Addiction Support Waiting Times
Excessively long waiting times and delays in accessing addiction support and residential rehabilitation placements.
190 items
10 sources
Source spread
Where this theme appears
Addiction Support Waiting Times has been flagged across 10 independent accountability sources:
78 PFD reports
41 committee recs
1 CQC action
18 PPO recs
10 IMB reports
15 IMB recs
3 detention investigation recs
13 PHSO decisions
9 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (78) — showing 50 strongest matches
Paul Nash
Concerns: A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and potential delays.
Response (Department of Health and Social Care): • Officials made enquiries with NHS England to address the coroner's concerns. • The government is committed to improving care for people with neurological conditions, including epilepsy, and ensuring they …
Responded
Pauline Meredith
Concerns: Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Response (Browning Street Surgery): The practice will endeavor to identify patients with additional complex needs for specific discussion at practice meetings to improve service to patients. They will also aim to maximise the health …
Overdue
Lee Bonsall
Concerns: Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding repeat prescriptions of citalopram, referencing NICE guidelines. It states that NICE guidelines are not rules and do not restrict prescribing, including …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding citalopram prescriptions and psychotherapy waiting times but states these are the responsibility of the Welsh Government. It includes information about Citalopram's …
Responded
Alan Stanfield Browning
Concerns: A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of robust discharge planning.
Overdue
Richard White
Concerns: Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Response (700 Club2): The 700 Club clarifies that it does not store or administer medication to clients, emphasizing that responsibility for safeguarding clients regarding medication lies with GPs. They will receive medication if …
Responded
Michael Tarratt
Concerns: There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
Response (Leicestershire Partnership NHS Trust): An urgent memo was sent to the Drug & Alcohol team regarding GP communication standards (minimum every 3 months). Standard GP letter templates have been reviewed to ensure detailed updates …
Responded
Sindy Woodhall
Concerns: A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and enforcement powers that poses a health risk.
Response (Trading Standards Institute): The Trading Standards Institute states that it is a professional body without powers to get involved and that the matter is for local authority trading standards departments. It highlights a …
Response (Oldham Council): Oldham Council will ensure the trader concerned is visited and spoken to by officers on the safety/health implications and moral obligations related to addictions, and about sales to minors of …
Response (UK Health Security Agency): Public Health England has been working with the Department of Health to restrict access to volatile substances, has refined information collected on VSA as part of the National Treatment Monitoring …
Response (Department of Health): The Department of Health acknowledges the concerns and refers to the response from Public Health England, expressing full support for their views and advice.
Responded
Graham Darby
Concerns: A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
Overdue
Anthony Huggan
Concerns: The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged after overdoses.
Response (Bury Council): The council provides contextual information about commissioned substance misuse services and describes the services available, but does not outline specific changes in response to the concerns.
Responded
Sian Armstrong
Concerns: A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.
Overdue
William Maskell
Concerns: The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to force entry for a student in distress, risking future deaths.
Overdue
Darren Mindham
Concerns: The report identifies that pentobarbital, a drug commonly used in suicides, is not subject to strict controls despite evidence showing that reduced access to means of suicide can decrease suicide rates.
Overdue
Richard Breatnach
Concerns: Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or correct guidance.
Response (NHS England): NHS England will assimilate current regulatory and professional guidance into one place for online prescribing, and will use this learning to inform its Digital Strategy. They will also include advice …
Overdue
Shane Hardy
Concerns: Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was a lack of inter-agency information sharing and no identified lead agency for communication.
Overdue
Robert Lloyd
Concerns: Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased engagement for island residents.
Response (The Health Centre): The Health Centre met with the Drug and Alcohol Action Team, will host a new Addaction worker every 2 weeks, and has provided training for pharmacists to identify those at …
Response (Drug Alcohol Action Team): The DAAT conducted a needs assessment with the Isles of Scilly, put in place a joint improvement plan with Addaction, trained GPs and pharmacy staff, and plans to offer training …
Overdue
David Read
Concerns: After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of over 16 weeks, during which time the patient died.
Response (Norfolk and Suffolk NHS Trust): Norfolk and Suffolk NHS Trust has fully staffed its team and made amendments to practice. If a service user does not attend an appointment the team will have a phone …
Responded
Jamie Pashley
Concerns: The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability of an alcohol liaison nurse post-discharge.
Response (Kings College Hospital NHS Trust): The Trust acknowledges concerns about alcohol dependency patient follow-up. They are considering a business case to expand the Alcohol Liaison team to reduce ED attendances and admissions.
Overdue
Aaron McCaffrey
Concerns: The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of addiction and overdose.
Overdue
Thomas Wall
Concerns: The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for dual diagnosis patients is critically needed, as current separation of care increases risk.
Response (Susssex Partnership NHS Trust): Sussex Partnership NHS Foundation Trust explains that they were not chosen by Brighton and Hove City Council to continue providing local substance misuse services and encourages the coroner to write …
Response (Brighton Hove City Council): Brighton & Hove City Council's Public Health department, as commissioner for adult and substance misuse in-patient detoxification beds, explains the history of service provision, noting the decision to work with …
Response (Brighton and Hove Clinical Commissioning Group): Brighton and Hove CCG highlights existing measures like a Dual Diagnosis integrated model, co-located DD workers, accommodation with support, and a Rough Sleepers project. Service user feedback is regularly reviewed, …
Overdue
Naomi Sourbut
Concerns: Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent to self-harm were not clearly implemented.
Overdue
Stuart Campbell
Concerns: Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet patient needs.
Response (Addiction Dependency Solutions): ADS has re-negotiated with Pennine Care NHS Trust for clinical advice and supervision, and has commissioned Applied Suicide Intervention Skills Training (ASIST) for shared care staff.
Responded
Christopher Hutton
Concerns: Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was not commenced, despite his anxiety to complete it.
Response (HM Prison and Probation Services): To address the increased demand for sex offender treatment programs, the North West Division is increasing staff from 23 to 35 facilitators and training them, with the first 11 in …
Responded
Lakhminder Kaur
Concerns: Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to prevent serious self-harm.
