem as prohibitive. Perhaps the size of the problem dictates only the size of the solution required.
At inquest, I heard about other aspects of the prison regime that were sub optimal, but it appeared that since Mr Campbell’s death, the staff at Pentonville had taken steps to address these.
However, the mass availability of drugs apparently persists without abatement . This is not in any way peculiar to Pentonville, but Pentonville is an exemplar.
” Source location Peter Asher CAMPBELL · Prevention of Future Deaths report
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 Equip adult male closed prisons with X-ray body scanners to detect and deter internally concealed illicit items.
Verbatim wording from the response “We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist” Source location Response from HMPPS
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 trace detection equipment to public sector prisons to identify drugs on physical items.
Verbatim wording from the response “We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist” Source location Response from HMPPS
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 dedicated search teams equipped with specialist tools to detect and retrieve illicit items, including mobile phones.
Verbatim wording from the response “We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist” Source location Response from HMPPS
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 a dedicated counter-corruption unit providing staff training, support and guidance while pursuing corruption cases.
Verbatim wording from the response “HMPPS recognises that the vast majority of prison staff are hardworking and dedicated, but unfortunately a very small minority engage in corrupt activity, including the conveyance of drugs into prisons. To prevent and deter staff from engaging in this, we have a dedicated counter corruption unit, which provides training, support and guidance to staff, as well as pursuing those who engage in this kind of criminality. Outcomes for staff found guilty of corruption can range from dismissal through to criminal prosecution. To support this work, 54 priority establishments have airport-style enhanced gate security, including archway metal detectors, handheld wands, and X-ray baggage scanners, to screen staff and visitors.” Source location Response from HMPPS
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 airport-style enhanced gate security at 54 priority establishments to screen staff and visitors.
Verbatim wording from the response “HMPPS recognises that the vast majority of prison staff are hardworking and dedicated, but unfortunately a very small minority engage in corrupt activity, including the conveyance of drugs into prisons. To prevent and deter staff from engaging in this, we have a dedicated counter corruption unit, which provides training, support and guidance to staff, as well as pursuing those who engage in this kind of criminality. Outcomes for staff found guilty of corruption can range from dismissal through to criminal prosecution. To support this work, 54 priority establishments have airport-style enhanced gate security, including archway metal detectors, handheld wands, and X-ray baggage scanners, to screen staff and visitors.” Source location Response from HMPPS
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 Responsibility for concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
Verbatim wording from the response “We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisations.” Source location Response from Practice Plus Group (1)
Open published response
17 Feb 2026 Edward James HANDS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3
Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence View source Failure to observe and monitor prisoners suspected to be under the influence of illicit substances View source Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service Northamptonshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Northamptonshire Healthcare NHS Foundation Trust
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.
View source
Northamptonshire Healthcare NHS Foundation Trust
Circulate the UTI protocol and amended UTI recording log to healthcare and prison staff.
View source
HM Prison and Probation Service
Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.
View source
HM Prison and Probation Service
Issue the updated UTI protocol to prison and healthcare staff through briefings, written notices, meeting updates and daily checks.
View source
HM Prison and Probation Service
Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.
View source
HM Prison and Probation Service
Appoint a substance misuse lead to conduct daily assurance and visit suspected UTI cases to support consistent protocol adherence.
View source
HM Prison and Probation Service
Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.
View source See 4 more actions
×
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
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
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
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
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
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
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
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
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
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
Open published response
6 Feb 2026 Emmett Peter MORRISON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Continued influx of illicit drugs into HMP Long Lartin View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
HM Prison and Probation Service
Invest in physical security and anti-drone measures benefiting HMP Long Lartin.
View source
HM Prison and Probation Service
Operate the Crime in Prisons Taskforce to improve referrals and prosecutions with police and prosecutors.
View source
HM Prison and Probation Service
Fund Incentivised Substance Free Living Units, including at HMP Long Lartin.
View source
HM Prison and Probation Service
Deploy body scanners, enhanced gate security, drug-trace equipment and specialist search teams to detect and disrupt contraband conveyance.
View source
HM Prison and Probation Service
Expand the national Serious Organised Crime operational function to strengthen specialist support and law-enforcement partnerships.
View source See 2 more actions
×
AI-generated summary
Emmett Peter MORRISON · 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
Emmett Peter Morrison, a serving prisoner at HMP Long Lartin, was found suspended by a ligature in his cell on 13 October 2024 and died from his injuries at hospital on 16 October 2024. The report raised concerns about the continued influx of illicit drugs into the prison and failures to record support actions in ACCT care plans and arrange a further ACCT review sooner.
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 Continued influx of illicit drugs into HMP Long Lartin
Wider context from the report “1) Continued influx of drugs into HMP Long Lartin
Throughout Emmett’s time at HMP Long Lartin, and at the time of his death, the influx of illicit drugs into the prison was a major problem . HMP Long Lartin is a high security prison, a large proportion of whose inmates are serving lengthy sentences. The demand for, supply and distribution of drugs within the prison is therefore capable of causing significant disruption to its security and stability, as well as posing significant risk to the wellbeing of prisoners and staff working there.
Staff at the prison are doing all they can to try to reduce the demand for these drugs, and to assist those dependent on them, but their job is being made considerably harder by the continued and steady flow of illicit substances into the prison .
I have been told in evidence that HMP Long Lartin has been identified as one of the two prisons in the country with the biggest issues in this regard.
I have also heard evidence that measures put in place since Emmett’s death have reduced the number of drone drops of drugs into the prison, and that funding is now in place to install grilles on windows at the prison to prevent prisoners reaching out to retrieve drugs from those drones, although that work is yet to be carried out.
Those involved in the supply of drugs within the prison are often part of highly sophisticated organised crime groups, and unless proper measures are put in place at the prison, its regime and the welfare of its staff and prisoners will continue to be placed at risk as the influx of drugs continues .
Class A drugs, which continue to be used within the prison, present a clear and obvious risk to the lives of those who use them.
Novel Psychoactive Substances, like Spice, the make-up of which can change from batch to batch and makes detection problematic, and whose effects can be both unpredictable and life-threatening, as was apparent in EM’s case, also remain prevalent throughout the prison.
” Source location Emmett Peter MORRISON · Prevention of Future Deaths report
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 Invest in physical security and anti-drone measures benefiting HMP Long Lartin.
Verbatim wording from the response “As you will be aware there are multiple routes through which drugs can enter prisons, influenced by factors such as security measures, geographical location and the prisoner cohort. Common attempted conveyance routes include prisoners arriving into custody, prison visits, correspondence, items thrown over perimeter walls and the use of drones. Our approach to tackling conveyance is therefore multi-faceted. In the 2025/26 financial year, we are investing over £40 million in physical security measures across 34 prisons, including £10 million on anti-drone measures such as window replacements, external window grilles and specialist netting across 15 priority prisons, both of which initiatives HMP Long Lartin will benefit from. Prisoners caught smuggling contraband may face additional time in custody, loss of privileges and other sanctions depending on the nature and quantity of the items.” Source location 2026-0071 - Response from Director General of Operations HMPPS
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 Crime in Prisons Taskforce to improve referrals and prosecutions with police and prosecutors.
Verbatim wording from the response “cases, including smuggling drugs with intent to supply, are referred to the police, and the Crime in Prisons Taskforce has been established to work closely with police and the CPS to improve the quality of referrals and prosecutions for crimes committed in prisons.” Source location 2026-0071 - Response from Director General of Operations HMPPS
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 Fund Incentivised Substance Free Living Units, including at HMP Long Lartin.
Verbatim wording from the response “We work closely with health partners to identify prisoners with a drug use need, refer them into treatment, support recovery and reduce demand. We have funded Incentivised Substance Free Living Units in 88 prisons, including at HMP Long Lartin, where prisoners sign a behaviour compact, agree to regular drug testing and can access enhanced opportunities compared to a standard wing. There are 54 Drug Strategy Leads in key prisons, including HMP Long Lartin, whose role is to support effective implementation of local drug strategies and ensure a whole-system approach to tackling drugs, complemented by Drug and Alcohol Leads at Prison Group level who support prisons across the estate. Naloxone, an essential life-saving medication capable of reversing opiate overdose, is now available in 99% of prisons.” Source location 2026-0071 - Response from Director General of Operations HMPPS
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 Deploy body scanners, enhanced gate security, drug-trace equipment and specialist search teams to detect and disrupt contraband conveyance.
Verbatim wording from the response “We have also invested in multiple physical countermeasures and initiatives to address conveyance. X-ray body scanners are in place across all adult male closed prisons and are used where prisoners are suspected of internally concealing illicit items. HMP Long Lartin is one of 54 priority establishments where Enhanced Gate Security operates to search staff and visitors using archway metal detectors, handheld detection wands and x-ray baggage scanners. Drug trace detection equipment is available in all public-sector prisons to test suspect items and incoming mail for drug-laced paper or fabric, and dedicated search teams are also available to be deployed, equipped with specialist tools to deter conveyance and disrupt drug dealing within the estate.” Source location 2026-0071 - Response from Director General of Operations HMPPS
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 Expand the national Serious Organised Crime operational function to strengthen specialist support and law-enforcement partnerships.
