Dear Ms Griffin.

Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death of Mr Sheldon Jeans at HMP Guys Marsh, which was sent to the Secretary of State for Health and Social Care, Chief Executive at Oxleas NHS Foundation Trust, Minister of State for Prisons, Probation and Reducing Reoffending and myself, , Governing Governor at HMP Guys Marsh.

In the first instance, I would like to express my condolences the family of Sheldon Jeans for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

I am responding directly, to provide assurances that local actions and commitments agreed have been formally introduced where applicable.

The management of illicitly brewed alcohol (IBA):

The Drug and Alcohol Group (DAG) in HMPPS has developed and disseminated a range of materials specifically focused on IBA. Notably, the Drugs in Prison and Probation (DiPP) guide provides comprehensive information for staff at all levels — from frontline officers to heads of function.

The material is designed to enhance understanding of substances, support structured discussions, raise awareness, and assist with induction processes for new staff.

Harm reduction support for alcohol use is growing, with mutual aid groups like Alcoholics Anonymous playing a key role.

In addition, we have further developed our Incentivised Substance Free Living (ISFL) unit here at HMP Guys Marsh. This specialised unit offers a supportive environment for individuals to address both alcohol and drug-related issues.

As part of wider awareness efforts, we are aware that the National Prison Radio initiative is being recommissioned to feature speakers with lived experience of alcohol-related harm, helping to highlight the impact of illicit substance use and promote the support available.

In response to seasonal increases in IBA reported usage, the DAG issued a targeted briefing note outlining specific risks, indicators of IBA production, and guidance on effective operational responses. These materials have been shared with the Drug Strategy Lead here at HMP Guys Marsh to support local awareness-raising, harm reduction initiatives, and inform our decision- making.

We have also implemented a series of targeted local measures to mitigate the risks of IBA.

A comprehensive Local Operating Procedure (LOP) has been introduced, to guide staff in managing incidents involving prisoners found under the influence, including those affected by IBA.

Searching operations continue with a specific focus on identifying and safely removing IBA, which is subsequently reported and destroyed by the Security Department when discovered.

To strengthen these efforts, the regional Dedicated Searching Team (DST) is regularly deployed to support intelligence-led searches where IBA is a priority concern.

In addition, preventative steps have been taken to limit the availability of ingredients commonly used in brewing IBA. Yeast-based items have been removed from the canteen list, and fruit and natural sugar-based products have been restricted. These measures aim to reduce the opportunity for prisoners to produce IBA.

Medication – In possession:

The handling of medication held in possession (IP) by prisoners and prescribing practices in prisons are the responsibility of NHS England. Here at HMP Guys Marsh, our commissioned partner is Oxleas NHS Foundation Trust.

The safe management of medication is governed by clinical guidance and national service specifications, which set out standards for prescribing, dispensing, and monitoring medication.

In addition, in cell medication safes are available and we have renewed our focus on ensuring these are available and fit-for-purpose where utilised.

Oxleas operate Medicines Management Committees, and I (Or delegated authority in my absence) attends these meetings to ensure collaborative oversight.

Decisions about which medications are issued to prisoners, including those held in possession, are made by healthcare professionals following a comprehensive risk assessment of both the medication and the individual.

Locally, at HMP Guys Marsh, non-tradeable medications may be issued as IP on a case-by-case basis, subject to a formal risk assessment conducted by healthcare staff. The provision of IP medication is designed to support independent living and prepare prisoners for reintegration into the community.

Prisoners receiving IP medication must sign a compact agreeing to the safe storage and use of their medication, including the use of in-cell lockers. Breaches of this compact will result in the removal of IP medication.

Oxleas NHS Foundation Trust, has committed to introducing regular assurance checks for all prisoners in receipt of IP medication, as agreed at the Local Quality Delivery Board in August 2025.

Thank you again for bringing your concerns to our attention.

I trust that this response provides assurance that action is being taken to address the matters identified.

Dear Ms. Griffin,

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

Please find our response to the Regulation 28 Report to Prevent Future Deaths following the inquest touching the death of Mr. Sheldon Lawrence Jeans, who died on 13 November 2022 at HMP Guys Marsh. The matters of concern are outlined and responded to.

The matters of concern are as follows:

(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol. Illicitly brewed alcohol is a common substance across the prisoner estate. (2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prison estate.

There are many ways in which alcohol can be illicitly brewed in the prison setting. It is known that certain prescribed medications could be used to assist in the fermenting process and, where possible, we have already removed these from the prescribing formulary or Oxleas NHS Foundation Trust

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ensure that they are only provided on a supervised (not-in-possession) basis and are consumed at the medication hatch to minimise the risk of diversion. There is no national NHS policy to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol. Change, Grow, Live (CGL) our psychosocial substance misuse provider, deliver the following in relation to the use of alcohol with our prison population:

• Alcohol workshops and associated workbooks
• Harm reduction sessions, information and resources – including hooch specific information.
• Specific training for staff – recently delivered at HMP Guys Marsh
• Welfare checks/brief interventions for anyone suspected to have been under the influence of hooch/other alcohol
• Assessments, reviews and personalised recovery planning – including use of motivational interviewing techniques
• Access to recovery programmes and mutual aid

We acknowledge the concerns raised regarding the governance and safety of in-possession medication at HMP Guys Marsh and more broadly across the prison estate. The wellbeing of individuals in custody remains our top priority, and we are committed to ensuring that medication management practices are both safe and supportive of rehabilitation.

