Peter Campbell
PFD Report
All Responded
Ref: 2026-0211
All 4 responses received
· Deadline: 11 May 2026
Coroner's Concerns (AI summary)
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide a meaningful interaction with the deceased between a collapse on 18 September 2024 and the fatal collapse on 3 October 2024; harm minimisation guidance was given without the recovery worker reading his medical records or having a meaningful discussion with him about his drug use.
View full coroner's concerns
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.
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 so to do. 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.
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.
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 so to do. 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.
Responses
Noted
(AI summary)
(AI summary)
View full response
RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Senior Coroner, ME Hassell for the Coroner Area INNER NORTH LONDON in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Peter Campbell that concluded on 10 March 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Practice Plus Group (PPG) provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 6 MAY 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: 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. Spice, a drug many times more potent and dangerous than cannabis, is impregnated onto pieces of paper so that it can be smoked. 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. For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of spice, 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 so to do. 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
3. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here]. Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. 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. 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. The latter 2 bullet points raised however, do touch upon PPG and our internal processes for post incident reviews. It is important to note, as identified by the learned Coroner, that the PPO investigation also did not identify the issues raised. Our internal process for learning reports are thorough and of great importance to us as an organisation. We carry out multiple reports into all deaths in custody in order to identify issues and areas of good practice, and to learn lessons and implement change where required.
As noted, we conduct a number of responses to any event where learning points may arise and this is always completed for any death in custody across all PPG establishments. Learning responses can include:
• Swarm Huddles – this is a rapid, informal team-based meeting held shortly after an incident to build a shared understanding of what happened, capture early learning and identify any immediate safety actions.
• Hot debrief – this takes place immediately after a clinical event to identify early learning points but also to support staff involved.
• Post-Incident Initial Review (PIIR) – this is a structured discussion conducted within 72 hours of an incident. It seeks to understand what happened and why, explore outcomes and promote learning. This involves staff directly.
• Clinical Case Review (CCR) – this is a structured multi-disciplinary discussion after an event to learn from both successes and failures. It explores the care provided, identifies any contributing factors, examines systems and gains a broader insight into any specific safety themes, pathways and/or processes. This investigation process aims to foster a culture of continuous improvement and sustainability of good practices.
• Patient Safety Incident Investigation (PSII) – this is a formal systems based investigation triggered by incidents that pose significant safety risks or have potential for further learning. This follows on from a PIIR and CCR where further review may be considered beneficial or necessary.
• Thematic Reviews – used to analyse a group of related incidents.
• Other investigations include; complaint reviews, HR matters and professional regulation reviews. For all deaths in custody a PIIR and CCR is completed, and a PSII is completed on occasion where deemed necessary by the patient safety team. There may be some exceptions where a CCR is not completed but this would only be where the death was expected and no issues arise from the PIIR, or post-release deaths, again where no issues arise out of the PIIR. These reports are thorough and include a multi-disciplinary approach. As will have been seen in the CCR for Peter Campbell this includes stakeholders from Phoenix Futures, BEH and HMPPS, as well as PPG managers and medical leads. A chronology of the care is reviewed and it identifies areas that went well and what could have been done better. Subcontractors and organisations which we work closely with are included to promote wider learning and obtain different perspectives which is vital to build a culture of good communication and collaboration within the establishments we operate. 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. 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
subcontractors such as Phoenix Futures is managed via Practice Plus Groups ‘Standard Operating Procedure for management of Sub-Contracted Services’. This formalises a local, regional and national process that is adhered to by HMP Pentonville. Additional regional scrutiny will be implemented at HMP Pentonville for the following 6 months to ensure that the SOP is being implemented correctly and any issues arising from either organisation can be addressed quickly and effectively. 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. 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.
4. DETAILS OF FURTHER ACTION PROPOSED Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. For additional resource about our incident response and patient safety team, please find the attached:
• Patient Safety Incident Response Plan PPG HIJ services 2025-2026
• PPG HIJ Patient Safety Governance Position Statement – March 2026
SIGNATURE
Medical Director
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Practice Plus Group (PPG) provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 6 MAY 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: 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. Spice, a drug many times more potent and dangerous than cannabis, is impregnated onto pieces of paper so that it can be smoked. 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. For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of spice, 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 so to do. 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
3. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here]. Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. 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. 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. The latter 2 bullet points raised however, do touch upon PPG and our internal processes for post incident reviews. It is important to note, as identified by the learned Coroner, that the PPO investigation also did not identify the issues raised. Our internal process for learning reports are thorough and of great importance to us as an organisation. We carry out multiple reports into all deaths in custody in order to identify issues and areas of good practice, and to learn lessons and implement change where required.
As noted, we conduct a number of responses to any event where learning points may arise and this is always completed for any death in custody across all PPG establishments. Learning responses can include:
• Swarm Huddles – this is a rapid, informal team-based meeting held shortly after an incident to build a shared understanding of what happened, capture early learning and identify any immediate safety actions.
• Hot debrief – this takes place immediately after a clinical event to identify early learning points but also to support staff involved.
• Post-Incident Initial Review (PIIR) – this is a structured discussion conducted within 72 hours of an incident. It seeks to understand what happened and why, explore outcomes and promote learning. This involves staff directly.
• Clinical Case Review (CCR) – this is a structured multi-disciplinary discussion after an event to learn from both successes and failures. It explores the care provided, identifies any contributing factors, examines systems and gains a broader insight into any specific safety themes, pathways and/or processes. This investigation process aims to foster a culture of continuous improvement and sustainability of good practices.
• Patient Safety Incident Investigation (PSII) – this is a formal systems based investigation triggered by incidents that pose significant safety risks or have potential for further learning. This follows on from a PIIR and CCR where further review may be considered beneficial or necessary.
• Thematic Reviews – used to analyse a group of related incidents.
• Other investigations include; complaint reviews, HR matters and professional regulation reviews. For all deaths in custody a PIIR and CCR is completed, and a PSII is completed on occasion where deemed necessary by the patient safety team. There may be some exceptions where a CCR is not completed but this would only be where the death was expected and no issues arise from the PIIR, or post-release deaths, again where no issues arise out of the PIIR. These reports are thorough and include a multi-disciplinary approach. As will have been seen in the CCR for Peter Campbell this includes stakeholders from Phoenix Futures, BEH and HMPPS, as well as PPG managers and medical leads. A chronology of the care is reviewed and it identifies areas that went well and what could have been done better. Subcontractors and organisations which we work closely with are included to promote wider learning and obtain different perspectives which is vital to build a culture of good communication and collaboration within the establishments we operate. 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. 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
subcontractors such as Phoenix Futures is managed via Practice Plus Groups ‘Standard Operating Procedure for management of Sub-Contracted Services’. This formalises a local, regional and national process that is adhered to by HMP Pentonville. Additional regional scrutiny will be implemented at HMP Pentonville for the following 6 months to ensure that the SOP is being implemented correctly and any issues arising from either organisation can be addressed quickly and effectively. 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. 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.