Verbatim wording from the response “The Ministry of Justice takes the threat of serious and organised crime extremely seriously, recognising that drone conveyance is intrinsically linked to organised crime groups. HMPPS has a dedicated national Serious Organised Crime operational function which works collaboratively with law enforcement and partners to identify and disrupt organised criminal” Source location 2026-0071 - Response from Director General of Operations HMPPS
Open published response
4 Feb 2026 Ryan Harding · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2
Failure to maintain the gate house at a security level that restricts entry of illicit materials View source Failure to maintain prison-block windows at a security level that restricts entry of illicit materials View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Clyde & Co Claims LLP
Plan expansion works for a new Gate House and refurbishment of the existing Gate House to accommodate Enhanced Gate Security.
View source
Clyde & Co Claims LLP
Use specialist screening equipment routinely to screen staff, professional visitors and social visitors entering the prison.
View source
Clyde & Co Claims LLP
Expand the Special Searching Team to increase the frequency and quality of staff and visitor searches.
View source
Clyde & Co Claims LLP
Fund and deploy additional external dog patrols to reduce contraband throwovers and support searching.
View source
Clyde & Co Claims LLP
Develop a business case seeking funding for staffing and additional dogs to support searching seven days a week during core hours.
View source
Clyde & Co Claims LLP
Deliver the phased replacement of vulnerable prison windows to reduce contraband ingress.
View source See 3 more actions
×
AI-generated summary
Ryan Harding · 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
Ryan Harding died overnight between 7 and 8 January 2023 in his prison cell after consuming drugs. Concerns included prison infrastructure and gatehouse security measures that required upgrading to reduce illicit materials entering the prison, and a delayed morning welfare check due to insufficient staffing.
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 the gate house at a security level that restricts entry of illicit materials
Wider context from the report “(3) The gate house continues to require upgrading to enable enhanced security to be afforded to reduce the ability of illicit materials including drugs and mobile phones to enter the prison .
” Source location Ryan Harding · Prevention of Future Deaths report
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 maintain prison-block windows at a security level that restricts entry of illicit materials
Wider context from the report “(3) The inquest heard evidence that the windows of Alpha and Bravo blocks did in 2023 and continue to require upgrading in order to reduce the ability of illicit materials including drugs and mobile phones to enter the prison.
” Source location Ryan Harding · Prevention of Future Deaths report
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 Plan expansion works for a new Gate House and refurbishment of the existing Gate House to accommodate Enhanced Gate Security.
Verbatim wording from the response “HMP & YOI Parc is designated a Category C prison, and as such, was not originally funded or risk assessed to provide full Enhanced Gate Security. Increased and changing security challenges, including those enabled by technological advancements and changes to the make-up and nature of contraband items, have led to agreement by HMPPS that the prison should now be funded and risk assessed for Enhanced Gate Security, and the Director has, since June 2024, prioritised addressing identified requirements in Enhanced Gate Security provision.” Source location 2026-0054 - Response from HM Prison Parc
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 Use specialist screening equipment routinely to screen staff, professional visitors and social visitors entering the prison.
Verbatim wording from the response “The conventional scanning equipment which is part of the traditional Enhanced Gate Security model will be installed within the new Gate House building once it is constructed. Pending construction of the new Gate House building, G4S identified a solution to the current logistical restriction by purchasing specialist technological equipment, similar to the latest equipment used in some airports. This equipment is now routinely used to screen staff, professional visitors and social visitors coming into the prison. HMP & YOI Parc was the first prison in the UK to deploy this technology, following a review of best practice across other sectors.” Source location 2026-0054 - Response from HM Prison Parc
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 Expand the Special Searching Team to increase the frequency and quality of staff and visitor searches.
Verbatim wording from the response “Enhanced Gate Security is provided by a range of additional tools and measures which are already being used at HMP & YOI Parc. Bag scanners and handheld metal detectors are routinely used by staff to support improved searching when visitors and staff enter the prison. The Director has expanded the size of the Special Searching Team, significantly increasing the frequency and quality of searches, and there are now an average of approximately 1,700 staff entry and exit searches per month, which represents a significant increase compared with 2022. This compares favourably with the majority of establishments within the prison’s comparative prison group. G4S has funded additional external dog patrols which have worked to significantly reduce the number of throwovers experienced at HMP & YOI Parc.” Source location 2026-0054 - Response from HM Prison Parc
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 Fund and deploy additional external dog patrols to reduce contraband throwovers and support searching.
