PFD report

Peter Asher CAMPBELL · Prevention of Future Deaths report

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Issued 11 Mar 2026•Inner North London

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
9

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
28

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 raised9

  1. Failure to prevent drugs from entering the prison
    Part of recurring concern: Inadequate control of illicit substance use and supply in secure institutions
  2. Failure to follow up when recovery-worker engagement is ineffective
    Part of recurring concern: Inadequate engagement with prisoners at risk from drug use
  3. Failure to conduct recovery-worker interactions privately
    Part of recurring concern: Failure to provide private healthcare conversations for prisoners
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.17

  1. Action

    Provide trace detection equipment to public sector prisons to identify drugs on physical items.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  2. Action

    Provide airport-style enhanced gate security at 54 priority establishments to screen staff and visitors.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  3. Action

    Maintain dedicated search teams equipped with specialist tools to detect and retrieve illicit items, including mobile phones.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Responsibility for concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.

    Stated by Practice Plus GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Failure to prevent drugs from entering the prison

Wider context from the report

“For HMPPS and Pentonville In the narrative conclusion, the jury recorded a failure to prevent drugs from entering the prison. Every witness at inquest who expressed a view gave evidence that drugs are rife within Pentonville, as they are across the prison estate. They enter attached to drones and in throw overs; via prison officers, visitors and prisoners; and, to a lesser extent these days, in the post. ████████, a drug many times more potent and dangerous than cannabis, ████████ It has infiltrated the prison population with enormous reach and with potentially devastating consequences for the prisoners themselves and for others - there is a risk of prisoners leaving prison in a worse state than when they went in, a state that may of course be reflected in violent reoffending. Initially, I was not going to include that failure within my prevention of future deaths report, because the availability of drugs in prison seems such a huge and intractable problem. However, on reflection it seems to me that it would be complacent to view the size of the problem as prohibitive. Perhaps the size of the problem dictates only the size of the solution required. At inquest, I heard about other aspects of the prison regime that were sub optimal, but it appeared that since Mr Campbell’s death, the staff at Pentonville had taken steps to address these. However, the mass availability of drugs apparently persists without abatement. This is not in any way peculiar to Pentonville, but Pentonville is an exemplar. ”

Is this part of a recurring concern?

Yes — Inadequate control of illicit substance use and supply in secure institutions.

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 to follow up when recovery-worker engagement is ineffective

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

Yes — Inadequate engagement with prisoners at risk from drug use.

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 to conduct recovery-worker interactions privately

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

Yes — Failure to provide private healthcare conversations for 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of post-incident investigations to identify gaps in drug recovery care

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 to have meaningful discussions about prisoners’ drug use

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

Yes — Inadequate engagement with prisoners at risk from drug use.

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

Harm-minimisation guidance failing to address risks to cellmates

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 to review medical records before recovery-worker interactions

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions.

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 routine supervision or audit to identify gaps in drug recovery care

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies.

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 to ensure recovery-worker practice complies with training

Wider context from the report

“For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide trace detection equipment to public sector prisons to identify drugs on physical items.

Verbatim wording from the response

“We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist”

Source location

Response from HMPPS
Page 1 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide airport-style enhanced gate security at 54 priority establishments to screen staff and visitors.

Verbatim wording from the response

“HMPPS recognises that the vast majority of prison staff are hardworking and dedicated, but unfortunately a very small minority engage in corrupt activity, including the conveyance of drugs into prisons. To prevent and deter staff from engaging in this, we have a dedicated counter corruption unit, which provides training, support and guidance to staff, as well as pursuing those who engage in this kind of criminality. Outcomes for staff found guilty of corruption can range from dismissal through to criminal prosecution. To support this work, 54 priority establishments have airport-style enhanced gate security, including archway metal detectors, handheld wands, and X-ray baggage scanners, to screen staff and visitors.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Maintain dedicated search teams equipped with specialist tools to detect and retrieve illicit items, including mobile phones.

Verbatim wording from the response

“We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist”

Source location

Response from HMPPS
Page 1 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Equip adult male closed prisons with X-ray body scanners to detect and deter internally concealed illicit items.

