PFD report

DEAN GARY GEORGE · Prevention of Future Deaths report

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Issued 24 Apr 2020•Swansea and Neath Port Talbot

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
6

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. Lack of funding and implementation of the Integrated Drug Treatment System in Wales
    Part of recurring concern: Unreliable integration of substance misuse services into patient care
  2. Failure to automatically offer opiate substitution therapy on the day of arrival to eligible 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.4

  1. Action

    Develop a new Substance Misuse Treatment Framework for prison services in Wales.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020.
  2. Action

    Provide a pathway for opiate substitution therapy on the day of arrival through the Early Days Opiate Treatment Pilot at HMP Swansea.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 5 June 2020.
  3. Action

    Offer opiate substitution therapy routinely on the day after admission where appropriate and safe.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 5 June 2020.

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

  1. Position

    Welsh prisons need not implement England’s IDTS because existing Welsh guidance and comparative opioid-substitution services provide equivalent treatment options.

    Stated by Welsh GovernmentExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 funding and implementation of the Integrated Drug Treatment System in Wales

Wider context from the report

“The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival. There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019. ”

Is this part of a recurring concern?

Yes — Unreliable integration of substance misuse services into patient care.

Open source report

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Failure to automatically offer opiate substitution therapy on the day of arrival to eligible prisoners

Wider context from the report

“The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival. There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019. ”

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

Develop a new Substance Misuse Treatment Framework for prison services in Wales.

Verbatim wording from the response

“In 2018, an Early Days Opiate Treatment Pilot was launched in HMP Swansea which provides a pathway for opiate substitution therapy on the day of arrival. The pilot has been formally reviewed by Public Health Wales and will inform future planned improvements to substance misuse services in the prisons in Wales. Through the Partnership Agreement on Prison Health, Welsh Government is working with Public Health Wales to develop a new Substance Misuse Treatment Framework for prisons. The new Substance Misuse Treatment Framework will underpin the provision of services in prisons in Wales, and the draft of the SMTF will be available by Autumn 2020.”

Source location

2020-0104-Response-from-Welsh-Government-Redacted.pdf
Page 2 · response
Published 5 June 2020

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 a pathway for opiate substitution therapy on the day of arrival through the Early Days Opiate Treatment Pilot at HMP Swansea.

Verbatim wording from the response

“In 2018, an Early Days Opiate Treatment Pilot was launched in HMP Swansea which provides a pathway for opiate substitution therapy on the day of arrival. The pilot has been formally reviewed by Public Health Wales and will inform future planned improvements to substance misuse services in the prisons in Wales. Through the Partnership Agreement on Prison Health, Welsh Government is working with Public Health Wales to develop a new Substance Misuse Treatment Framework for prisons. The new Substance Misuse Treatment Framework will underpin the provision of services in prisons in Wales, and the draft of the SMTF will be available by Autumn 2020.”

Source location

2020-0104-Response-from-Welsh-Government-Redacted.pdf
Page 2 · response
Published 5 June 2020

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

Offer opiate substitution therapy routinely on the day after admission where appropriate and safe.

Verbatim wording from the response

“Opiate substitution therapy is now offered routinely in HMP Swansea, the day following admission, where appropriate and safe. In addition, the healthcare team in the prison is expanding to provide a more joined up service (with GPs employed by the Health Board alongside nursing and pharmacy staff) and strengthening the availability of mental health support for primary mental health issues and crisis response.”

Source location

2020-0104-Response-from-Welsh-Government-Redacted.pdf
Page 2 · response
Published 5 June 2020

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

Allocate additional annual funding to improve access to health services in Wales’s public prison estate.

Verbatim wording from the response

“Welsh Government has also identified prison health and wellbeing as a priority for health boards, and has allocated an additional £1million per year to improve access to health services in the public prison estate. This includes the provision of an additional £329,026 for 2020/21 (reoccurring) for Swansea Bay University Health Board. This funding is being used to provide a team of mental health practitioners to broadly fulfil the tasks of the Primary Mental Health Service in the community, as well as providing a service to those in mental health crisis. The Substance Misuse Nurse Prescriber (SMNP) in the healthcare team in HMP Swansea works directly with the new mental health team in planning care for those with a dual diagnosis and in continuing to support the Early Days Opiate Treatment Pilot.”

Source location

2020-0104-Response-from-Welsh-Government-Redacted.pdf
Page 2 · response
Published 5 June 2020

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

Welsh prisons need not implement England’s IDTS because existing Welsh guidance and comparative opioid-substitution services provide equivalent treatment options.

Verbatim wording from the response

“Although, in Wales, we do not have IDTS, we do offer comparative services, which are set out in the Welsh Government’s Substance misuse: Treatment of offenders (2009) guidance, and in the 2017 UK Guidelines on Clinical Management Drug Misuse and Dependence (the Orange Book).”

Source location

2020-0104-Response-from-Welsh-Government-Redacted.pdf
Page 1 · response
Published 5 June 2020

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.2

  1. 1

    Strengthen mental health support for primary mental health needs and crisis response in HMP Swansea.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020.
  2. 2

    Expand the HMP Swansea healthcare team to provide a more joined-up service involving GPs, nursing staff and pharmacy staff.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020.

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

Strengthen mental health support for primary mental health needs and crisis response in HMP Swansea.

Verbatim wording from the response

“Opiate substitution therapy is now offered routinely in HMP Swansea, the day following admission, where appropriate and safe. In addition, the healthcare team in the prison is expanding to provide a more joined up service (with GPs employed by the Health Board alongside nursing and pharmacy staff) and strengthening the availability of mental health support for primary mental health issues and crisis response.”

Source location

2020-0104-Response-from-Welsh-Government-Redacted.pdf
Page 2 · response
Published 5 June 2020

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

Expand the HMP Swansea healthcare team to provide a more joined-up service involving GPs, nursing staff and pharmacy staff.

Verbatim wording from the response

“Opiate substitution therapy is now offered routinely in HMP Swansea, the day following admission, where appropriate and safe. In addition, the healthcare team in the prison is expanding to provide a more joined up service (with GPs employed by the Health Board alongside nursing and pharmacy staff) and strengthening the availability of mental health support for primary mental health issues and crisis response.”

Source location

2020-0104-Response-from-Welsh-Government-Redacted.pdf
Page 2 · response
Published 5 June 2020

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