28 Aug 2020 Carlington Maurice Spencer · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 18 Lack of training on confirmation bias affecting staff decision making View source Lack of clear escalation pathways for presumed Spice-related incidents View source Failure to establish the timing, quantity and potency of drug consumption View source Lack of instructions on duration of conservative observation for presumed Spice consumption View source Lack of meaningful training in self-induced intoxication and new psychoactive substances View source Partial, incomplete and unverifiable record keeping by Discipline and healthcare staff View source Inadequate access, review, storage and retrieval of CCTV footage View source Failure to appreciate, record or actively seek co-detainee concerns View source Inaccurate, irregular and unavailable records of incapacitated detainees View source Failure to consult Illicit Substance Misuse Programme information View source Inadequate knowledge and training in diagnosis, treatment and care of new psychoactive substance intoxication View source Lack of diversity awareness training for dealing with Afro-Caribbean detainees View source Lack of escalation pathways for drug-related incidents developing into medical emergencies View source Lack of escalation protocols recognising healthcare primacy in ongoing detainee care View source Confusion and uncertainty over emergency alarm activation View source Failure to challenge, test or verify presumed drug intoxication View source Failure to consider differential diagnoses and exacerbation of pre-existing co-morbidities View source Failure to clinically verify presumed recent drug consumption View source See 15 more concerns
Responses linked to these concerns
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AI-generated summary
Carlington Maurice Spencer · 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
Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.
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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of training on confirmation bias affecting staff decision making
Wider context from the report “4. Training is needed to enable staff to appreciate the potential for their decision making to be affected by "confirmation bias" in addition to the need for diversity awareness training when dealing with detainees of Afro-Caribbean heritage;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of clear escalation pathways for presumed Spice-related incidents
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident ;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the timing, quantity and potency of drug consumption
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency ;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of instructions on duration of conservative observation for presumed Spice consumption
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption ;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful training in self-induced intoxication and new psychoactive substances
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice" ;
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Partial, incomplete and unverifiable record keeping by Discipline and healthcare staff
Wider context from the report “5. Record keeping, both for Discipline and healthcare staff was established in this case to be partial, incomplete and undertaken in circumstances where the provenance of such records is unverifiable ;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate access, review, storage and retrieval of CCTV footage
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory ;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate, record or actively seek co-detainee concerns
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought ;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Inaccurate, irregular and unavailable records of incapacitated detainees
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel ;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consult Illicit Substance Misuse Programme information
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme ;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate knowledge and training in diagnosis, treatment and care of new psychoactive substance intoxication
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances" ;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of diversity awareness training for dealing with Afro-Caribbean detainees
Wider context from the report “4. Training is needed to enable staff to appreciate the potential for their decision making to be affected by "confirmation bias" in addition to the need for diversity awareness training when dealing with detainees of Afro-Caribbean heritage ;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation pathways for drug-related incidents developing into medical emergencies
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency ;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation protocols recognising healthcare primacy in ongoing detainee care
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee , in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Confusion and uncertainty over emergency alarm activation
Wider context from the report “3. In this case, a "general alarm" was called and in evidence from both Discipline and Healthcare staff, there exists on-going confusion and uncertainty as to the calling of a general alarm or a "Code 1" or "Code 2" alarm or "Code Red" or "Code Blue" (the replacement codification) confirming the need for training or re-training on this issue.
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge, test or verify presumed drug intoxication
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consider differential diagnoses and exacerbation of pre-existing co-morbidities
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities ;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Morton Hall Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to clinically verify presumed recent drug consumption
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations