Matthew Singh Prevention of future deaths report
PFD Report
Partially Responded
Ref: 2025-0567
85 days overdue · 3 responses outstanding
Sent To
Response Status
Responses
1 of 4
56-Day Deadline
31 Dec 2025
85 days past deadline — 3 responses outstanding
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Tel 01824 708047 | The report from HM Inspectorate of Prisons into HM Berwyn from June 2025 (inspection visit 27 January to 7 February 2025) noted that:- ‘The entry and conveyance of illicit items into the prison was a major threat to its stability. In the previous 12 months, there had been over 1,000 reported finds, including 500 relating to drugs. The positive mandatory drug test rate for the previous year was high at 33.5%, and suspicion-led testing had yielded positive results of 77% over the same period. It was not surprising, therefore, that in our survey, 60% of prisoners said it was easy to get illicit drugs at Berwyn’. Notably, the percentage of prisoners who said it was easy to get illicit drugs at Berwyn 48% in 2019, the year of Matthew’s death. It appears that there is continuing availability and use of psychoactive substances at HMP Berwyn despite ongoing initiatives. I consider that the use of psychoactive substances and the significant risks which they pose to the health of prisoners at HMP Berwyn will be the cause of future deaths in the prison.
Responses
HMPPS has implemented physical security enhancements, including anti-drone measures and window improvements, and invested over £40 million this financial year. They have also established Incentivised Substance Free Living Units in 85 prisons, embedded Drug Strategy Leads, and introduced the Adult Health, Care and Wellbeing Core Capabilities Framework in May 2025.
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Dear Ms Robertson
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR MATTHEW SINGH
Thank you for your Regulation 28 report of 5 November 2025 following the inquest into the death of Matthew Singh at HMP Berwyn on 23 November 2019. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with Mr Singh’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You raise concerns regarding the availability and use of psychoactive substances at HMP Berwyn. HMPPS and the prison acknowledge the seriousness of this issue and, as reflected in the evidence heard, is implementing targeted measures to reduce access to and use of illicit substances in prisons.
HMPPS is committed to deterring, detecting, and disrupting the use of illegal drones around prisons in England and Wales. Our approach is multi-faceted, combining physical security countermeasures, technological innovation, intelligence exploitation, strengthened legislation, and collaboration across Government and with international partners to address this global threat. Targeted measures include improvements to windows, specialist netting, and external grilles to prevent drones from delivering contraband. This financial year we are investing over £40 million in physical security enhancements across 34 prisons, including £10 million specifically for anti-drone measures.
We are also working closely with law enforcement partners supported by the National Crime Agency to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, vulnerability assessments are conducted across the estate to inform mitigation plans, and comprehensive guidance has been developed for staff, upskilling them to improve operational responses.
We continue to work in close partnership with health providers to identify individuals with substance misuse needs, facilitate access to treatment, and establish an environment that promotes recovery through structured incentives. To support this, Incentivised Substance Free Living Units have been implemented in 85 prisons, requiring prisoners to sign a behavioural compact and undergo regular drug testing, where they can benefit from enhanced opportunities beyond those available on standard wings. In addition, 54 Drug Strategy Leads are now embedded in key establishments, and in 2025 17 Group Drug and Alcohol Leads were appointed to provide strategic oversight and assurance across prison groups.
In May 2025, the Adult Health, Care and Wellbeing Core Capabilities Framework was introduced, strengthening staff guidance on substance misuse and recovery. Building on this, the Ministry of Justice, HMPPS, and NHS England and Wales are collaborating through the Enable Programme to accelerate specialist training on drugs, alcohol dependency, and trauma-informed care. Furthermore, a comprehensive redesign of Foundation Training for new prison officers is underway, ensuring mandatory modules on drug and alcohol misuse are embedded for all staff.
At a local level, the establishment continues to work on enhancing intelligence-driven strategies to disrupt supply chains, with particular emphasis on countering drone-enabled delivery methods, and to support prisoners in moving away from drug use by, for example, strengthening attendance at purposeful activities through rigorous daily monitoring to mitigate boredom-related behaviours that contribute to illicit drug use.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR MATTHEW SINGH
Thank you for your Regulation 28 report of 5 November 2025 following the inquest into the death of Matthew Singh at HMP Berwyn on 23 November 2019. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with Mr Singh’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You raise concerns regarding the availability and use of psychoactive substances at HMP Berwyn. HMPPS and the prison acknowledge the seriousness of this issue and, as reflected in the evidence heard, is implementing targeted measures to reduce access to and use of illicit substances in prisons.
HMPPS is committed to deterring, detecting, and disrupting the use of illegal drones around prisons in England and Wales. Our approach is multi-faceted, combining physical security countermeasures, technological innovation, intelligence exploitation, strengthened legislation, and collaboration across Government and with international partners to address this global threat. Targeted measures include improvements to windows, specialist netting, and external grilles to prevent drones from delivering contraband. This financial year we are investing over £40 million in physical security enhancements across 34 prisons, including £10 million specifically for anti-drone measures.
We are also working closely with law enforcement partners supported by the National Crime Agency to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, vulnerability assessments are conducted across the estate to inform mitigation plans, and comprehensive guidance has been developed for staff, upskilling them to improve operational responses.
We continue to work in close partnership with health providers to identify individuals with substance misuse needs, facilitate access to treatment, and establish an environment that promotes recovery through structured incentives. To support this, Incentivised Substance Free Living Units have been implemented in 85 prisons, requiring prisoners to sign a behavioural compact and undergo regular drug testing, where they can benefit from enhanced opportunities beyond those available on standard wings. In addition, 54 Drug Strategy Leads are now embedded in key establishments, and in 2025 17 Group Drug and Alcohol Leads were appointed to provide strategic oversight and assurance across prison groups.
In May 2025, the Adult Health, Care and Wellbeing Core Capabilities Framework was introduced, strengthening staff guidance on substance misuse and recovery. Building on this, the Ministry of Justice, HMPPS, and NHS England and Wales are collaborating through the Enable Programme to accelerate specialist training on drugs, alcohol dependency, and trauma-informed care. Furthermore, a comprehensive redesign of Foundation Training for new prison officers is underway, ensuring mandatory modules on drug and alcohol misuse are embedded for all staff.
At a local level, the establishment continues to work on enhancing intelligence-driven strategies to disrupt supply chains, with particular emphasis on countering drone-enabled delivery methods, and to support prisoners in moving away from drug use by, for example, strengthening attendance at purposeful activities through rigorous daily monitoring to mitigate boredom-related behaviours that contribute to illicit drug use.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Report Sections
Investigation and Inquest
On 26 November 2011 an investigation was commenced into the death of Matthew Lucas Sundeep Singh (DOB 13/11/1993) who died on 23 November 2019. The investigation concluded at the end of the jury inquest on 5 November 2025. The conclusion of the inquest was drug related death.
Circumstances of the Death
The circumstances of the death are as follows :- Matthew Lucas Sundeep Singh was a prisoner at HMP Berwyn. He was found unresponsive in his cell at approximately 20:42 hours on 23 November 2019 after consuming a novel psychoactive substance. He died a short time later from a cardiac arrest due to abuse.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.