Verbatim wording from the response

“We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist”

Source location

Response from HMPPS
Page 1 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate a dedicated counter-corruption unit providing staff training, support and guidance while pursuing corruption cases.

Verbatim wording from the response

“HMPPS recognises that the vast majority of prison staff are hardworking and dedicated, but unfortunately a very small minority engage in corrupt activity, including the conveyance of drugs into prisons. To prevent and deter staff from engaging in this, we have a dedicated counter corruption unit, which provides training, support and guidance to staff, as well as pursuing those who engage in this kind of criminality. Outcomes for staff found guilty of corruption can range from dismissal through to criminal prosecution. To support this work, 54 priority establishments have airport-style enhanced gate security, including archway metal detectors, handheld wands, and X-ray baggage scanners, to screen staff and visitors.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Use a weekly national forum to review medium- and high-risk patient-safety incidents and determine the appropriate learning response.

Verbatim wording from the response

“In respect of investigations undertaken by PPG generally, the organisation has strengthened its governance arrangements to support more consistent and balanced decision-making regarding the appropriate level of investigation. A weekly national decision-making forum has been introduced to review medium to high-risk patient safety incidents and determine appropriate level of learning response i.e. whether a Patient Safety Incident Investigation (PSII) or other structured review methodology is required.”

Source location

Response from Practice Plus Group (1)
Page 5 · response
Published 17 April 2026

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

Require senior clinical leaders to provide quality assurance and sign-off for all patient-safety incident investigations.

Verbatim wording from the response

“In addition, senior clinical leaders now provide quality assurance and sign-off for all patient safety incident investigations to ensure appropriate clinical scrutiny, learning and response to incidents.”

Source location

Response from Practice Plus Group (1)
Page 5 · response
Published 17 April 2026

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

Continue seeking staff perspectives from significant or recent patient interactions during death-in-custody and other incident reviews.

Verbatim wording from the response

“As part of the processes staff involved in the patient’s care are spoken to, interviewed or asked for statements so that their perspectives are taken into consideration. We will continue to seek the views of staff who had significant interactions with patients involved in a DIC or other incident, as well as those who may have been the last or latter interactions.”

Source location

Response from Practice Plus Group (1)
Page 4 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide investigation training, guidance and support to improve systems-based investigation capability and report quality.

Verbatim wording from the response

“In addition, we are prioritising improvements in the quality and consistency of patient safety investigations and reporting. Training, guidance and support are being provided to staff involved in investigations to strengthen capability in systems-based investigation methodologies and improve the clarity and quality of investigation reports.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate a multidisciplinary Professional Decisions Panel to oversee professional practice and fitness-to-practise concerns.

Verbatim wording from the response

“As part of strengthening governance arrangements, we also established a HiJ Triage Professional Decisions Panel (PDP) in early 2025. The PDP provides multidisciplinary oversight and guidance where concerns arise relating to professional practice or fitness to practise. The panel enables cases to be reviewed holistically with senior clinical input and supports proportionate and consistent decision-making regarding professional conduct concerns.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 17 April 2026

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

Review incident learning through national patient safety and quality assurance governance forums to identify emerging themes across services.

Verbatim wording from the response

“The centralisation of the Patient Safety Team has enabled a more structured approach to reviewing learning from individual patient safety incidents and identifying emerging themes across services. Learning identified through incident reviews is now considered through strengthened national”

Source location

Response from Practice Plus Group
Page 1 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate a weekly national forum to determine appropriate learning responses for medium- and high-risk patient safety incidents.

Verbatim wording from the response

“In response, the organisation has strengthened its governance arrangements to support more consistent and balanced decision-making regarding the appropriate level of investigation. A weekly national decision-making forum has been introduced to review medium to high-risk patient safety incidents and determine appropriate level of learning response i.e., whether a Patient Safety Incident Investigation (PSII) or other structured review methodology is required.”

Source location

Response from Practice Plus Group
Page 1 · response
Published 17 April 2026

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

Centralise the Patient Safety Team to strengthen oversight, consistency and identification of cross-site safety themes.

Verbatim wording from the response

“In August 2025, PPG HiJ directorate further strengthened its patient safety governance arrangements through the centralisation of the Patient Safety Team. The purpose of this change was to improve organisational oversight of patient safety incidents across services, enhance the consistency and quality of incident management and investigation, and strengthen the organisation’s ability to identify emerging safety themes across multiple sites.”

Source location

Response from Practice Plus Group
Page 1 · response
Published 17 April 2026

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

Cross-reference learning from external reviews with internal patient safety incident reviews.

Verbatim wording from the response

“The organisation has also introduced a centralised process to cross-reference learning from external review mechanisms, including Prisons and Probation Ombudsman investigations and independent clinical reviewer reports, ensuring that learning identified through external processes is considered alongside internal incident reviews.”

Source location

Response from Practice Plus Group
Page 1 · response
Published 17 April 2026

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

Require senior clinical leaders to provide quality assurance and sign-off for all patient safety investigations.

Verbatim wording from the response

“In addition, senior clinical leaders now provide quality assurance and sign-off for all patient safety incident investigations to ensure appropriate clinical scrutiny, learning and response to incidents.”

Source location

Response from Practice Plus Group
Page 1 · response
Published 17 April 2026

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

Remind all Recovery Workers to check SystmOne records before visiting people accessing services.

Verbatim wording from the response

“Our process was, and remains, that wherever possible staff check SystmOne records before supporting people accessing services. There are occasions where records cannot be viewed by way of example where prison officers ask a Recovery Worker to review another person or if they require urgent support. In other words, there are circumstances where, because of the urgency of a request, it is not possible to consult the records.”

Source location

Response from Phoenix Futures
Page 2 · response
Published 17 April 2026

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

Reinforce SystmOne-record checking through team meetings, six-month communications and supervision.

Verbatim wording from the response

“As soon as the above concern was raised by the Learned Coroner, we immediately reminded all Recovery Workers to check SystmOne before visiting people accessing services to ensure they are aware of any recent incidents or changes in care needs. This reminder will be reinforced during upcoming team meetings and will continue to be communicated every six months and, supported through supervision as per our protocol.”

Source location

Response from Phoenix Futures
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Responsibility for concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.

Verbatim wording from the response

“We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisations.”

Source location

Response from Practice Plus Group (1)
Page 3 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.

Verbatim wording from the response

“Likewise, the points raised under the heading for Phoenix and PPG mainly relate to Phoenix Futures and the steps taken by one of their employees. Whilst we work closely with Phoenix as one of our subcontractors at Pentonville and work together to improve services and continue our strong working partnership, we do not propose to comment on their service or individual employees. We understand that Phoenix will be responding to the points raised separately.”

Source location

Response from Practice Plus Group (1)
Page 3 · response
Published 17 April 2026

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

Prison authorities decide whether cell doors open, and Phoenix Futures staff cannot open them because they do not carry cell keys.

Verbatim wording from the response

“Phoenix Futures is committed to continuous learning and to developing best practice that safeguards the wellbeing of both people who access services and our colleagues. Whether a cell door is opened is not a decision that Phoenix Futures make, Phoenix Futures are not permitted to carry cell keys. Additionally, within the prison environment it is commonplace for a variety of disciplines; Chaplain, Iman, Education and civilians, to speak to prisoners through their door.”

Source location

Response from Phoenix Futures
Page 2 · response
Published 17 April 2026

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

Records cannot always be reviewed before consultations when requests are urgent or staff are redirected to support another person.

Verbatim wording from the response

“Our process was, and remains, that wherever possible staff check SystmOne records before supporting people accessing services. There are occasions where records cannot be viewed by way of example where prison officers ask a Recovery Worker to review another person or if they require urgent support. In other words, there are circumstances where, because of the urgency of a request, it is not possible to consult the records.”

Source location

Response from Phoenix Futures
Page 2 · response
Published 17 April 2026

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

Unscheduled care appropriately prioritises brief essential harm-minimisation guidance, with comprehensive substance-misuse advice provided during scheduled appointments.

