Prison drug policy enforcement
61 items
1 source
Failures in enforcing prison drug policies, including acting on positive drug tests for non-prescribed substances.
Cross-Source Insight
Prison drug policy enforcement has been flagged across 1 independent accountability source:
61 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (61)
Rajwinder Singh
Concerns: HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Pending
Josh Tarrant (3)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Emmett Morrison
Concerns: HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded for a prisoner with a history of self-harm.
Pending
Fallon Adams
Concerns: There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause fatal over-sedation.
Response: The Trust has reminded prescribing clinicians of expectations regarding assessment and management of sedative burden, re-emphasised documentation standards for clinical observations, and introduced a new harm minimisation advice leaflet for …
Responded
Anthony Binfield
Concerns: A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.
Responded
Sundeep Ghuman
Concerns: Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Response: HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with …
Overdue
Oliver Mulangala
Concerns: The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety concerns.
Response: HMPPS is investing over £40m in physical security measures across 34 prisons in 2025/2026, including anti-drone technology, and all adult male closed prisons are equipped with X-ray body scanners. They …
Overdue
Steven Ruddick
Concerns: Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent search was also potentially inadequate.
Responded
Derrion Adams
Concerns: Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing levels may be insufficient to manage these challenges.
Response: HM Prison and Probation Service has implemented Incentivised Substance Free Living Units in 85 prisons, embedded Drug Strategy Leads, and introduced the Adult Health, Care and Wellbeing Core Capabilities Framework. …
Responded
Samuel Stewart
Concerns: No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for support and policy enforcement.
Response: Practice Plus Group clarifies that healthcare was not informed of the positive drug test, which prevented them from taking action. They then detail their existing process for managing positive drug …
Response: HM Prison and Probation Service confirms that following a positive drug test on an ISFL wing, prison staff are required to refer the prisoner to the Forward Trust, who then …
Overdue
Matthew Singh Prevention of future deaths report
Concerns: High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
Response: HMPPS has implemented physical security enhancements, including anti-drone measures and window improvements, and invested over £40 million this financial year. They have also established Incentivised Substance Free Living Units in …
Overdue
Declan Carr
Concerns: Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
Response: NHS England confirmed that a national pathway for transferring non-clinical healthcare information, including psycho-social support, between prisons was implemented on 24 November 2025. They also conducted an audit confirming 100% …
Responded
Martin Collins
Concerns: The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Response: HM Prison and Probation Service confirms initial discussions are underway with BT to explore the technical feasibility of implementing automated monitoring of prisoner call volumes, with this work to be …
Overdue
Lewis Petryszyn
Concerns: Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed care and intervention from the Dyfodol service.
Overdue
Sheldon Jeans
Concerns: The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.
Responded
Gavin Wheale
Concerns: The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with concealed items.
Responded
Isaiah Olugosi
Concerns: A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
Responded
Jonathon Lawlor
Concerns: Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
Responded
Amanda Richardson
Concerns: Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a mental health hospital allowed illicit drugs to be present.
Overdue
Liam Turner
Concerns: It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.
Responded
Kane Boyce
Concerns: Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Responded
John Singleton
Concerns: The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround is inefficient and poses significant risks.
Responded
John Pace
Concerns: A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk to future prisoners' safety.
Overdue
Steven Sanders
Concerns: An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses significant risk to vulnerable patients with mental illness and compromised judgment.
Overdue
Kristopher Tilbury
Concerns: HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.
Overdue
Stephen Weatherley
Concerns: Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Responded
Christopher Ryan
Concerns: The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.
Responded
Thomas Smith
Concerns: Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks or patient care plans, compromising safety.
Overdue
Ian Miller
Concerns: A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Overdue
Kyle Nel
Concerns: The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.
Responded
Anthony Clacher
Concerns: A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.
Responded
Daniel Coleman
Concerns: Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.
Responded
Luke Jones
Concerns: Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.
Overdue
Neville McNair
Concerns: Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no clear local protocol existed for its use.
Responded
Mark Jarvis
Concerns: The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.
Overdue
Imran Mahmood
Concerns: E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related to both illicit drug use and potential fires.
Responded
Martin Haines
Concerns: Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented responsibility across multiple agencies with poor communication and separate IT systems.
Responded
Leroy Medford
Concerns: Police officers were critically unaware of a mandatory Drugs SOP requiring in-cell observation, highlighting systemic failures in how police training is delivered, monitored, and confirmed as taken up.
Overdue
Stephen Harte
Concerns: Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not being searched upon entry.
Responded
Andrew Carr
Concerns: Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.
Overdue
Tyrone Givans
Concerns: Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to significant safety concerns within the prison.
Overdue
Ricardo Holgate
Concerns: Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.
Overdue
Natasha Chin
Concerns: Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.
Overdue
Daniel Stokes
Concerns: Prison healthcare staff lacked training and authorization to administer diazepam, despite having it available, indicating a systemic failure in emergency drug administration protocols for prisoners.
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.
Responded
Andrew Craig
Concerns: Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.
Responded
Timothy Shaw
Concerns: Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.
Overdue
John O’Meara
Concerns: Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.
Responded
Jonathan Palmer
Concerns: There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
Overdue
James Spencer
Concerns: Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.
Responded
Matthew Russell
Concerns: Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.
Overdue
Imran Douglas
Responded
Dean Boland
Concerns: Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, lack of overnight monitoring, and poor external security measures allow widespread drug use and concealment.
Overdue
Kevin Forster
Concerns: HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.
Responded
Liam Smith
Concerns: Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.
Overdue
Sharon Butcher
Concerns: Delays in calling ambulances following emergency medical codes and inconsistent adherence to prison protocols for medical emergencies represent a recurring and dangerous systemic failure.
Overdue
William Anderson
Concerns: Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.
Overdue
Yohannes Kidane
Concerns: Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.
Responded
Edward Devlin
Concerns: Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Overdue
Wayne Broad
Concerns: There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees also need alignment with best practice.
Response: The Department of Health clarifies that local arrangements exist for substance misuse liaison in police custody, and that providing specialist nurses in hospitals for substance misuse is a local resource …
Overdue
Adrian Johnson
Concerns: Systemic failures in prison healthcare led to inadequate screening and management of tobacco withdrawal, significantly increasing the prisoner's vulnerability and anxiety. This was exacerbated by poor communication and inconsistent ACCT reviews.
Response: NOMS and NHS England agree to give further consideration to identifying tobacco dependence and withdrawal during prisoner screenings. They will reinforce policy regarding segregation unit placement for prisoners subject to …
Overdue