Overdue
John Derwent
Concerns: Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely access to essential mental health treatment.
Overdue
Karl Willis
Concerns: "Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a crucial safeguard.
Response (NHS England): NHS England explains its commissioning responsibilities and lack of jurisdiction over private healthcare providers. It states that it cannot breach patient confidentiality to share private consultation details with a patient's …
Responded
Scott Carton
Concerns: Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Overdue
Jerome Jones
Concerns: Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited access to medical records, posed significant dangers.
Response (Shropshire Community Health NHS Trust): The trust describes current practices for observing prisoners using illegal substances and referring them to support services. It notes that Forward Trust's access to medical records is under discussion with …
Response (HM Prison Probation Service): An updated drug strategy has been launched at the establishment, and staff were reminded of communication protocols for prisoners at risk from repeated use of psychoactive substances. By April 2019, …
Overdue
Benjamin Williamson
Concerns: The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate with his GP or address consent for information sharing, creating a significant care gap.
Response (Addaction): Addaction has reviewed and improved how they record confidentiality and consent reviews. They will provide the Health Centre with client numbers, have a designated worker attend practice multi-disciplinary team meetings …
Response (Kernow CCG NHS Trust): NHS Kernow is working with partner agencies to implement a multi-agency strategy, including developing a dynamic risk register for individuals with dual diagnosis, with priority given to immediate actions. Contract …
Responded
Paul Gillam
Concerns: Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor working relationship between Addaction and the Community Mental Health Team.
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow CCG, CFT and Cornwall Council are undertaking a review of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT. The review of the strategy and …
Overdue
Matthew Hamilton
Concerns: Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.
Response (HM Prison Probation Service): HMP Durham's Drug and Alcohol Reduction Team (DART) has updated their guidance pack to be offered to all prisoners on discharge, is offering Naloxone to prisoners at risk of opiate …
Responded
Conor Crutchley
Concerns: The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by recruitment and retention issues.
Response (Pennine Care NHS Trust): The trust details steps taken to improve early intervention services, including funding an additional psychological therapist and training staff in family intervention. The management of the waiting list for psychological …
Responded
Justin Brown
Concerns: Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug services meant referrals were not effectively monitored for vulnerable patients.
Overdue
Joanna Flynn
Concerns: There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help patients safely wean off addictive prescription opiates.
Response (NHS England): NHS England/Improvement acknowledges the need for national-level guidance and support, highlighting a review group established in response to the PHE review. They note the complexity of patients with addiction to …
Response (the Department of Health and Social Care): The Department of Health and Social Care highlights the PHE report on prescription drug dependence and the review of overprescribing led by Dr Keith Ridge. The Mid-Essex CCG will implement …
Response (Mid Essex CCG): Mid Essex CCG details plans for a Local Enhanced Service for substance misuse, joint guidance for de-prescribing, and a session on Opioids and Safe Prescribing at the CCG's Time to …
Overdue
Ricky Barcock
Concerns: The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially drug users, to properly monitor their wellbeing.
Response (Oasis Recovery Communities): Oasis Bradford has reviewed and updated its Observation and Client Wellbeing Checks Policy December 2019 and plans to provide staff training to ensure working practice is safe and effective and …
Overdue
Joseph Gingell
Concerns: Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.
Response (NHS England): NHS England acknowledges concerns about drug toxicity, self-certification, and not informing GPs but states the death appears to be from services outside the NHS, restating commitment to improving the safety …
Responded
Holly Chevassut
Concerns: Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to people overtaken by these vehicles.
Response (GRS Recovery): GRS Recovery has removed the offending mirrors, and rotated the remaining mirrors to reduce the width of the vehicles.
Responded
Daniel Mervis
Concerns: Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus support may discourage students with addiction from seeking help.
Response (St Johns College Oxford): St John's College will adopt a template policy for drug misuse, rewrite the student handbook for clarity, and include information in Fresher's week. They will also run a Welfare week …
Responded
Natasha Crabb
Concerns: There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals addicted to obtain large amounts despite fatal risks.
Response (Dept. of Health and Social Care): The Department of Health and Social Care directs readers to the Talk to FRANK website, mentions contact with the Home Office re: powers under the Psychoactive Substances Act 2016, and …
Overdue
Helen Spicer
Concerns: Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns about opioid overuse and misuse. They outline actions taken, including a PHE evidence review, front-of-pack warnings on opioid medications, and structured …
Response (ACMD): The ACMD acknowledges the concerns and will gather more information on the scale of the issue of morphine sulfate solution misuse, being mindful of its legitimate use. They will request …
Responded
Jade Rayner
Concerns: Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. There was also a lack of clear multi-agency strategy for complex cases involving trauma and alcohol misuse.
Response (Greater Manchester Health and Social Care Partnership): Two task and finish groups will review Section 42 and Multi Agency Adults at Risk System processes, with learning to be shared with the Greater Manchester Quality Board and commissioners …
Response (Greater Manchester Police): GMP has implemented the vulnerability assessment framework to identify and assess risk factors, and officers now record care plans after safe and well interviews with vulnerable adults.
Responded
Parys Lapper
Concerns: A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.
Response (NHS England): NHS England and NHS Improvement acknowledge concerns about individuals obtaining excess medications and checking prescriptions across providers. They cite GMC guidance on prescribing practices and describe ongoing programs to improve …
Responded
Steven Allen
Concerns: Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.
Response (Stockport Clinical Commissioning Group): Stockport CCG's Medicines Management Team is in discussion with Primary Care Network Leads to explore how the Stockport Integrated Pharmacy Service can support practices in medication reviews for vulnerable patients. …
Responded
Elaine Inns
Concerns: Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage instructions, posing a significant risk.
Response (Stockport Clinical Commissioning Group): The Stockport CCG reports that the GP practice involved had already undertaken a detailed significant event analysis. The practice has changed its administrative process to refer all out of hours …
Responded
Jane Bush
Concerns: Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.
Response (Hellesdon Hospital): Hellesdon Hospital has implemented several actions including increasing capacity of the Central Youth Team, developing a locality model, developing a transition service, and recruiting senior nurses and consultant psychologists. They …
Responded
Nicholas Spooner
Concerns: There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health crises intertwined with substance abuse, who are often denied adequate support.
