PFD report

Samuel Anthony Donald STEWART · Prevention of Future Deaths report

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Issued 28 May 2025•West 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
2

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
4

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 raised2

  1. Failure to support and discuss positive drug test results with prisoners
    Part of recurring concern: Unreliable prison response to positive drug tests
  2. Failure to ensure clear and followed pathways for action after a positive drug test
    Part of recurring concern: Unreliable prison response to positive drug tests
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.3

  1. Action

    Operate a clinical pathway for communicated positive drug tests, including medication checks, clinical substance-misuse review, confirmatory screening, assessment, incident reporting and an individual care plan.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.
  2. Action

    Remind all ISFL wing managers in writing of the requirements following a positive drug test.

    Stated by HM Prison and Probation Service and Ministry of Justice and Wormwood Scrubs PrisonStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.
  3. Action

    Remind ISFL wing staff of their duties during staff briefings.

    Stated by HM Prison and Probation Service and Ministry of Justice and Wormwood Scrubs PrisonStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Healthcare was not aware of the positive test because prison staff did not communicate it, so healthcare was not in a position to act.

    Stated by Practice Plus GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 support and discuss positive drug test results with prisoners

Wider context from the report

“Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him ”

Is this part of a recurring concern?

Yes — Unreliable prison response to positive drug tests.

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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 clear and followed pathways for action after a positive drug test

Wider context from the report

“Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him ”

Is this part of a recurring concern?

Yes — Unreliable prison response to positive drug tests.

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

Operate a clinical pathway for communicated positive drug tests, including medication checks, clinical substance-misuse review, confirmatory screening, assessment, incident reporting and an individual care plan.

Verbatim wording from the response

“However, Practice Plus Group, and the wider healthcare team at HMP Wormwood Scrubs, do have a process in place when positive results are communicated to us. For context, whilst Practice Plus Group provide the primary healthcare services and clinical substance misuse services, Forward Trust provide non-clinical substance misuse (Psychosocial) services and North London NHS Foundation Trust (formally Barnet, Enfield and Haringey NHS Trust) provide secondary mental health services. We have outlined the steps which would be taken below:”

Source location

Response from Practice Plus Group
Page 2 · response
Published 14 November 2025

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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 ISFL wing managers in writing of the requirements following a positive drug test.

Verbatim wording from the response

“Governor of HMP Wormwood Scrubs that she has reminded all managers on the ISFL wing, in writing, of the requirements following a positive test. The managers have and will continue to remind staff working in the ISFL of their duties during briefings.”

Source location

Response from HM Prison and Probation Service and MOJ
Page 2 · response
Published 14 November 2025

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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 ISFL wing staff of their duties during staff briefings.

Verbatim wording from the response

“Governor of HMP Wormwood Scrubs that she has reminded all managers on the ISFL wing, in writing, of the requirements following a positive test. The managers have and will continue to remind staff working in the ISFL of their duties during briefings.”

Source location

Response from HM Prison and Probation Service and MOJ
Page 2 · response
Published 14 November 2025

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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

Healthcare was not aware of the positive test because prison staff did not communicate it, so healthcare was not in a position to act.

Verbatim wording from the response

“Response: We consider it is important to outline at the outset that in this case healthcare was unfortunately not made aware of the positive test and therefore were not in a position to take”

Source location

Response from Practice Plus Group
Page 1 · response
Published 14 November 2025

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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

Healthcare staff are responsible for subsequent actions after prison staff refer a prisoner who tests positive for illicit substances.

Verbatim wording from the response

“Following a positive test prison staff are required to complete a referral to the Forward Trust. It is then the responsibility of healthcare staff to take the subsequent actions, such as discussing the positive result with the prisoner. I have received assurances from the”

Source location

Response from HM Prison and Probation Service and MOJ
Page 1 · response
Published 14 November 2025

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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.1

  1. 1

    Coordinate weekly multi-agency meetings led by the Modern Matron to share drug-related incident information and ensure affected patients are identified across reporting systems.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.

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

Coordinate weekly multi-agency meetings led by the Modern Matron to share drug-related incident information and ensure affected patients are identified across reporting systems.

Verbatim wording from the response

“- Communication processes are in place between Forward Trust, the prison and healthcare. This is led by the Modern Matron and all parties meet weekly to discuss the three different incident reporting systems used (Ulysses, Datix and incident reporting). The aim of this meeting is to ensure all areas have shared the relevant information and all patients are captured.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 14 November 2025

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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