Verbatim wording from the response “Enhanced Gate Security is provided by a range of additional tools and measures which are already being used at HMP & YOI Parc. Bag scanners and handheld metal detectors are routinely used by staff to support improved searching when visitors and staff enter the prison. The Director has expanded the size of the Special Searching Team, significantly increasing the frequency and quality of searches, and there are now an average of approximately 1,700 staff entry and exit searches per month, which represents a significant increase compared with 2022. This compares favourably with the majority of establishments within the prison’s comparative prison group. G4S has funded additional external dog patrols which have worked to significantly reduce the number of throwovers experienced at HMP & YOI Parc.” Source location 2026-0054 - Response from HM Prison Parc
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 business case seeking funding for staffing and additional dogs to support searching seven days a week during core hours.
Verbatim wording from the response “The prison is currently in communication with the Authority around submission of a business case seeking funding for additional staffing to support searching seven days a week during core hours (from the time the door opens until it is secured for night state), together with additional searching dogs to support this activity.” Source location 2026-0054 - Response from HM Prison Parc
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 the phased replacement of vulnerable prison windows to reduce contraband ingress.
Verbatim wording from the response “In mid-2024, agreement was reached to move forward with a programme of window replacement works to replace the designated windows as quickly as possible, whilst maintaining the integrity of the establishment, allowing HMP & YOI Parc to remain fully operational. The significant cost of the replacement works (each replacement window unit costing in excess of £3,500) is being shared by HMPPS and G4S. A timetable for the replacement programme has been agreed with the Authority.” Source location 2026-0054 - Response from HM Prison Parc
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A temporary gatehouse extension was not pursued because existing interim searching measures were considered a better use of finances, though less comprehensive.
Verbatim wording from the response “G4S previously submitted a proposal to HMPPS for a temporary extension (modular building) to accommodate Enhanced Gate Security. Understandably, this was not seen as the best use of finances since the local team had introduced interim measures to support and enhance the searching of staff and visitors, albeit not to the same level of searching achievable with Enhanced Gate Security provision. Any changes to the design of the building must be approved and funded by HMPPS.” Source location 2026-0054 - Response from HM Prison Parc
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 HMPPS must approve and fund building-design changes, while G4S is contracted only to manage and maintain the existing facility.
Verbatim wording from the response “His Majesty’s Prisons & Probation Service (HMPPS) (“the Authority”) oversaw the construction of HMP & YOI Parc leading to the establishment becoming operational in 1997. Following sign-off and approval of the construction works, operational responsibility for HMP & YOI Parc was handed over by HMPPS to G4S Care & Justice Services (UK) Limited (G4S).” Source location 2026-0054 - Response from HM Prison Parc
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 Window replacement cannot be completed widescale or faster because approved suppliers, specialist contractors, prisoner relocation and security logistics constrain delivery.
Verbatim wording from the response “Practical issues dictate the speed at which window replacement works can be achieved. The windows, by their very nature and purpose, require specialist manufacture and there are a very limited number of HMPPS approved suppliers manufacturing the windows to the requisite specification. Such suppliers are in demand, not only in relation to manufacturing replacement windows for existing prisons across the nationwide prison estate, but also manufacturing windows for new establishments currently under construction.” Source location 2026-0054 - Response from HM Prison Parc
Open published response
8 Dec 2025 OLIVER MULANGALA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Use of drones to deliver drugs and other contraband into prison View source Easy availability of new psychoactive substances in prison View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
HM Prison and Probation Service
Invest over £40 million in physical security across 34 prisons, including anti-drone measures at more than 15 priority prisons.
View source
HM Prison and Probation Service
Develop comprehensive guidance for responding to drone activity affecting prisons.
View source
HM Prison and Probation Service
Deliver staff upskilling to improve responses to drone activity affecting prisons.
View source
HM Prison and Probation Service
Conduct vulnerability assessments across the prison estate to understand drone risks and inform mitigation plans.
View source
HM Prison and Probation Service
Operate X-ray body scanners in all adult male closed prisons to detect and deter internally concealed illicit items.
View source
HM Prison and Probation Service
Provide trace-detection equipment to all public sector prisons to identify drugs on physical items.
View source
HM Prison and Probation Service
Equip 54 priority establishments with enhanced gate security, including metal detectors and X-ray baggage scanners, to screen staff and visitors.
View source See 4 more actions
×
AI-generated summary
OLIVER MULANGALA · 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
Oliver Mulangala was in custody at HMP High Down, had epilepsy and a history of serious seizures, and was found dead in his cell on 13 July 2024 after suffering a drug-induced seizure. The report identifies concerns about the easy availability and use of illicit new psychoactive substances in HMP High Down, including their contribution to drug-related deaths, coercion and risks to prisoners. It also raises concerns about the availability of mobile phones and the use of drones to facilitate the delivery of drugs and other contraband into prisons.
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 Use of drones to deliver drugs and other contraband into prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Source location OLIVER MULANGALA · Prevention of Future Deaths report
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 Easy availability of new psychoactive substances in prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Source location OLIVER MULANGALA · Prevention of Future Deaths report
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 Invest over £40 million in physical security across 34 prisons, including anti-drone measures at more than 15 priority prisons.