Response (BHCC CCG SPFT and CGL): BHCC CCG SPFT and CGL acknowledge concerns regarding services for those with co-occurring substance misuse and mental ill-health and outline future plans to review the existing co-existing conditions group, ensure …
Response (Dept. of Health and Social Care): The Dept. of Health and Social Care details plans for improving mental health services for those with coexisting substance use, including providing support to local authorities via the Public Health …
Response (NHS Social Care): NHS Social Care provides an update to their October 2021 response, stating that the procurement process for a new crisis house has been completed and the contract awarded to Mental …
Overdue
Daniel Hall
Concerns: University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk factors like ASD.
Response (University of South Wales): The University has commissioned an independent external review of wellbeing policies and procedures. Since October 2021, it has worked to improve understanding of support services and has improved and extended …
Responded
Daniel France
Concerns: A vulnerable young person known to the County Council and Mental Health Trust did not receive timely support, facing a long wait for psychological therapy, potentially dangerous given the risk of impulsive acts; there were also considerable delays in obtaining appointments for the Gender Identity Clinic and a shortage of psychological therapies.
Overdue
Claire Copeland
Concerns: The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective mechanisms to detect or remedy failed deliveries, risking discontinuity of vital medical treatment.
Response (HumanKind): Humankind has implemented a standard operating procedure for prescription deliveries, including mandatory witnessed delivery and recording in the service user's notes. They have also established a contact procedure and contingency …
Response (Boots UK): Boots UK acknowledges the concerns raised and states the gravitas is duly noted.
Responded
Robyn Skilton
Concerns: Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource increases have made the service unsustainable, endangering young people.
Response (department of Health and Social Care): The response acknowledges concerns about access to child and adolescent mental health services (CAMHS) in West Sussex. It outlines national initiatives to increase funding for and access to mental health …
Responded
Colin Smith
Concerns: Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical intervention, creating significant safety gaps.
Overdue
Committee Recommendations (41)
#1 — Committee gathered evidence on alcohol treatment services from key stakeholders
Recommendation: On the basis of a Report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department) on alcohol treatment services.1 We also took evidence from Alice Wiseman, Director of Public Health, …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The government has already published a comprehensive assessment of effective and cost-effective strategies to tackle alcohol harm in England through the former Public Health England. This …
Accepted
#200 — Mandate overhauling prison substance misuse commissioning, separating services from general healthcare contracts.
Recommendation: The MoJ and Department of Health and Social Care (DHSC) must mandate an overhaul of the current commissioning model for prison-based substance misuse treatment services. We agree with Dame Carol Black that these services must be commissioned directly and separately …
Gov response: Partially accept NHS England is responsible for the delivery of healthcare services in prisons under the Health and Care Act 2012. This includes substance misuse services, ensuring health services in prison are integrated to build …
Partially Accepted
#199 — Complex and fragmented commissioning structure compromises prison substance misuse and healthcare services.
Recommendation: The commissioning structure for substance misuse and healthcare services is complex and fragmented. This compromises the efficacy of treatment outcomes and continuity of care for prisoners. The current healthcare model, where a single contractor covers all health services and then …
Gov response: Partially accept NHS England is responsible for the delivery of healthcare services in prisons under the Health and Care Act 2012. This includes substance misuse services, ensuring health services in prison are integrated to build …
Partially Accepted
#179 — Require balancing prisoner punishments with mandatory drug treatment referrals and resourcing consistent adjudications
Recommendation: We recommend that punishments, such as the loss of privileges, are balanced with a mandatory referral to drug treatment services. This ensures that individuals are held accountable while also directed towards the support they need to break the cycle of …
Gov response: The threat posed by illicit mobile phones and other contraband within prisons is escalating, and so we have a wide-ranging programme in place to prevent these from entering prisons in order to detect and disrupt …
Partially Accepted
#164 — Revise drug testing policy for dual response: disciplinary action and treatment referral.
Recommendation: The MoJ and HMPPS must revise the drug testing policy to ensure that positive test results consistently trigger a dual response: swift and certain disciplinary action (with a rehabilitative element) and an immediate, 60 mandatory referral for a clinical needs …
Gov response: We acknowledge the significant risk posed by the diversion and misuse of prescription medication within prisons. To prevent this, guidance on supervising medicine queues is already included in Prison Officer Guides, and harm reduction advice …
Partially Accepted
#160 — Widespread illicit substance availability normalises drug use and addiction within prisons.
Recommendation: The widespread and increasing availability of illicit substances has fostered a culture of acceptance that normalises drug use in prisons. This makes the presence of drugs inescapable for many prisoners. The situation is made worse by two key factors: the …
Gov response: We recognise the value of drug testing in achieving a range of outcomes, including supporting our understanding of the level and types of drug use in prisons, identifying individuals who may benefit from treatment referrals, …
Partially Accepted
#13 —
Recommendation: We recommend that this loophole, which allows consumers to continue to gamble using credit cards, should be closed as soon as practicable, following discussions with retailers. (Paragraph 72) Distributing Bodies
Under Consideration
#12 —
Recommendation: Exemptions within the ban on gambling on credit are ill thought through and subject to discretion. While the original ban goes most of the way to preventing this form of gambling harm, opt-outs for retailers maintain the possibility for those …
Under Consideration
#10 —
Recommendation: We recommend that, with immediate effect, all National Lottery products should carry GambleAware branding.