4. DETAILS OF FURTHER ACTION PROPOSED Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. For additional resource about our incident response and patient safety team, please find the attached:
• Patient Safety Incident Response Plan PPG HIJ services 2025-2026
• PPG HIJ Patient Safety Governance Position Statement – March 2026
SIGNATURE
Medical Director
Noted
(AI summary)
(AI summary)
View full response
Dear Senior Coroner Hassell, Prevention of future deaths report following the inquest into the death of Peter Campbell (died 8 October 2024) I refer to the Regulation 28, Prevention of Future Deaths report (“PFD report”) report, dated 11 March 2026, sent by you following the inquest into the death of Mr Campbell at HMP Pentonville. The PFD report was sent to the Chief Executive, HM Prison and Probation Service (HMPPS) Ministry of Justice, Governing Governor at HM Prison Pentonville, the Chief Executive at Practice Plus Group (PPG) and myself, Chief Executive at Phoenix Futures. In the first instance, we would again like to offer our sincere condolences to Mr Campbell’s family. Every death in custody is a tragedy, and we remain committed to supporting people accessing services in ways that help prevent circumstances such as those that led to Mr Campbell’s passing. Phoenix Futures is a charity dedicated to supporting people with a wide range of challenges. This commitment underpins all aspects of our work. Phoenix Futures operates in partnership with other agencies, both within prison settings and in the community. A supplementary statement from the Service Manager was submitted during the inquest that captured many of the issues raised in the report. As a learning organisation, we remain committed to reflecting further on the concerns identified in the PFD report. The PFD highlighted the following points (summarised): Concern one: Failure to review SystmOne records in advance of providing harm minimisation advice SystmOne is the healthcare record system used by both PPG and Phoenix Futures at HMP Pentonville. Recovery Workers joining Phoenix Futures receive SystmOne training from their line manager during their first week, supported further through shadowing with experienced colleagues. Additional guidance is also provided in the Recovery Worker Handbook.
Working alongside experienced colleagues provides new colleagues with practical support in navigating systems such as SystmOne. Phoenix Futures staff also have access to an IT support line if needed. 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. 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. As outlined above, there will, however, be occasions when a Recovery Worker cannot review SystmOne beforehand. Concern two: Conducting the consultation through the cell door, in the presence of a cellmate. Concern three: Having meaningful conversation regarding substance misuse, including attempts at persuasion. 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; Chaplin, Iman, Education and civilians, to speak to prisoners through their door. 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. Substance use within a prison environment is complex, and every person presents differently. As such, Phoenix Futures relies on Recovery Workers to complete a dynamic, multifactorial risk assessment that considers both the needs of the service user and their own personal safety. In response to the Coroner’s concern and within the regime of the prison, the importance of these points will be reinforced in team meetings. There will be occasions when, for the safety of staff, consultations must be conducted through the cell door. This may occur when the prison regime does not permit cell doors to be opened or when staff determine, following a risk assessment, that it would not be safe to conduct the intervention otherwise
Mr Campbell was seen during an unscheduled care visit, where the Recovery Worker is temporarily removed from their usual key-working duties to focus on supporting individuals who require more urgent harm-reduction advice. A new Recovery Worker does not join the unscheduled care rota until they have been signed off as competent to work independently. The timeframe for this can vary depending on the individual’s capability and previous experience but typically occurs within a few months. 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. The main focus during unscheduled care should be on providing essential harm-minimisation guidance, while more comprehensive advice is best delivered during scheduled appointments. Harm minimisation under pins all interactions and evidence shows that the brief harm minimisation interventions that explain the risk of drug use and how to minimise risks are persuasive in reducing harm. At certain points such as unscheduled care it should be a key focus, whilst during planned care, due to the structured nature, a broader range of interventions can also be employed. The above is provided by way of context, and to highlight the manner in which Unscheduled Care is provided by Phoenix Futures. Summary Phoenix Futures remains deeply saddened by the circumstances surrounding Mr Campbell’s passing. We have reflected, and continue to reflect, on the events leading up to his death. As outlined in the supplementary statement submitted during the inquest, Phoenix Futures not only promptly identified the necessary learning points and implemented changes where required. We hope these improvements provide strong assurance that the actions taken will be not only be implemented but will be sustained in the long term. We hope the above sets out the complex nature of assessments our colleagues undertake on a daily basis, and crucially that every individual person who accesses services is unique in their presentation. We hope that this response gives the Coroner assurance that these matters are taken extremely seriously by Phoenix Futures and demonstrates our commitment to learn and provide the best services possible.