Verbatim wording from the response “HMPPS is aware of the available routes for contraband, such as drugs and mobile phones, to enter prisons and how they are influenced by factors such as security measures, geographical location and prisoner cohort. Due to this, our approach to conveyance is multi-faceted. In the 2025/2026 financial year, HMPPS is investing over £40m in physical security measures across 34 prisons, including £10m on anti-drone measures, such as window replacements, external window grilles and specialist netting in over 15 priority prisons.” Source location Response from HM Prison and Probation Service
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 comprehensive guidance for responding to drone activity affecting prisons.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” Source location Response from HM Prison and Probation Service
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 staff upskilling to improve responses to drone activity affecting prisons.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” Source location Response from HM Prison and Probation Service
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 vulnerability assessments across the prison estate to understand drone risks and inform mitigation plans.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” Source location Response from HM Prison and Probation Service
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 X-ray body scanners in all adult male closed prisons to detect and deter internally concealed illicit items.
Verbatim wording from the response “HMPPS utilises multiple countermeasures and initiatives to tackle the conveyance of drugs and mobile phones into our prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of” Source location Response from HM Prison and Probation Service
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 trace-detection equipment to all public sector prisons to identify drugs on physical items.
Verbatim wording from the response “illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, 54 priority establishments have airport-style enhanced gate security to screen staff and visitors, including archway metal detectors, handheld wands, and X-ray baggage scanners.” Source location Response from HM Prison and Probation Service
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 Equip 54 priority establishments with enhanced gate security, including metal detectors and X-ray baggage scanners, to screen staff and visitors.
Verbatim wording from the response “illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, 54 priority establishments have airport-style enhanced gate security to screen staff and visitors, including archway metal detectors, handheld wands, and X-ray baggage scanners.” Source location Response from HM Prison and Probation Service
Open published response
18 Nov 2025 Derrion Jack ADAMS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Ongoing entry of novel psychoactive substances and other contraband into the prison View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
HM Prison and Probation Service
Invest in physical prison-security enhancements, including anti-drone measures, improved windows, specialist netting and external grilles.
View source
HM Prison and Probation Service
Work with law-enforcement partners to tackle drone-related criminality.
View source
HM Prison and Probation Service
Develop comprehensive staff guidance to improve operational responses to drone-related threats.
View source
HM Prison and Probation Service
Conduct estate-wide vulnerability assessments to inform mitigation plans for drone-related threats.
View source See 1 more action
×
AI-generated summary
Derrion Jack ADAMS · 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
Derrion Adams died at HMP Birmingham on 31 October 2024 after being found unresponsive in his cell and subsequently being pronounced deceased following a cardiac arrest. The report states that his death was due to toxicity from a substance. The principal concerns were the availability of drugs and contraband in the prison, surges in drug-related incidents, and staffing levels that were insufficient to ensure his cell call bell was answered within the target time, delaying identification and 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 Ongoing entry of novel psychoactive substances and other contraband into the prison
Wider context from the report “1. The inquest heard evidence from the Head of Drug Strategy and the Head of Safety at HMP Birmingham at the time of Derrion's death. Their evidence included that novel psychoactive substances and other contraband items were able to enter the prison via ████████ and this continues . The following statements were made in evidence "████████ are ruining the safety of the prison".
2. The Heads of Drug Strategy and Safety gave clear and credible evidence that they at HMP Birmingham are doing everything they can using the measures available to them to stop and intercept ████████ delivering to HMP Birmingham but these measures are often not successful because the sophistication of the criminals using ████████ to deliver contraband to prisons is "more sophisticated than us".
” Source location Derrion Jack ADAMS · Prevention of Future Deaths report
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 Invest in physical prison-security enhancements, including anti-drone measures, improved windows, specialist netting and external grilles.
Verbatim wording from the response “The Ministry of Justice (MoJ) and HMPPS are committed to deterring, detecting, and disrupting the use of drones around prisons in England and Wales. Our approach is multi-faceted, combining physical security countermeasures, technological innovation, intelligence exploitation, strengthened legislation, and collaboration across Government and with” Source location Response from HM Prison and Probation Service
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 Work with law-enforcement partners to tackle drone-related criminality.
Verbatim wording from the response “We are working closely with law enforcement partners and are supported by the National Crime Agency, to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, HMPPS has developed comprehensive guidance for staff, upskilling them to improve operational responses, and conducts vulnerability assessments across the estate to inform mitigation plans.” Source location Response from HM Prison and Probation Service
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 comprehensive staff guidance to improve operational responses to drone-related threats.