Under Consideration
#9 —
Recommendation: While it is clearly the case that the National Lottery poses significantly fewer gambling harms than many other forms of gambling, to play a National Lottery game is undeniably gambling, which the National Lottery operator should bear in mind. Including …
Gov response: Appendix: National Lottery Distributors’ Response to Recommendation 9 in the Committee’s Fourth Report Recommendation 9: We recommend that, over the next six months, the distributing bodies consider how they might more effectively ensure that recipients …
Under Consideration
#7 —
Recommendation: We recommend that the Gambling Commission commissions research into the gambling harms of National Lottery advertising and marketing, including any personalisation that may lead to the promotion of higher-risk products to vulnerable players. We would expect that to occur within …
Under Consideration
#5 —
Recommendation: The fine imposed against Camelot earlier this year regarding the National Lottery’s inappropriate targeting of vulnerable consumers is concerning enough in isolation, and more so when considered alongside concerns raised by gambling harms experts that such targeting is being used …
Under Consideration
#28 —
Recommendation: We recommend a plan be prepared by the FCDO for providing material support for long-term arbitrarily detained persons on their release as well as support during detention for families especially where the detainee is the primary earner. In this context …
Gov response: 28. The task force approach to complex consular cases, and process of informing and accounting to Ministers described to the Committee in our written and oral evidence, and in paragraph 16, is designed to ensure …
Under Consideration
#10 — Continuity of drug treatment for prison leavers remains consistently low after release.
Recommendation: The continuity of prison leavers’ drug treatment in the community has remained low for many years. In 2021–22, 37% of prison leavers in England with a substance misuse treatment referral were engaged in community-based treatment three weeks after release (38.1% …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2024 2.2 The government is committed to engaging offenders in substance misuse treatment at all stages of the criminal justice system to reduce …
Accepted
#6 — Increase funding to radically reduce autism assessment waiting times backlog.
Recommendation: Too many people are waiting far too long to get their autism assessment and the backlog is getting worse. It is clear that current efforts to address the waiting list backlog are inadequate and that the additional funding that has …
Response Pending
#25 — Prioritise identifying and addressing local barriers to drug treatment and recovery.
Recommendation: We recommend that Combating Drugs Partnerships prioritise identifying the likely barriers to treatment and recovery for people within their local area and take steps to address these barriers as part of fulfilling their commitments under the 10-Year Drugs Strategy.
Gov response: The Government accepts these recommendations. The Drug Strategy acknowledges that some groups face greater barriers to accessing treatment and recovery support than others. These include women, people from ethnic minority groups, veterans, people experiencing homelessness, …
Accepted
#8 —
Recommendation: We think that any operator should, by default, meet the Gambling Commission’s suggested donation to GambleAware, and have an ambition to go beyond that. We will reassess this issue following the publication of the gambling White Paper.
Under Consideration
#6 —
Recommendation: The Lottery operator and Gambling Commission should collect and share player data with the public, in order to enable independent research into the users of the National Lottery and the potential harms faced by different demographics. This should include frequency …
Under Consideration
#22 — Despite increased access, significant treatment gaps and long waiting lists persist for mental health services.
Recommendation: It is good to see that the number of people accessing NHS funded mental services has increased, from 3.6 million in 2016–17 to 4.5 million in 2021–22. However, this equates to only around one third of people with mental health …
Gov response: 4.1 The government agrees with the Committee’s recommendation Target implementation date: January 2024 4.2 DHSC is working with NHS England to produce a definition of parity of esteem, incorporating feedback from key stakeholders and lived …
Not Addressed
#15 — Eating disorder waiting time standards unmet, while mental health standards remain too limited
Recommendation: We are concerned about the NHS still not meeting the eating disorder service standards, and how long young people suffering from eating disorders have to wait for treatment. NHSE explained to us that this is because it took time for …
Gov response: 5.1 The government agrees with the Committee’s recommendation Target implementation date: January 2024 5.2 Waiting time standards already exist within Mental Health services; specifically for CYP Eating Disorder Services (95% of CYP with eating disorders …
Not Addressed
#2 — Agree and routinely publish metrics measuring end-to-end success in treating offender substance misuse.
Recommendation: We are concerned that government is not doing enough to support prisoners with substance misuse needs before they are released. Despite the previous Committee’s recommendations in 2017, HMPPS and NHS England have been slow to improve the collection and sharing …
Gov response: The government agrees with the Committee’s recommendation. all stages of the criminal justice system to reduce reoffending. The National Combatting Drugs Outcomes Framework sets out the key metrics that the government is using to measure …
Accepted
#29 — Embed specialist practical and mental health support for families of drug users.
Recommendation: We recommend that local authorities use the funding allocated under the 10-Year Drugs Strategy to embed specialist practical and mental health support within drug treatment and support services for the families and the loved ones of people who use, or …
Gov response: The Government accepts these recommendations. The Drug Strategy acknowledges the invaluable role that families and carers play in supporting people in treatment and recovery, and states that services should ensure that family members and carers …
Accepted
#24 — Specific groups face significant barriers accessing drug treatment and support.
Recommendation: We were concerned to hear about the barriers people, such as women and black, Asian and minority ethnic people, can face when accessing treatment. No-one should be unable, or feel unable, to receive treatment and support. (Paragraph 100) Drugs 75
Gov response: The Government accepts these recommendations. The Drug Strategy acknowledges that some groups face greater barriers to accessing treatment and recovery support than others. These include women, people from ethnic minority groups, veterans, people experiencing homelessness, …
Accepted
#5 —
Recommendation: HMPPS’s innovative use of technology in its expansion projects has yielded some encouraging early results. HMPPS has achieved some initial positive results from using new technology in its alcohol monitoring scheme and acquisitive crime Transforming electronic monitoring services 7 project. …
Gov response: The government agrees with the Committee’s recommendation Recommendation implemented The government has consulted on a revised National Air Pollution Control Programme (NAPCP) which includes robust actionable measures for further consideration to deliver compliance with the …
Not Addressed
#18 —
Recommendation: We recommend that a clear majority of National Lottery product advertising should prominently feature the link between playing the National Lottery and supporting good causes. (Paragraph 103) What next for the National Lottery? 37
Under Consideration
#17 —
Recommendation: Public awareness of the link between the National Lottery and funding for good causes remains lower than it should be. This risks the public losing sight of the National Lottery’s original purpose, to raise money for good causes, and instead …
Under Consideration
#12 — New substance misuse treatment funding is welcomed, but remains short-term and insufficient.