Working alongside experienced colleagues provides new colleagues with practical support in navigating systems such as SystmOne. Phoenix Futures staff also have access to an IT support line if needed. 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. 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. As outlined above, there will, however, be occasions when a Recovery Worker cannot review SystmOne beforehand. Concern two: Conducting the consultation through the cell door, in the presence of a cellmate. Concern three: Having meaningful conversation regarding substance misuse, including attempts at persuasion. 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; Chaplin, Iman, Education and civilians, to speak to prisoners through their door. 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. Substance use within a prison environment is complex, and every person presents differently. As such, Phoenix Futures relies on Recovery Workers to complete a dynamic, multifactorial risk assessment that considers both the needs of the service user and their own personal safety. In response to the Coroner’s concern and within the regime of the prison, the importance of these points will be reinforced in team meetings. There will be occasions when, for the safety of staff, consultations must be conducted through the cell door. This may occur when the prison regime does not permit cell doors to be opened or when staff determine, following a risk assessment, that it would not be safe to conduct the intervention otherwise
Mr Campbell was seen during an unscheduled care visit, where the Recovery Worker is temporarily removed from their usual key-working duties to focus on supporting individuals who require more urgent harm-reduction advice. A new Recovery Worker does not join the unscheduled care rota until they have been signed off as competent to work independently. The timeframe for this can vary depending on the individual’s capability and previous experience but typically occurs within a few months. 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. The main focus during unscheduled care should be on providing essential harm-minimisation guidance, while more comprehensive advice is best delivered during scheduled appointments. Harm minimisation under pins all interactions and evidence shows that the brief harm minimisation interventions that explain the risk of drug use and how to minimise risks are persuasive in reducing harm. At certain points such as unscheduled care it should be a key focus, whilst during planned care, due to the structured nature, a broader range of interventions can also be employed. The above is provided by way of context, and to highlight the manner in which Unscheduled Care is provided by Phoenix Futures. Summary Phoenix Futures remains deeply saddened by the circumstances surrounding Mr Campbell’s passing. We have reflected, and continue to reflect, on the events leading up to his death. As outlined in the supplementary statement submitted during the inquest, Phoenix Futures not only promptly identified the necessary learning points and implemented changes where required. We hope these improvements provide strong assurance that the actions taken will be not only be implemented but will be sustained in the long term. We hope the above sets out the complex nature of assessments our colleagues undertake on a daily basis, and crucially that every individual person who accesses services is unique in their presentation. We hope that this response gives the Coroner assurance that these matters are taken extremely seriously by Phoenix Futures and demonstrates our commitment to learn and provide the best services possible.
Action Taken
• HMPPS stated it is committed to tackling the ingress of drugs and other contraband into prisons. • All adult male closed prisons are equipped with X-ray body scanners. • All public sector prisons have been provided with trace detection equipment. (AI summary)
• HMPPS stated it is committed to tackling the ingress of drugs and other contraband into prisons. • All adult male closed prisons are equipped with X-ray body scanners. • All public sector prisons have been provided with trace detection equipment. (AI summary)
View full response
Dear Ms Hassell,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR PETER CAMPBELL
Thank you for your Regulation 28 report of 11 March 2026 following the inquest into the death of Peter Campbell at HMP Pentonville on 8 October 2024. 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 Campbell’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 have raised concerns regarding the measures taken to prohibit the conveyance of drugs into prisons.
HMPPS is committed to tackling the ingress of drugs and other contraband into prisons, which I recognise can cause serious harm, fuel violence, create instability, and undermine rehabilitation in prisons. As prison security threats constantly evolve, we continuously shift and adapt our security measures to ensure we keep pace with changing threats.
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
tools to detect and retrieve mobile phones, which we know are used to facilitate drug conveyance and dealing within the estate. 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.
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.
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.
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.
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 PETER CAMPBELL
Thank you for your Regulation 28 report of 11 March 2026 following the inquest into the death of Peter Campbell at HMP Pentonville on 8 October 2024. 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 Campbell’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 have raised concerns regarding the measures taken to prohibit the conveyance of drugs into prisons.
HMPPS is committed to tackling the ingress of drugs and other contraband into prisons, which I recognise can cause serious harm, fuel violence, create instability, and undermine rehabilitation in prisons. As prison security threats constantly evolve, we continuously shift and adapt our security measures to ensure we keep pace with changing threats.
