High Down Prison

Justice · Prison or young offender institution

Pin Request correction

First report 27 Nov 2016•Latest report 8 Dec 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from High Down Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Surrey

    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. The report was sent to High Down Prison; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Easy availability of mobile phones 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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to hold statistics on drug-related deaths in prisons

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to protect vulnerable prisoners from forced testing of illegal drugs

    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. ”
    Open source report

  2. Surrey

    AI-generated summary

    Matthew RUSSELL · 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 Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.

    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. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation

    Wider context from the report

    “HM Prison High Down a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on: • Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend. • Risk Assessments in relation to individual prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate foundation and ongoing ACCT-procedure training for staff responsible for patients in prison

    Wider context from the report

    “e. Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-going training in the ACCT procedure. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to properly and regularly monitor repeat-prescription medication

    Wider context from the report

    “Central and North West London Foundation Trust a. The proper and regular monitoring of all medication that is prescribed by way of a repeat prescription. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of structured care plans for each patient

    Wider context from the report

    “b. The preparation of structured care plans for each patient. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Ineffective communication about patients’ needs with GPs and primary healthcare practitioners at HMP High Down

    Wider context from the report

    “g. Ensuring that there is regular effective communication about a patient’s needs with the GPs and the primary healthcare practitioners at HMP High Down. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls

    Wider context from the report

    “b. Ensuring that all Gate House staff understand the proper procedure to adopt when receiving a call from a prisoner's family or friends expressing concerns for that prisoner’s safety or wellbeing. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to effectively use Read Codes to flag significant patient-care risk factors

    Wider context from the report

    “d. The effective use of Read Codes on the System One record, to flag up and highlight significant risk factors in a patient’s care. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to effectively follow up patients who miss pre-booked clinical appointments

    Wider context from the report

    “c. An effective procedure for following up patients who fail to attend pre-booked appointments with clinicians. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of caseworkers to be aware of and attend ACCT Case Reviews

    Wider context from the report

    “f. Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their care. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct risk assessments for individual prisoners

    Wider context from the report

    “HM Prison High Down a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on: • Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend. • Risk Assessments in relation to individual prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to High Down Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate foundation and ongoing ACCT-procedure training for staff

    Wider context from the report

    “HM Prison High Down a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on: • Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend. • Risk Assessments in relation to individual prisoners. ”
    Open source report
Back to top

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026