Verbatim wording from the response “We are working closely with law enforcement partners and are supported by the National Crime Agency, to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, HMPPS has developed comprehensive guidance for staff, upskilling them to improve operational responses, and conducts vulnerability assessments across the estate to inform mitigation plans.” Source location Response from HM Prison and Probation Service
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 estate-wide vulnerability assessments to inform mitigation plans for drone-related threats.
Verbatim wording from the response “We are working closely with law enforcement partners and are supported by the National Crime Agency, to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, HMPPS has developed comprehensive guidance for staff, upskilling them to improve operational responses, and conducts vulnerability assessments across the estate to inform mitigation plans.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 1
Continuing availability and use of psychoactive substances posing significant health risks to prisoners View source
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
HM Prison and Probation Service
Invest in windows, specialist netting, external grilles and other physical security enhancements to prevent drones delivering contraband.
View source
HM Prison and Probation Service
Maintain 400-metre Restricted Fly Zones around all closed prisons and young offender institutions.
View source
HM Prison and Probation Service
Conduct estate-wide vulnerability assessments to inform mitigation plans for drone and related security risks.
View source
HM Prison and Probation Service
Work with health providers to identify substance-misuse needs, facilitate treatment access and promote recovery through structured incentives.
View source
HM Prison and Probation Service
Operate Incentivised Substance Free Living Units in 85 prisons, using behavioural compacts and regular drug testing.
View source
HM Prison and Probation Service
Enhance establishment intelligence-driven strategies to disrupt substance supply chains, particularly drone-enabled deliveries.
View source
HM Prison and Probation Service
Strengthen attendance at purposeful activities through rigorous daily monitoring to mitigate boredom-related behaviours contributing to illicit drug use.
View source See 4 more actions
×
AI-generated summary
Matthew Lucas Sundeep 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
Matthew Lucas Sundeep Singh, a prisoner at HMP Berwyn, was found unresponsive in his cell on 23 November 2019 after consuming a novel psychoactive substance and died shortly afterwards from cardiac arrest due to substance abuse. The report identified the continuing availability and use of psychoactive substances at HMP Berwyn, and the significant risks they pose to prisoners, as a concern for future deaths.
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 Continuing availability and use of psychoactive substances posing significant health risks to prisoners
Wider context from the report “It appears that there is continuing availability and use of psychoactive substances at HMP Berwyn despite ongoing initiatives.
I consider that the use of psychoactive substances and the significant risks which they pose to the health of prisoners at HMP Berwyn will be the cause of future deaths in the prison.
” Source location Matthew Lucas Sundeep Singh · Prevention of Future Deaths report
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 Invest in windows, specialist netting, external grilles and other physical security enhancements to prevent drones delivering contraband.
Verbatim wording from the response “HMPPS is committed to deterring, detecting, and disrupting the use of illegal drones around prisons in England and Wales. Our approach is multi-faceted, combining physical security countermeasures, technological innovation, intelligence exploitation, strengthened legislation, and collaboration across Government and with international partners to address this global threat. Targeted measures include improvements to windows, specialist netting, and external grilles to prevent drones from delivering contraband. This financial year we are investing over £40 million in physical security enhancements across 34 prisons, including £10 million specifically for anti-drone measures.” Source location Response from HM Prison & Probation Service
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 400-metre Restricted Fly Zones around all closed prisons and young offender institutions.
Verbatim wording from the response “We are also working closely with law enforcement partners supported by the National Crime Agency to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, vulnerability assessments are conducted across the estate to inform mitigation plans, and comprehensive guidance has been developed for staff, upskilling them to improve operational responses.” Source location Response from HM Prison & Probation Service
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 estate-wide vulnerability assessments to inform mitigation plans for drone and related security risks.
Verbatim wording from the response “We are also working closely with law enforcement partners supported by the National Crime Agency to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, vulnerability assessments are conducted across the estate to inform mitigation plans, and comprehensive guidance has been developed for staff, upskilling them to improve operational responses.” Source location Response from HM Prison & Probation Service
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 Work with health providers to identify substance-misuse needs, facilitate treatment access and promote recovery through structured incentives.
Verbatim wording from the response “We continue to work in close partnership with health providers to identify individuals with substance misuse needs, facilitate access to treatment, and establish an environment that promotes recovery through structured incentives. To support this, Incentivised Substance Free Living Units have been implemented in 85 prisons, requiring prisoners to sign a behavioural compact and undergo regular drug testing, where they can benefit from enhanced opportunities beyond those available on standard wings. In addition, 54 Drug Strategy Leads are now embedded in key establishments, and in 2025 17 Group Drug and Alcohol Leads were appointed to provide strategic oversight and assurance across prison groups.” Source location Response from HM Prison & Probation Service
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 Incentivised Substance Free Living Units in 85 prisons, using behavioural compacts and regular drug testing.