Verbatim wording from the response

“Unscheduled care is a vital part of Phoenix Futures’ service. It forms part of the immediate response when a person has taken a substance or following a code blue incident. It refers to immediate, unplanned intervention following suspected drug use or overdose. Its purpose is to provide rapid response and harm-reduction advice, often bridging gaps between scheduled treatment. These visits may be undertaken by a Recovery worker who is not previously known to the service user.”

Source location

Response from Phoenix Futures
Page 3 · response
Published 17 April 2026

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

Through-door consultations remain necessary where prison rules or staff risk assessments determine that opening the door would be unsafe.

Verbatim wording from the response

“Before offering any guidance or support to a person accessing services, an assessment of risk must be carried out. If that person appears to be under the influence, the prison guidelines dictate that the cell door will not be opened furthermore Recovery Workers are not expected to place themselves in situations that could compromise their safety. We also recognise that many of our colleagues are female, and this must be factored into any assessment of risk.”

Source location

Response from Phoenix Futures
Page 2 · response
Published 17 April 2026

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.11

  1. 1

    Provide targeted headquarters support to at-risk prisons so local security strategies reflect national intelligence and operational priorities.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
  2. 2

    Gather and analyse intelligence on serious and organised crime within prisons through area intelligence units.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
  3. 3

    Maintain 400-metre restricted fly zones around all closed prisons and young offender institutions.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  4. 4

    Implement physical security measures across 34 prisons, including counter-drone measures such as window replacements, grilles and specialist netting.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  5. 5

    Work with law enforcement agencies to deter, detect and disrupt drone activity targeting prisons.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
  6. 6

    Develop comprehensive guidance to improve prison responses to drone activity.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  7. 7

    Upskill prison staff to improve responses to drone activity.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
  8. 8

    Conduct estate-wide vulnerability assessments and develop and implement plans to mitigate identified threats.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
  9. 9

    Implement additional regional scrutiny at HMP Pentonville for six months to verify subcontracted-services procedures and address emerging issues.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 17 April 2026.
  10. 10

    Continue reviewing and strengthening patient safety processes across Health in Justice services to support safer care.

    Stated by Practice Plus GroupStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
  11. 11

    Reinforce in team meetings the importance of risk assessment, staff safety and appropriate consultation arrangements.

    Stated by Phoenix FuturesStated plannedThe respondent said that this action was planned when they made their response on 17 April 2026.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide targeted headquarters support to at-risk prisons so local security strategies reflect national intelligence and operational priorities.

Verbatim wording from the response

“The holistic work between HMPPS and law enforcement agencies also applies to tackling the threat of serious and organised crime. Our area intelligence units play a critical role in gathering and analysing intelligence on serious and organised crime within prisons and our headquarters teams provide targeted support to the most at-risk prisons, ensuring that local security strategies are informed by national intelligence and operational priorities.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

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

Gather and analyse intelligence on serious and organised crime within prisons through area intelligence units.

Verbatim wording from the response

“The holistic work between HMPPS and law enforcement agencies also applies to tackling the threat of serious and organised crime. Our area intelligence units play a critical role in gathering and analysing intelligence on serious and organised crime within prisons and our headquarters teams provide targeted support to the most at-risk prisons, ensuring that local security strategies are informed by national intelligence and operational priorities.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Maintain 400-metre restricted fly zones around all closed prisons and young offender institutions.

Verbatim wording from the response

“HMPPS works closely with law enforcement agencies to tackle the issue of drones, which has already resulted in over 200 arrests linked to their use and has disrupted the activity of serious and organised crime networks. All closed prisons and young offender institutions have a 400-metre restricted fly zone in place which make all unauthorised drone incursions a crime. Additionally, we have developed comprehensive guidance and are upskilling staff to improve the response to drone activity at our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk and to develop and implement plans to mitigate the threat.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement physical security measures across 34 prisons, including counter-drone measures such as window replacements, grilles and specialist netting.

