PFD report

Neville Lewis MCNAIR · Prevention of Future Deaths report

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Issued 5 Nov 2019•East Sussex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Unavailability of Naloxone on prison wings outside the healthcare wing
    Part of recurring concern: Failure to ensure naloxone is available and usable for opioid overdose emergencies
  2. Lack of a local protocol for accessing and administering Naloxone
    Part of recurring concern: Failure to ensure naloxone is available and usable for opioid overdose emergenciesPart of recurring concern: Inadequate control of illicit substance use and supply in secure institutionsPart of recurring concern: Unsafe access to and application of Naloxone guidance
  3. Lack of prison officer training in Naloxone use
    Part of recurring concern: Failure to ensure naloxone is available and usable for opioid overdose emergenciesPart of recurring concern: Inadequate prison staff training for responding to medical emergencies
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

    Determine how prison staff could identify opioid overdoses and administer naloxone, including the training required.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 December 2019.
  2. Action

    Prepare a pilot to train prison staff in selected prisons in northern England.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Broader prison staff administration of naloxone cannot yet proceed because risks, role requirements, training needs and trade union consultation require further consideration.

    Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unavailability of Naloxone on prison wings outside the healthcare wing

Wider context from the report

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

Is this part of a recurring concern?

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

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a local protocol for accessing and administering Naloxone

Wider context from the report

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

Is this part of a recurring concern?

Yes — Failure to ensure naloxone is available and usable for opioid overdose emergencies; Inadequate control of illicit substance use and supply in secure institutions; Unsafe access to and application of Naloxone guidance.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of prison officer training in Naloxone use

Wider context from the report

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

Is this part of a recurring concern?

Yes — Failure to ensure naloxone is available and usable for opioid overdose emergencies; Inadequate prison staff training for responding to medical emergencies.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of prison staff to know the Naloxone requirement and availability

Wider context from the report

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

Is this part of a recurring concern?

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

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Determine how prison staff could identify opioid overdoses and administer naloxone, including the training required.

Verbatim wording from the response

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

Source location

Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 2019

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Prepare a pilot to train prison staff in selected prisons in northern England.

Verbatim wording from the response

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

Source location

Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 2019

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Broader prison staff administration of naloxone cannot yet proceed because risks, role requirements, training needs and trade union consultation require further consideration.

Verbatim wording from the response

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

Source location

Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Increase naloxone availability in approved premises and issue it to prisoners at high risk of overdose on release.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.
  2. 2

    Consult trade unions while developing the approach to involving prison staff in naloxone administration.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 December 2019.
  3. 3

    Assess alternatives to intramuscular naloxone, including nasal naloxone.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2019.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Increase naloxone availability in approved premises and issue it to prisoners at high risk of overdose on release.

Verbatim wording from the response

“You may be interested to know that, in line with the clinical guidelines set out in the ‘Orange Book’, we have made naloxone more available to individuals in approved premises, and are issuing it to prisoners who are believed to be at high risk of overdose on release (e.g. those who have recently completed detoxification programmes). However, you will appreciate that we need to take the necessary time to establish the best way to protect both staff and prisoners from the risks associated with the deployment of naloxone before making it more broadly available within the custodial environment.”

Source location

Response from HM Prisons and Probation Service
Page 2 · response
Published 27 December 2019

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Consult trade unions while developing the approach to involving prison staff in naloxone administration.

Verbatim wording from the response

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

Source location

Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 2019

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Assess alternatives to intramuscular naloxone, including nasal naloxone.

Verbatim wording from the response

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

Source location

Response from HM Prisons and Probation Service
Page 1 · response
Published 27 December 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026