Verbatim wording from the response “We continue to work in close partnership with health providers to identify individuals with substance misuse needs, facilitate access to treatment, and establish an environment that promotes recovery through structured incentives. To support this, Incentivised Substance Free Living Units have been implemented in 85 prisons, requiring prisoners to sign a behavioural compact and undergo regular drug testing, where they can benefit from enhanced opportunities beyond those available on standard wings. In addition, 54 Drug Strategy Leads are now embedded in key establishments, and in 2025 17 Group Drug and Alcohol Leads were appointed to provide strategic oversight and assurance across prison groups.” Source location Response from HM Prison & Probation Service
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 Enhance establishment intelligence-driven strategies to disrupt substance supply chains, particularly drone-enabled deliveries.
Verbatim wording from the response “At a local level, the establishment continues to work on enhancing intelligence-driven strategies to disrupt supply chains, with particular emphasis on countering drone-enabled delivery methods, and to support prisoners in moving away from drug use by, for example, strengthening attendance at purposeful activities through rigorous daily monitoring to mitigate boredom-related behaviours that contribute to illicit drug use.” Source location Response from HM Prison & Probation Service
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 Strengthen attendance at purposeful activities through rigorous daily monitoring to mitigate boredom-related behaviours contributing to illicit drug use.
Verbatim wording from the response “At a local level, the establishment continues to work on enhancing intelligence-driven strategies to disrupt supply chains, with particular emphasis on countering drone-enabled delivery methods, and to support prisoners in moving away from drug use by, for example, strengthening attendance at purposeful activities through rigorous daily monitoring to mitigate boredom-related behaviours that contribute to illicit drug use.” Source location Response from HM Prison & Probation Service
Open published response
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Lack of effective NPS-specific drug policy View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Anthony Binfield and 2 others · 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
Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.
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 effective NPS-specific drug policy
Wider context from the report “There is no requirement for prisons to have an NPS specific drug policy and I am concerned that generic drug reduction strategies are ineffective against this particular threat .
NPS is highly dangerous and carries a risk of death. I am concerned that more young men will die in custody as a result of NPS use.
” Source location Anthony Binfield and 2 others · Prevention of Future Deaths report
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 Provide synthetic-cannabinoid risk training through an eLearning package for prison staff.
Verbatim wording from the response “However, to ensure staff understand the risks specific to PS use, an eLearning package is available for all staff to access. This course has been designed to increase awareness of the types of synthetic cannabinoids; understanding their effects, how to deal with them and where to signpost for support to assist staff in reducing the demand for these substances, managing the associated risks and promoting recovery from dependency.” Source location Response from HMPPS
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 local drug-strategy governance, staffing, supply-restriction, harm-reduction and recovery measures at Lowdham Grange.
Verbatim wording from the response “At Lowdham Grange the drug strategy is overseen at a monthly meeting attended by senior leaders and operational managers, and there are two dedicated drug strategy officers in place. Supply restriction measures include work to prevent drone drops, body scans for prisoners, and a network of security liaison officers are on each houseblock to ensure that information on those organising and using illicit items is passed on. Future plans include the installation of windows that will prevent the entry of parcels and a publicity programme to raise awareness in the community of the drone problem and to encourage the reporting of suspicious behaviour. The local drug strategy also includes various measures to reduce demand, enable recovery and reduce harm. These include a video on the dangers of synthetic opioids that was created” Source location Response from HMPPS
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 Each prison is responsible for understanding local psychoactive-substance risks and developing local strategies to manage them.
Verbatim wording from the response “HMPPS has a prison drug strategy that adopts a whole system approach to restricting supply and reducing the demand for drugs and to building recovery. PS is often used in conjunction with other drugs, and as a result our strategy sets out a set of principles and actions that are sufficiently flexible to apply across the estate, rather than a drug-specific approach. As the risk and impact of drug and alcohol use is variable between prisons it is the responsibility of each prison to understand local risk and develop local strategies to ensure the risks are identified, understood, and effectively managed.” Source location Response from HMPPS
Open published response
29 Sep 2023 Steven Sanders · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to adequately mitigate illicit substance use, entry and distribution within SAH View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Care Quality Commission
Conduct an unannounced comprehensive inspection covering safety, including illicit-drug supply and the concerns raised in the report.
View source
×
AI-generated summary
Steven Sanders · 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
Steven Sanders was a detained patient at St Andrew's Healthcare who was found unresponsive and not breathing on 20 November 2022 after returning from authorised leave, and was pronounced deceased at 23:04. A pathologist initially attributed his death to coronary artery disease, but later information raised suspicion that he may have taken an illicit substance. The principal concern was that illicit substances were entering and being distributed within the hospital, creating a risk to life among vulnerable detained patients.