The practice of allowing prisoners to hold certain medications in-possession is designed to promote personal responsibility and mirror community standards. This approach supports individuals in preparing for release and reintegration with the community and aligns with the principle of equivalence of care. It is also in line with a variety of nationally applicable guidance. https://www.rpharms.com/recognition/setting-professional- standards/optimising-medicines-in-secure-environments.

Before any medication is issued in-possession, a comprehensive risk assessment is undertaken to evaluate both the medication(s) and the individual’s suitability. This risk assessment can be updated / changed at any time but particularly in the event of a change of an individual’s circumstances.

As people arrive in prison, they are required to sign a Compact that clearly outlines their responsibilities regarding the safe storage, use, and return of prescribed medication. While patients are requested to return any unused or discontinued medication to healthcare, we recognise that mandating this process is operationally challenging and relies heavily on individual compliance and would require assistance of the Prison Service.

It should be highlighted that in addition to prescribed medication, prisoners are entitled to purchase a limited number of low-risk medications through the prison canteen. However, healthcare remains the preferred route for people to access medication, as it is more cost- effective and provides clinical oversight.

Healthcare teams conduct intelligence-led and random in-possession checks to monitor compliance and safety. Nonetheless, the overall security of the prison environment,

including the safeguarding of medication, is the responsibility of His Majesty’s Prison and Probation Service (HMPPS). We work closely with HMPPS to ensure that security protocols are upheld and adapted as needed. This also includes the supervision of not-in-possession medication provided by Prison staff at the medication hatches.

To further support safe medication practices, we will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh, but also within the wider Oxleas NHS Foundation Trust prison portfolio. These materials will focus on:

• Safe storage of prescribed medication, including the use of personal lockable safes – responsibility of HMPPS.
• Proper disposal of unused or discontinued medication.

There is no national policy around the governance of medication held in possession in the prison estate. Attached is our recently published local In-possession Medication Compliance procedure which outlines bi-monthly in-cell compliance checks for patients on in-possession medication. This process, which is led by pharmacy staff with HMPPS support, checks to ensure medication adherence, prevent diversion, and upholds the safety of medication. Any discrepancies would trigger a review, disciplinary action, or changes to in- possession status. Documentation is maintained via SystmOne. If required, formal notification letters are sent to the patients. The procedure aligns with NICE and Royal Pharmaceutical Society guidelines. Oversight is shared between pharmacy, wider healthcare and HMPPS teams and ensures that there are robust assurance mechanisms in place.

Our shared goal is to ensure that all individuals in custody are supported in managing their health safely and responsibly.

Dear Ms Griffin

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR SHELDON JEANS

Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death of Sheldon Jeans at HMP Guys Marsh, which was sent to the Secretary of State for Health and Social Care, Chief Executive at Oxleas NHS Foundation Trust, Minister of State for Prisons, Probation and Reducing Reoffending and the Governing Governor at HMP Guys Marsh. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr Jeans’ family, and I would firstly 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.

Following evidence heard at the inquest, you have raised concerns regarding the national policy and local guidance at HMP Guys Marsh of the management of illicitly brewed alcohol and the handling of medication held in possession by prisoners.

Regarding the management of illicitly brewed alcohol, the Drug and Alcohol Group (DAG) in HMPPS has developed and disseminated a range of materials specifically focused on illicitly brewed alcohol (IBA). Notably, the Drugs in Prison and Probation (DiPP) guide provides comprehensive information for staff at all levels—from frontline officers to heads of function. It is designed to enhance understanding of substances, support structured discussions, raise awareness, and assist with induction processes for new staff. Harm reduction support for alcohol use is growing across the prison estate, with mutual aid groups like Alcoholics Anonymous playing a key role. In addition, Incentivised Substance Free Living (ISFL) units are now available in 85 prisons, including at HMP Guys Marsh,

offering a supportive environment for individuals to address both alcohol and drug-related issues. As part of wider awareness efforts, Prison Radio is being recommissioned to feature speakers with lived experience of alcohol-related harm, helping to highlight the impact of substance use and promote the support available.

In response to seasonal increases in IBA reported usage, the DAG issued a targeted briefing note outlining specific risks, indicators of IBA production, and guidance on effective operational responses. These materials have been shared with Drug Strategy Leads across the prison estate to support local awareness-raising, harm reduction initiatives, and inform decision-making.

Operational colleagues are encouraged to remain vigilant regarding the ingredients and equipment commonly used in the production of IBA. Volumetric control is promoted as a key preventative measure during cell searches and wider area inspections, ensuring that ingredients and implements commonly used in the production of IBA are restricted to approved quantities.

