Source · IAPDC
Protecting Lives: A Cross-System Approach to Addressing Alcohol and Drug-Related Deaths within the Criminal Justice System
Published: 14 January 2022
Sector: Cross-cutting
Type: Joint Report
Joint with: Royal College of General Practitioners
Recommendations: 10
Response received
Joint report with the Royal College of General Practitioners examining cross-system approaches to preventing drug and alcohol-related deaths in all forms of state custody. Contains 10 recommendations.
Government response
Joint response from MBDC Ministers Kit Malthouse MP, Victoria Atkins MP, and Gillian Keegan MP (15 March 2022). The response noted the report "with interest" and stated the government's 10-Year Drugs Strategy "From harm to hope" (December 2021) aligns with a number of IAPDC recommendations. Specific actions cited: exploring long-acting buprenorphine availability in prisons, and supplying naloxone to staff in prisons and approved premises. No per-recommendation commitments made.
Recommendations
| # | Recommendation | Addressee | Status |
|---|---|---|---|
| 1 | The number of substance misuse-related deaths in the criminal justice system is still unclear. The last dataset analysed for deaths in prison is now five years old. The Office for National Statistics (ONS) and HMPPS should collaborate again on a review to detail the current size of the problem in prisons, with similar work carried out for deaths on community probation. Understanding who is dying and their characteristics should inform the prioritisation of future work to prevent deaths. | ONS, HMPPS | Open |
| 2 | The use of naloxone as a form of harm-reduction for opioid abuse should be expanded, with training provided to prison staff (and members of the public) to raise awareness of overdose response. The use of naloxone would help prevent deaths associated with opioid overdose in the general public and promote a greater awareness of risks relating to drugs. The rollout of staff training in the use of naloxone is already in place in most Approved Premises. Relevant substance misuse commissioners and community providers should work together to encourage its use. | HMPPS, NHS England, substance misuse commissioners | Open |
| 3 | While funding has been sourced for the rollout of some Court-based Liaison and Diversion services (L&D) and Community Sentence Treatment Requirements (CSTRs), additional resources are still required to ensure greater coverage. Both initiatives help divert individuals with substance misuse problems away from short custodial sentences into treatment and help prevent deaths. However, for these to be effective, community drug and alcohol services need to be adequately resourced by the Ministry of Justice, NHS England and NHS Wales and the Department of Health and Social Care to ensure full coverage and reduce the waiting times between court sentence and treatment starting. Courts need to be informed about the availability of treatment in the community and provided with updates on treatment outcomes and evaluation. | MoJ, NHS England, NHS Wales, DHSC | Open |
| 4 | Drug and alcohol misuse is often associated with, or caused by, wider social and economic issues. A streamlined approach which encourages services to be collaborative, and ideally co-located, is required to enable services to work in an integrated way in response to multiple social needs (including housing, employment, mental and physical health and the effects of prior trauma) and not just achieving abstinence. HMPPS, Ministry of Justice and the Department of Health and Social Care should consider collaborative commissioning of providers, so they become 'catch-all' services rather than providers of a collection of different parts of an individual's recovery. | HMPPS, MoJ, DHSC | Open |
| 5 | NHS England and NHS Wales, HMPPS and the Ministry of Justice should set out a specific approach to substance misuse treatment for women in the criminal justice system and wider community health to account for the large catchment areas of women's prisons and the specific needs and vulnerabilities of women, for example relating to domestic violence and coercion. | NHS England, NHS Wales, HMPPS, MoJ | Open |
| 6 | People are at particular risk of substance misuse-related death when they are in transition between prison and the community. The introduction of 'bridging liaison' roles, created jointly by HMPPS and NHS England and NHS Wales, would reduce the risk of professionals working in silos and ensure continuity in treatment plans. Pre-release work should involve greater outreach from prisons to community services. This has a direct positive impact on an individual's compliance post-release and improves staff awareness of support available in the community. | HMPPS, NHS England, NHS Wales | Open |
| 7 | The increased use of the newly available formulation of prolonged-release buprenorphine as an opioid substitution therapy (OST), given as weekly or monthly injection, would help to reduce risk and improve the continuity of treatment to service users as they move between community and prisons. Substance misuse commissioners and community providers should work together to ensure continuity in its use. | Substance misuse commissioners, community providers | Open |
| 8 | To enable the learning of lessons by services and establishments following a substance-related death, independent recommendations made by investigators and scrutiny bodies should be given to specific owners and made with the clear appreciation as to what changes are realistically possible. Greater attention needs to be paid to communication with, and the respectful involvement of, bereaved families. Recommendations and their responses should be centrally stored by HMPPS so that they can be easily accessed by both operational and policy staff so future deaths can be prevented. This should include jury verdicts as well as matters of concern raised by coroner-written PFDs. The establishment of a national oversight body would serve to ensure timely compliance with recommendations made by coroners and scrutiny bodies. | HMPPS, investigators, scrutiny bodies | Open |
| 9 | Investigators of substance misuse-related deaths should take into account both the clinical and security factors relevant to the incident. Where possible, scrutiny bodies should identify where there had been missed opportunities for diversion. Staff from the relevant agencies should be supported by their organisations during the investigation process. | Investigators, scrutiny bodies | Open |
| 10 | NHS England and Health Inspectorate Wales should work in collaboration with investigators to ensure commissioned independent clinical reviewers who assist in investigations into substance misuse-related deaths are qualified and experienced in the subject area. Experienced reviewers should also be involved in investigations into deaths in Approved Premises, where they are currently not utilised. | NHS England, Health Inspectorate Wales | Open |
Report details
- Published
- 14 January 2022
- Sector
- Cross-cutting
- Type
- Joint Report
- Joint with
- Royal College of General Practitioners
- Response date
- 15 March 2022
Status breakdown
| Open | 10 |
Addressees
| ONS, HMPPS | 1 |
| HMPPS, NHS England, substance misuse commissioners | 1 |
| MoJ, NHS England, NHS Wales, DHSC | 1 |
| HMPPS, MoJ, DHSC | 1 |
| NHS England, NHS Wales, HMPPS, MoJ | 1 |
| HMPPS, NHS England, NHS Wales | 1 |
| Substance misuse commissioners, community providers | 1 |
| HMPPS, investigators, scrutiny bodies | 1 |
| Investigators, scrutiny bodies | 1 |
| NHS England, Health Inspectorate Wales | 1 |