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
tools to detect and retrieve mobile phones, which we know are used to facilitate drug conveyance and dealing within the estate. 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.
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.
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.
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.
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.
Noted
(AI summary)
(AI summary)
View full response
Position Statement Development of Patient Safety Governance within Practice Plus Group Health in Justice Services – March 2026 Practice Plus Group’s (PPG) Health in Justice (HiJ) directorate began implementing the Patient Safety Incident Response Framework (PSIRF) in 2023 as one of the early adopters ahead of the national requirement for providers to transition. Since the introduction of PSIRF, we have undertaken a programme of work to embed the framework across our prison, immigration removal and non- custodial health care services. This has involved developing governance structures, investigation methodologies and learning processes designed to support proportionate responses to patient safety incidents while ensuring that meaningful learning is identified and translated into improvements in care. 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. As PSIRF was embedded in practice and the organisation’s approach matured, internal review indicated that the application of proportionality in some cases had tended toward the least intensive investigation approach when decisions were taken at an individual level. While this reflected the intention of PSIRF to avoid unnecessarily burdensome investigations, it was recognised that this approach could risk limiting opportunities for deeper system learning and may not always provide the level of analysis helpful to external processes such as coronial review. 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. 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. 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. 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
governance forums, including Patient Safety Incident Response Group and National Quality Assurance governance structures. 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. 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. The PDP operates alongside the organisation’s patient safety governance arrangements and is closely connected. Where concerns relating to professional practice arise during the review of patient safety incidents, these may be escalated to the PDP for further consideration. Similarly, matters considered within the PDP may highlight wider system risks or learning which are then reviewed through the Patient Safety Team’s governance processes. PPG recognises that PSIRF learning responses and coronial investigations serve different but complementary purposes. PSIRF focuses on organisational learning and improvement through systems-based review, while coronial processes seek to establish the circumstances surrounding an individual death, including matters relating to causation. In line with guidance issued by NHS England and the Chief Coroner in early 2026, PPG aims to ensure that its patient safety investigation processes support organisational learning while also providing clear factual information and context where required to assist coronial processes. 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. Deputy Director of Nursing and Quality 5th March 2026
governance forums, including Patient Safety Incident Response Group and National Quality Assurance governance structures. 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. 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. The PDP operates alongside the organisation’s patient safety governance arrangements and is closely connected. Where concerns relating to professional practice arise during the review of patient safety incidents, these may be escalated to the PDP for further consideration. Similarly, matters considered within the PDP may highlight wider system risks or learning which are then reviewed through the Patient Safety Team’s governance processes. PPG recognises that PSIRF learning responses and coronial investigations serve different but complementary purposes. PSIRF focuses on organisational learning and improvement through systems-based review, while coronial processes seek to establish the circumstances surrounding an individual death, including matters relating to causation. In line with guidance issued by NHS England and the Chief Coroner in early 2026, PPG aims to ensure that its patient safety investigation processes support organisational learning while also providing clear factual information and context where required to assist coronial processes. 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. Deputy Director of Nursing and Quality 5th March 2026
Sent To
- HM Prison Pentonville
- HM Prison & Probation Service
- Practice Plus Group
Response Status
Linked responses
4 of 4
56-Day Deadline
11 May 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 17 October 2026, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Peter Campbell aged 36 years. The investigation concluded at the end of the inquest yesterday. The jury made a determination that death was drug related, and also gave a narrative that I attach.
The medical cause of death was recorded as: 1a pneumonia and ischaemic hypoxic brain injury 1b cardiac arrest 1c toxic effects of
The medical cause of death was recorded as: 1a pneumonia and ischaemic hypoxic brain injury 1b cardiac arrest 1c toxic effects of
Circumstances of the Death
On 3 October 2024, Mr Campbell collapsed in his prison cell at Pentonville whilst with his cell mate, having smoked . He was a frequent user of . Despite immediate attempts at resuscitation and conveyance to hospital, he died five days later.
Copies Sent To
North London NHS Foundation Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.