In addition to DAG’s workstreams, the Risk and Capabilities Unit (RaCU) provides operational guidance on managing IBA-related risks. This includes reviewing canteen items accessible to prisoners, identifying vulnerable areas, and reinforcing the importance of volumetric control.

Locally, HMP Guys Marsh has implemented a series of targeted local measures to mitigate the risks of IBA. A comprehensive Local Operating Procedure (LOP) has been introduced to guide staff in managing incidents involving prisoners found under the influence, including those affected by IBA. Searching operations continue with a specific focus on identifying and safely removing IBA, which must be reported and destroyed by the Security Department. To strengthen these efforts, the Dedicated Searching Team is deployed to support intelligence- led searches where IBA is a priority concern.

In addition, preventative steps have been taken to limit the availability of ingredients commonly used in brewing IBA. Yeast-based items have been removed from the canteen list, and fruit and natural sugar-based products have been restricted. These measures aim to reduce the opportunity for prisoners to produce IBA.

The handling of medication held in possession (IP) by prisoners and prescribing practices in prisons are the responsibility of NHS England. The safe management of medication is governed by clinical guidance and national service specifications, which set out standards for prescribing, dispensing, and monitoring medication.

In addition, in cell medication safes are available on the National Prison Industries Product List and every prison is able to order them.

Healthcare providers are required to operate Medicines Management Committees, and prison governors are invited to attend these meetings to ensure collaborative oversight. Decisions about which medications are issued to prisoners, including those held in possession, are made by healthcare professionals following a comprehensive risk assessment of both the medication and the individual.

Locally, at HMP Guys Marsh, non-tradeable medications may be issued as IP on a case-by- case basis, subject to a formal risk assessment conducted by healthcare staff. The provision of IP medication is designed to support independent living and prepare prisoners for reintegration into the community. Prisoners receiving IP medication must sign a compact agreeing to the safe storage and use of their medication, including the use of in-cell lockers. Breaches of this compact will result in the removal of IP medication.

The healthcare provider at HMP Guys Marsh, Oxleas NHS Foundation Trust, has committed to introducing regular assurance checks for all prisoners in receipt of IP medication, as agreed at the Local Quality Delivery Board in August 2025.

Additionally, in-cell lockers will be replaced if damaged and their condition will be monitored through daily Accommodation Fabric Checks across all residential units.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters identified.

Dear Ms Griffin,

Thank you for the Regulation 28 report of 25 July 2025 sent to the Secretary of State for Health and Social Care about the death of Sheldon Lawrence Jeans. I am replying as the Minister with responsibility for mental health and offender health. Thank you for the additional time provided to the Department to provide a response to the concerns raised in your report.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Jean’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns over the availability illicitly brewed alcohol and a lack of national and local policy at HMP Guys Marsh, around the governance of medication held in prisoners’ possession in the prison estate. The first of these is a matter for my Ministerial colleagues at the Ministry of Justice.

I understand your concerns about medication held in prisoners’ possession. It is important that robust governance processes are in place to ensure safe and effective medicines management. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.

National NHS policies relating to the overarching use, governance and supply of medicines for prisoners are the same as those used for people in the community. As in the community, prescribed medicines are the patient’s property and taking them is an act of daily living which the patient is responsible for. Any unused medicines should be returned to the pharmacy or healthcare team for safe disposal.

NHS England commissions healthcare services for prisoners that are underpinned by specific service, regulatory and professional standards and national guidance. The main underpinning standards and guidance for health, wellbeing and use of medicines in prisons are:

• HM Inspectorate of Prisons Expectations. These describe the living environment expectations which include safe storage facilities (lockable cupboards) for prisoners to store their personal possessions including medicines. They also set out the importance of rehabilitation and the need for prisoners to take responsibility for meeting their own needs. This underpins the policy to provide medicines in- possession so that prisoners continue to manage their health and wellbeing whilst in prison, enabling them to continue to do so on release. Specific measures for in- possession medicines are also included making it clear that, subject to a regularly reviewed in-possession risk assessment, patients can store their medicines securely and self-administer them.

• The Royal Pharmaceutical Society’s professional standards for the optimisation of medicines in secure environments. These set out standards for medicines management for prisoners on admission, during their stay and on release.

I recognise that that there is a difficult balance to be had between allowing prisoners to look after their own prescription medicines (as they would in the community) and mitigating the risk of the illicit diversion of these medicines within a prison environment for all the reasons you set out in your report.

Procedures and governance around the management of prescription medicines will vary between different prison categories and local risks and incidents. Various processes are used to inform medicines use and safety in each prison including security and clinical incident management and review; in-cell searches and clinical therapeutic or substance misuse testing. National guidance could further complicate what is already a complex issue for both prisoners and prison staff.

Instead, NHS service commissioners use contractual monitoring, outcomes from regulatory inspections and regional governance to provide assurance that the standards and guidance are being delivered.

In the light of any serious incidents or fatalities attributed to medicines use and safety, NHS England has assured me that it proactively shares and uses the learning from these to remind stakeholders of the standards and expectation for safe practice and to inform the review of local policies.

I hope this response is helpful. Thank you for bringing these concerns to my attention.