Recommendation: We heard from Ms Wiseman that local government welcomes the additional £533 million boost to funding for substance misuse treatment services provided through the 10-year drug strategy, and that it was good to have it ringfenced. However, Ms Wiseman cautioned …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government is committed to improving certainty around funding for drug and alcohol treatment services to local authorities and agrees that this is important …
Accepted
#11 — Significant Public Health Grant cuts have severely reduced funding for alcohol treatment services.
Recommendation: The Department is responsible for allocating the annual ring-fenced Public Health Grant (PHG) to local authorities each year. The PHG fell by £630 million (in 2021–22 prices), from £3.96 billion to £3.32 billion, over the period from 2015–16 to 2021–22.23 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government is committed to improving certainty around funding for drug and alcohol treatment services to local authorities and agrees that this is important …
Accepted
#3 — Confirm Public Health Grant allocations earlier to provide long-term funding certainty for treatment services
Recommendation: Delays by the Department in finalising the allocation of the Public Health Grant, coupled with short-term funding and reductions to the public health grant, make it difficult for local authorities to plan and commission alcohol treatment services effectively. Since 2015–16, …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The government is committed to improving certainty around funding for drug and alcohol treatment services to local authorities and agrees that this is important to enable …
Accepted
#16 — Implementation of new mental health waiting time standards for community services remains uncertain.
Recommendation: In 2022, NHSE consulted on new waiting times standards for mental health services in the community and A&E for both children and adults, with most (81%) respondents to the consultation in favour of the new standards. If implemented, these would …
Gov response: 5.1 The government agrees with the Committee’s recommendation Target implementation date: January 2024 5.2 Waiting time standards already exist within Mental Health services; specifically for CYP Eating Disorder Services (95% of CYP with eating disorders …
Accepted
#14 — NHS fails to meet waiting time standards for children and young people's eating disorder services
Recommendation: From 2015, NHSE introduced specific waiting times standards for three service areas —talking therapy services, early intervention in psychosis services and eating disorder services for children and young people—which set ambitions for people to enter treatment quickly. While the NHS …
Gov response: 5.1 The government agrees with the Committee’s recommendation Target implementation date: January 2024 5.2 Waiting time standards already exist within Mental Health services; specifically for CYP Eating Disorder Services (95% of CYP with eating disorders …
Accepted
#28 — Drug strategy overlooks family role in recovery; mental health support for families insufficient.
Recommendation: We welcome the strategy’s commitment to supporting families. It focuses on the important role of the family in preventing drug use, particularly in relation to young people. However, it does not recognise the role that families can play in the …
Gov response: The Government accepts these recommendations. The Drug Strategy acknowledges the invaluable role that families and carers play in supporting people in treatment and recovery, and states that services should ensure that family members and carers …
Accepted
#26 — Inclusion of lived experience in national drug strategy implementation questioned.
Recommendation: We welcome the strategy’s recommendation that the membership of local Combating Drugs Partnerships should include people affected by drug-related harm because it gives people with lived experience a platform to help reduce barriers to treatment and recovery at a local …
Gov response: The Government accepts these recommendations. The Drug Strategy acknowledges that some groups face greater barriers to accessing treatment and recovery support than others. These include women, people from ethnic minority groups, veterans, people experiencing homelessness, …
Not Addressed
#12 — Increase monitoring of synthetic drug trafficking and prioritise heroin dependency treatment.
Recommendation: To mitigate this risk, we recommend the Government, in partnership with the devolved administrations, increase its monitoring of synthetic drugs being trafficked in, and around, the UK, and prioritise supporting people with a chronic heroin dependency into treatment and recovery.
Gov response: UK agencies are highly alert to the threat from synthetic drugs, including synthetic opioids like fentanyl, as well as synthetic cannabinoids and benzodiazepines, which have been linked to drug related deaths in the UK. Combating …
Accepted
#11 — Alarm over synthetic opioid harms and potential shift from heroin dependency.
Recommendation: We are alarmed by the health and social harms of synthetic opioids, such as fentanyl. We are concerned that a reduction in the global supply of heroin will have the effect of people with an opioid dependency turning to even …
Gov response: UK agencies are highly alert to the threat from synthetic drugs, including synthetic opioids like fentanyl, as well as synthetic cannabinoids and benzodiazepines, which have been linked to drug related deaths in the UK. Combating …
Accepted
#8 — Commission national review of anabolic steroid use and launch safe use awareness campaign.
Recommendation: We recommend that the Department commissions a national review of the growing use of anabolic steroids in England as it relates to body image. We further recommend that the Department introduces a national awareness campaign around safe anabolic steroid use. …
Gov response: The government acknowledges the possible link between digitally altered body images and mental health, including the potential harms such a link may cause. Through its work on the OAP , DCMS is considering how the …
Under Consideration
#5 — Require the Gambling Commission to set out plans to improve black market monitoring
Recommendation: While the black market is a risk the Government and Gambling Commission must be mindful of, it should not deter appropriate regulation of the licensed sector. The debate about the threat posed by the black market partly stems from a …
Gov response: 5. The Government’s white paper set out 62 specific policy proposals for the Government, the Gambling Commission, and the gambling industry to take forward in order to implement the reform of gambling regulation. As the …
Under Consideration
#4 — Address unlicensed gambling sites targeting self-excluded users through new legislative powers.
Recommendation: We consider that while it will be important to monitor the size of the black market in response to greater regulation, more pertinent is the fact that, right now, a number of easily-accessible illegal sites are targeting some of those …
Gov response: 5. The Government’s white paper set out 62 specific policy proposals for the Government, the Gambling Commission, and the gambling industry to take forward in order to implement the reform of gambling regulation. As the …
Under Consideration
#3 — Strengthen cross-departmental efforts to protect children from screen addiction and online harms.
Recommendation: For children and adolescents alike the rapid rise of the use of screens and devices has come at a substantial cost and Government needs to do more across departments to protect them from addiction, online harms and the mental health …
Gov response: There is still uncertainty about the relationship between screen time and mental health. Research findings have been mixed and it has been challenging to keep pace with changing technology and practices. In 2019, the UK’s …
Not Addressed
#2 — Screen time harms significantly outweigh benefits for young children, requiring minimal use.
Recommendation: The overwhelming weight of evidence submitted to us suggests that the harms of screen time and social media use significantly outweigh the benefits for young children, whereas limited use of screens and genuinely educational uses of digital technology can have …
Gov response: We will continue to build a robust evidence base on the effectiveness on school mobile phone policies. This will include a call for evidence which will ask questions about schools policies’ on mobile phones. Schools …
Accepted
#27 — Explain recognition and inclusion of lived experience voices in national drug strategy implementation.
Recommendation: We recommend that the Government explain how the voices of people with experience of drug-related harms are being recognised and included in national efforts to implement the strategy.
Gov response: The Government accepts these recommendations. The Drug Strategy acknowledges that some groups face greater barriers to accessing treatment and recovery support than others. These include women, people from ethnic minority groups, veterans, people experiencing homelessness, …
Not Addressed
PPO Death in Custody Recommendations (18)
The Head of Healthcare and the Head of the Substance …
The Head of Healthcare and the Head of the Substance Misuse Service should ensure that healthcare staff: complete follow up COWS assessments and appointments for prisoners who have previously displayed substance misuse withdrawal symptoms, to ensure continuity of care; and …
The Head of Healthcare
The Head of Healthcare should ensure that staff: • carry out a breathalyser test on prisoners who are withdrawing from alcohol when they arrive; and • put an appropriate monitoring plan in place for prisoners withdrawing from drugs or alcohol …
The Prison Group Director for women’s prisons
The Prison Group Director for women’s prisons should write to the Ombudsman setting out what he has done to satisfy himself that there is sufficient healthcare presence in the first night centre; that prison staff working in the first night …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all prisoners arriving with or developing signs of drug or alcohol withdrawal are regularly monitored, including clinical observations overnight and during the day, until they are stable.
The Head of Healthcare
The Head of Healthcare should consider, in collaboration with CGL and addictions services, how to ensure that a full physical and addictions assessment might be carried out if a prisoner is repeatedly showing signs of drunkenness.
The Head of Healthcare
The Head of Healthcare should ensure that the substance misuse team considers a prisoner’s substance misuse history and custodial behaviour when assessing the required level of substance misuse support.
The Head of Healthcare
The Head of Healthcare should ensure that all patients undertaking alcohol withdrawal are clinically monitored in line with local procedures.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who report acute symptoms receive timely medical appointments.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review the presence of healthcare and substance misuse staff in the First Night Centre.
The Governor, Head of Healthcare and Service Manager for Change, …
The Governor, Head of Healthcare and Service Manager for Change, Grow, Live should work together to ensure that referral processes to the service are clear and established and that all staff understand when and how to refer a prisoner to …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a communication plan in place between OMU and the mental health team so that referrals to the PIPE programme are progressed and prisoners are updated about the status of …
The Local Delivery Unit Manager of North & Northeast Lincolnshire …
The Local Delivery Unit Manager of North & Northeast Lincolnshire Probation Service should ensure that community offender managers check that necessary referrals have been made to community-based support services prior to release.
Head of Yorkshire and Humber Probation Delivery Unit
Mr Bennett’s COM did not refer him to community substance misuse services prior to his release because Mr Bennett said he would self-refer if he needed support after release. We consider that given Mr Bennett’s history of drug and alcohol …
The Governor of HMP Lewes
The Governor will wish to assure himself that robust actions are being taken to prevent medication being illicitly traded and that prisoners receive appropriate substance misuse support following intelligence that this is occurring.
Healthcare staff at HMP High Down (Central and Northwest London …
As prisoners are sometimes unwilling to share information or engage during the initial health screen, it would be helpful if healthcare staff routinely review prisoners’ medical records during their initial health screen to identify if there is a history of …
The Head of Healthcare (HMP Erlestoke)
The Head of Healthcare should ensure that all contact and interventions with prisoners under the care of the substance misuse service are properly recorded.
The Probation Service
The Probation Service should ensure that AP staff conduct daily alcohol tests for residents awaiting alcohol tags to be fitted.
The Head of Healthcare (HMP Eastwood Park)
The Head of Healthcare should consider including within their withdrawal observation policies, a specific process to support and guide healthcare staff on how to assess and monitor a patient’s level of hydration in the event of prolonged vomiting or diarrhoea …
IMB Annual Reports (10)
Dovegate (2024)
HMP Dovegate, a privately run Category B training prison for men aged 21 and over, operated at or near its 1160 operational capacity during the reporting year. The Board observed generally calm wings with good staff-prisoner relationships and commended improvements in education. Key concerns include three deaths in custody, long healthcare and mental health transfer waiting times, persistent issues with lost property during transfers, and regime restrictions due to tight staffing levels exacerbated by a more complex prisoner population.
PRISON
Key concerns
Parc (2024)
HMP/YOI Parc, a Category B/C resettlement prison, faced significant challenges including 19 deaths in custody, with a notable cluster of drug-related fatalities, and high levels of self-harm and violence, though a downtrend was observed towards the end of the reporting period. Persistent concerns included poor food quality and quantity, insufficient keyworkers, and ongoing issues with property transfers. Healthcare provision was strained by excessive waiting times for GP and mental health services, and staff shortages, though some improvements were noted in healthcare access and anti-drug measures.
PRISON
Key concerns
Cardiff (2025)
HMP Cardiff saw a significant reduction in self-harm, use of force, and violence incidents this year, alongside positive developments like the Launchpad project and improved GP services. However, the Board remains concerned about persistent issues such as severe staffing shortages in healthcare, particularly nursing and pharmacy, and delays in mental health transfers. Prison conditions, including heating, water, and accessibility, continue to be problematic, and the key worker scheme needs greater prioritisation amidst ongoing population pressures.
PRISON
Key concerns
Berwyn (2021)
HMP Berwyn, a category C resettlement prison, experienced its first period near full operational capacity during a reporting year largely impacted by the Covid-19 pandemic. Despite restrictions, the IMB found the establishment safe with generally good staff-prisoner relationships and efforts made to provide education and essential work. However, significant concerns persisted regarding infrastructure defects (heating, paint), lengthy healthcare waiting times, and delays in transferring prisoners with mental ill-health or those eligible for Category D.
PRISON
Key concerns
Dovegate (2022)
HMP Dovegate, a Category B training prison, operated in a calm and settled manner despite ongoing Covid challenges and staff shortages. The Board commended improvements in staff culture, the effective use of body-worn cameras, and the high standards of cleanliness and food provision. However, significant concerns persist regarding the lack of a national electronic system for property transfers, the slow progress on converting the healthcare inpatient unit, and the increasing number of remand prisoners. The Board has made recommendations to the Minister, Prison Service, and Director to address these issues, many of which have been highlighted in previous reports.
PRISON
Key concerns
Elmley (2022)
HMP Elmley, a local prison, navigated Covid disruptions to improve prisoner experience and reduce violence through increased key work and a young adult strategy. While the Board noted improvements in safety scrutiny, complaint resolution, and resettlement opportunities, significant concerns remain regarding the treatment and information provision for foreign national prisoners by the Home Office. Other challenges include the poor condition of the prison estate, persistent staffing shortages across key departments, and inadequate activity spaces impacting rehabilitation efforts.
PRISON
Key concerns
Haverigg (2022)
HMP Haverigg, an open Category D prison, maintains a safe and settled environment with very low levels of self-harm and violence. Despite significant staffing challenges, particularly in healthcare and offender management, the Board notes improvements in OMU staffing and highly regarded healthcare provision. Key concerns include the ineffective management of transfers from closed estates, inconsistencies across prisons, the need for enhanced IPP prisoner support, and persistent issues with prisoner property and communication from offender managers.
PRISON
Key concerns
Durham (2022)
HMP Durham, a reception and resettlement prison, housed 976 prisoners at year-end, with 61.6% on remand, operating above its certified capacity. The Board commends staff for managing a challenging environment, noting that 93% of prisoners feel safe. Key concerns include persistent overcrowding, the increasing time unsentenced prisoners spend on remand due to court backlogs, and inadequate access to dentistry and certain induction processes. The report highlights improvements in staff attendance at key meetings and UoF monitoring, but also calls for better embedding of BWVC use and addressing regime limitations affecting education and resettlement.
PRISON
Key concerns
Stoke Heath (2022)
HMP/YOI Stoke Heath maintained a safe and positive environment during the reporting year ending March 2022, despite ongoing Covid challenges. Key positives included improved in-cell telephony, good routine GP access, and declining use of force. However, significant concerns persist regarding the slow restoration of the key worker scheme, inadequate vocational training and resettlement support, and persistent delays in dental care and access to mental health beds.
PRISON
Key concerns
Sudbury (2022)
HMP/YOI Sudbury is an open Category D resettlement prison. The Board noted positive improvements in staff-prisoner relationships, healthcare provision, and the availability of work and vocational training opportunities. However, significant concerns remain regarding the extremely outdated accommodation, persistent staff shortages impacting various services, and issues with prisoner property transfers. The report also highlights long dental waiting times and the lack of psychologist services.
PRISON
Key concerns
IMB Recommendations (15)
Wymott (2020)
The Board is concerned that the drug-free therapeutic community has had to be closed during the pandemic (see paragraph 6.6.3), and would seek reassurance that it will be reinstated.
Governor / Director
Bronzefield (2023)
The Board has noted that there has been a severe and sustained shortage of staff provided by The Forward Trust for recovery services. How does NHS England plan to address this issue as a matter of urgency?
NHS / Healthcare Provider
Erlestoke (2025)
Is access to nicotine replacement therapy being considered, given the high incidence of issues relating to vapes (especially debt)?
NHS / Healthcare Provider
Norwich (2021)
Will the recognition of local need carry through to priority allocation of drug rehabilitation services in HMP/YOI Norwich?
Ministry of Justice
Wayland (2022)
The Board considers that there might be thought given by the Minister to a consideration of post-release drug treatment perhaps through a new sentence licence requirement, given the links now, operationally, through the combined Prison and Probation Service.
Ministry of Justice
Buckley Hall (2022)
Provide additional funding for the prison’s new incentivised substance free living unit.
HMPPS
Leicester (2023)
What plans does the governor have for working with the healthcare provider to ensure a full range of services are available for those who wish to reduce or cease their substance misuse?
Governor / Director
Highpoint (2020)
The Board hopes the provision of a dedicated wing for those prisoners wanting to engage fully with drug recovery programmes can go ahead in the near future.
Governor / Director
Isle of Wight (2024)
All positive drug test results are forwarded by security to the substance misuse treatment team so that support can be provided. Could a similar centralised approach be adopted so that the inclusion team is notified when a prisoner is under the influence or alcohol is found in their cell?
Governor / Director
Preston (2024)
An increase in the accommodation allocated to this project [F wing initiative (incentivised substance free living)] has the potential to increase the number prisoners that could benefit.
Governor / Director
Bronzefield (2024)
How does NHS England plan to address the shortage of GPs, nurses, and substance misuse practitioners in Bronzefield? (6.1, 6.5)
NHS / Healthcare Provider
Whatton (2022)
We ask the minister to look at the evidence and, again, address this issue directly with the Secretary of State for Health and Social Care to support prisons in providing reasonable and timely support for these prisoners.
Ministry of Justice
Foston Hall (2022)
Women with mental health issues and complex needs, including substance misuse, who would be better treated in the health rather than the criminal justice system continue to be sent to Foston Hall. There are delays in transferring prisoners to secure hospital. Are there plans to address these concerns? (See paragraphs 6.3.3, 6.3.5)
Other
Humber (2024)
Additionally, the Board looks forward to considering the proposed sentencing review and hopes there will be a greater emphasis on non-custodial sentences. Can the Minister provide a timeline for the review?
Ministry of Justice
Hewell (2024)
Will the Minister consider alternatives to custodial sentences?
Ministry of Justice
Health Investigations (2)
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must ensure that appropriate support is given to clients wishing to apply for self directed support funding, who are known to have gambling habits.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must ensure that appropriate support is given to clients wishing to apply for self directed support funding, who are known to have gambling habits.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Detention Investigations (3)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R44
G4S and the Home Office should discuss relocating the Forward Trust’s office at Brook House so that detainees have ready access to it. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R15
The SMT should ensure that staff dealing regularly with detainees with mental health problems or with drugs or other substance misuse issues receive specialist training. (To be completed within 3 months)
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 53
I recommend that the Home Office, in association with service providers, consider what can be done to reduce the use of new psychoactive substances and to advise detainees on the effects of their misuse.
Immigration Detention
PHSO Casework Decisions (13)
P-002701 — Leeds and York Partnership NHS Foundation Trust
Mr L complains about the waiting times for an attention deficit hyperactivity disorder (ADHD) assessment at the Trust. He also complains he was not told he could access an alternative NHS funded assessment through the right to choose pathway and about the lack of advice given to him while waiting …
NHS in England
Jun 2024
P-004213 — Mersey Care NHS Foundation Trust
Mr C complains about delays in receiving talking therapy from Mersey Care NHS Foundation Trust and that the therapy wasn't provided on an ongoing basis.
NHS in England
Nov 2025
P-002804 — Torbay and South Devon NHS Foundation Trust
Mr E and Mrs O complain about the how the Trust managed their father’s withdrawal from alcohol during his admission.
NHS in England
Upheld
Jul 2024
P-003489 — Humber Teaching Hospitals NHS Foundation Trust
Mrs H complains the Trust delayed offering a specialist psychiatric assessment, treatment, intervention or support to her son after his ADHD diagnosis, despite his ADHD report stating the importance of medicating him straight away.
NHS in England
Apr 2025
P-003476 — Psychiatry UK
Mr A complains Psychiatry UK removed him from its waiting list for attention deficit hyperactivity disorder (ADHD) medication titration. He complains it wrongly his removal was due to his lack of engagement with the process.
NHS in England
Apr 2025
P-003806 — County Durham and Darlington NHS Foundation Trust
Ms M complains County Durham and Darlington NHS Foundation Trust delayed a referral and a funding application for her son to see an eating specialist in May 2022.
NHS in England
Partly Upheld
Aug 2025
P-004241 — A practice in the Tameside area
Mr C complains the Practice failed to provide appropriate care to him in June 2024. He says the Practice refused to give him diazepam, failed to explore treatment options for his pain and acted in a hostile way when it asked him to leave the Practice.
NHS in England
Oct 2025
P-004699 — A practice in the Wealden area
Mrs K complains in November 2024 a Practice in East Sussex did not prescribe medication to help her mental health and sleep. She also says it delayed a referral to metal health services.
NHS in England
Jan 2026
P-001630 — Oxford Health NHS Foundation Trust
Mx U complains the Trust did not put them on the waiting list for an ADHD assessment. They also say the Trust caused delays in their medication and did not prepare for monthly sessions.
NHS in England
Nov 2022
P-001708 — South East London Integrated Care Board
Mr O complains the ICB refused to agree to prescribe fentanyl lozenges to help him manage his ongoing back pain.
NHS in England
Jan 2023
P-003614 — A practice in the Wigan area
Mr B complains the Practice would not prescribe him rescue packs and removed him from the patient list.
NHS in England
Jun 2025
P-003733 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr E complains about his brother's care and treatment from April - October 2019. He told us the Trust did not raise a safeguarding alert when concerns were raised by both his brother and his family about drug dealers taking over his flat.
NHS in England
Partly Upheld
Jul 2025
P-003163 — South Central Ambulance Service NHS Foundation Trust
Mrs X complains the Trust should have done more to prevent her son’s death from alcohol misuse. The day before two ambulances attended her home after him becoming unwell and he refused treatment.
NHS in England
Nov 2024
LGO / SPSO Decisions (9)
21-011-449 — Cambridgeshire County Council
Summary: Mr X complained about support for drug dependence for his late relative Mr Y. The Council which commissioned Change Grow Live, was at fault because there was no review of Mr Y’s long-term prescription of diazepam, no audit of the file and a failure to deal with a request …
LGO (Local Government & …
Other Categories
Upheld
Jul 2022
21-018-980 — We Do Recover CIC
Summary: We will discontinue the investigation into Ms X’s complaint about the care and support received at an alcohol and drug treatment centre as there is nothing more we could achieve. The care provider has offered a refund for the days after Ms X left the facility and has explained …
LGO (Local Government & …
Adult Care Services
Not Upheld
Dec 2022
24-018-275 — West Sussex County Council
Summary: Miss Y complained about a support service commissioned by the Council for people in its area recovering from alcohol and drug misuse and provided to Mr X, her late father. We have found fault, causing injustice, by the service provider in failing to: follow its proper procedure in response …
LGO (Local Government & …
Other Categories
Upheld
Dec 2025
25-001-629 — Change, Grow, Live
Summary: We cannot investigate Mr X’s complaint about the actions of his key workers at a community substance abuse service because it lies outside our jurisdiction. This is because the complaint is not made about, or in connection with, the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Jun 2025
25-003-682 — Broadway Lodge
Summary: We will not investigate this complaint about the actions of Mr X’s Care Provider. This is because the actions
LGO (Local Government & …
Adult Care Services
Aug 2025
22-007-831 — We Do Recover CIC
Summary: We will not investigate this complaint about We Do Recover. This is because the function complained about falls outside of our jurisdiction.
LGO (Local Government & …
Adult Care Services
Oct 2022
201810152 — Tayside NHS Board
C was referred to the board's urology service (specialists in the male and female urinary tract, and the male reproductive organs) via an urgent referral due to suspected cancer. C was diagnosed with transitional cell carcinoma (a type of cancer that typically occurs in the urinary system). C underwent laparoscopic …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2021
24-007-425 — Northumberland County Council
Summary: We will not investigate Mr X’s complaint about the Council not buying them pain relief. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Adult Care Services
Oct 2024
24-003-029 — London Borough of Barnet
Summary: We will not investigate this complaint about the Council’s response to a complaint about alleged drug use by council tenants who are Mr X’s neighbours. We have no jurisdiction to investigate complaints about the management of tenancies by socials housing landlords.
LGO (Local Government & …
Environment And Regulation
Jul 2024