Verbatim wording from the response

“Another identified route of entry is through the use of drones. HMPPS works hard to deter, detect and disrupt the illegal use of drones that target our establishments. Whilst we cannot share specific details on our counter-drone measures as doing so would aid serious and organised criminals, I can confirm that our approach to this multi-faceted. We have invested over £40m in physical security measures across 34 prisons, including £10m on counter-drone measures, such as window replacements, external window grilles and specialist netting.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work with law enforcement agencies to deter, detect and disrupt drone activity targeting prisons.

Verbatim wording from the response

“HMPPS works closely with law enforcement agencies to tackle the issue of drones, which has already resulted in over 200 arrests linked to their use and has disrupted the activity of serious and organised crime networks. All closed prisons and young offender institutions have a 400-metre restricted fly zone in place which make all unauthorised drone incursions a crime. Additionally, we have developed comprehensive guidance and are upskilling staff to improve the response to drone activity at our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk and to develop and implement plans to mitigate the threat.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop comprehensive guidance to improve prison responses to drone activity.

Verbatim wording from the response

“HMPPS works closely with law enforcement agencies to tackle the issue of drones, which has already resulted in over 200 arrests linked to their use and has disrupted the activity of serious and organised crime networks. All closed prisons and young offender institutions have a 400-metre restricted fly zone in place which make all unauthorised drone incursions a crime. Additionally, we have developed comprehensive guidance and are upskilling staff to improve the response to drone activity at our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk and to develop and implement plans to mitigate the threat.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

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

Upskill prison staff to improve responses to drone activity.

Verbatim wording from the response

“HMPPS works closely with law enforcement agencies to tackle the issue of drones, which has already resulted in over 200 arrests linked to their use and has disrupted the activity of serious and organised crime networks. All closed prisons and young offender institutions have a 400-metre restricted fly zone in place which make all unauthorised drone incursions a crime. Additionally, we have developed comprehensive guidance and are upskilling staff to improve the response to drone activity at our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk and to develop and implement plans to mitigate the threat.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Conduct estate-wide vulnerability assessments and develop and implement plans to mitigate identified threats.

Verbatim wording from the response

“HMPPS works closely with law enforcement agencies to tackle the issue of drones, which has already resulted in over 200 arrests linked to their use and has disrupted the activity of serious and organised crime networks. All closed prisons and young offender institutions have a 400-metre restricted fly zone in place which make all unauthorised drone incursions a crime. Additionally, we have developed comprehensive guidance and are upskilling staff to improve the response to drone activity at our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk and to develop and implement plans to mitigate the threat.”

Source location

Response from HMPPS
Page 2 · response
Published 17 April 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement additional regional scrutiny at HMP Pentonville for six months to verify subcontracted-services procedures and address emerging issues.

Verbatim wording from the response

“We continue to work closely with Phoenix Futures, specifically at HMP Pentonville, and have a strong working relationship with them. They continue to provide a vital resource to patients at HMP Pentonville and we are provided with assurances regarding their services, staff and management. The review of”

Source location

Response from Practice Plus Group (1)
Page 4 · response
Published 17 April 2026

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

Continue reviewing and strengthening patient safety processes across Health in Justice services to support safer care.

Verbatim wording from the response

“These developments form part of an ongoing programme of work to strengthen patient safety governance within our HiJ services and to ensure that incident responses are consistent, proportionate and focused on identifying meaningful system learning. The organisation will continue to review and strengthen its patient safety processes to support safer care for patients across all HiJ settings.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 17 April 2026

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

Reinforce in team meetings the importance of risk assessment, staff safety and appropriate consultation arrangements.

Verbatim wording from the response

“Before offering any guidance or support to a person accessing services, an assessment of risk must be carried out. If that person appears to be under the influence, the prison guidelines dictate that the cell door will not be opened furthermore Recovery Workers are not expected to place themselves in situations that could compromise their safety. We also recognise that many of our colleagues are female, and this must be factored into any assessment of risk.”

Source location

Response from Phoenix Futures
Page 2 · response
Published 17 April 2026

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