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 adequately mitigate illicit substance use, entry and distribution within SAH
Wider context from the report “Initially there was no evidence that illegal drugs were more widely being used and supplied within SAH and the hospital provided evidence of its policies and procedures for searches to address this risk and asserted that these policies and procedures were in appropriate operation.
However, on the 24th July 2023 I was informed that during a routine room search of Hurst ward (another secure ward in SAH Birmingham) over the weekend of the 22nd/23rd July 2023 a quantity of drugs and a lighter were discovered in a patient’s room. The patient (Patient A) whose room these items were found in alleged that these drugs were given to him by Mr Steven Sanders when they were both patients on Hawksley ward. SAH has confirmed that the patient and Mr Sanders were cared for on Hawksley ward at the same time prior to Mr Sanders’ death. The following further information was then provided by SAH on the 27th July 2023: the room search occurred on 23rd July, ████████ found in Patient A’s room, Patient A disclosed the substance ████████ from Mr Sanders on the day he died (20th November 2022) after Mr Sanders returned from unescorted leave, Patient A got ████████ from another patient, Patient B, whilst on Hawksley Ward. Patient A also disclosed that Patient B had brought ████████ into Hawksley Ward.
Subsequently, on the 24th July 2023 Patient A was found with what appeared to be cocaine in his room and he had hidden it in his anus during the room search on the 23rd July.
I wrote to the CQC and WMP on the 28th July 2023 explaining my concerns. I have not yet received any update on the action taken to date by the CQC. It was agreed at a meeting with WMP on the 11th August 2023 that they would conduct some enquiries, but I have not had any update on those enquiries.
Today I have become aware that on the 24th September 2023 a report was made to West Midlands Police that a patient had been supplying drugs to other patients. The details were that he had been keeping ████████. Three patients had tested positive for ████████ and a further 5 patients were acting under influence.
Also, on the 24th September 2023 another detained patient (Patient C) was found deceased lying on his bed in unexplained and unexpected circumstances. A separate investigation is being undertaken into Patient C’s death and it remains to be ascertained whether his death was drug related.
I am deeply concerned that the risk of illicit substance use is not being adequately mitigated at SAH and there is an endemic problem. This risk creates an obvious risk to life not merely from the risk of death inherent in illicit substance use but also because the population of SAH is particularly vulnerable: many suffer from mental illness affecting their judgement and assessment of risk, there will be a history of drug use amongst many patients and those patients taking illicit substances may not have an accurate perception of their tolerance due to their time in detention. The risk of death is also increased by the current presence of ████████ (new and highly potent synthetic opioids) ████████ being supplied within the West Midlands.
There needs to be an urgent and thorough investigation into all these incidents to identify how drugs are entering and being distributed within SAH and how this risk can be mitigated as far as possible in the future.
” Source location Steven Sanders · Prevention of Future Deaths report
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 Conduct an unannounced comprehensive inspection covering safety, including illicit-drug supply and the concerns raised in the report.
Verbatim wording from the response “○ CQC undertook an unannounced, comprehensive inspection of the service in January 2024. The inspection focussed on all five key questions which are safe, effective, caring, responsive and well-led and specifically included consideration of the concerns expressed in your report about illicit drug supply.” Source location Response from Care Quality Commission
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 An urgent unannounced inspection was not considered necessary at that time because the provider needed time to implement actions from its investigation.
Verbatim wording from the response “○ Following a management review meeting in which we considered all the relevant information including a review of the action plan submitted by the provider and their implementation of ward lockdowns, we concluded that an urgent unannounced inspection would not take place at that time. We determined that it was proportionate to give the provider time to implement the action identified following their own urgent investigation. This position however remained under continuous review. SAH provided CQC with weekly reports, which included actions they were taking to prevent the supply of illicit drugs, additional staff training, review of security protocols, risk assessments and care plans, alongside joint work with local substance misuse services.” Source location Response from Care Quality Commission
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 registered provider is primarily responsible for developing and implementing policies and processes that meet applicable safety duties and standards.
Verbatim wording from the response “While the essential standards contained in RAR 2014 set out the relevant standards that registered providers must meet, they do not prescribe how exactly and what precisely registered providers must do to meet them; those are things that the registered provider must determine in order to meet the standards and duties set out in Act, RAR 2014 and RR 2009. It is the primary responsibility of a registered provider such as SAH to develop and implement adequate policy and process to ensure that those duties, responsibilities, and standards are met. To assist providers, CQC have published details of our key lines of enquiry and rating characteristics and guidance for providers on meeting the regulations.” Source location Response from Care Quality Commission
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.