8 Dec 2025 OLIVER MULANGALA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Use of drones to deliver drugs and other contraband into prison View source Easy availability of new psychoactive substances in prison View source Easy availability of mobile phones in prison View source Failure to hold statistics on drug-related deaths in prisons View source Failure to protect vulnerable prisoners from forced testing of illegal drugs View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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
27 Nov 2016 Matthew RUSSELL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation View source Inadequate foundation and ongoing ACCT-procedure training for staff responsible for patients in prison View source Failure to properly and regularly monitor repeat-prescription medication View source Lack of structured care plans for each patient View source Ineffective communication about patients’ needs with GPs and primary healthcare practitioners at HMP High Down View source Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls View source Failure to effectively use Read Codes to flag significant patient-care risk factors View source Failure to effectively follow up patients who miss pre-booked clinical appointments View source Failure of caseworkers to be aware of and attend ACCT Case Reviews View source Failure to conduct risk assessments for individual prisoners View source Inadequate foundation and ongoing ACCT-procedure training for staff View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations