Amer Fareed

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Amer Fareed,
a prisoner at HMP High Down,
on 8 August 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist HM Prison and Probation Service in ensuring the standard of
care received by those within service remit is appropriate, our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of systemic
failure.
Mr Amer Fareed died from synthetic cannabinoid toxicity on 8 August 2023 while a
prisoner at HMP High Down. He was 40 years old. I offer my condolences to Mr Fareed’s
family and friends.
The clinical reviewer concluded that Mr Fareed’s clinical care was of a good standard and
equivalent to that which he could have received in the community.
Mr Fareed had a significant history of drug misuse both in the community and in prison.
Throughout his time in prison, he had received support from substance misuse services,
and he had completed a detoxification programme.
Substance misuse in prison is one of the biggest challenges that HMPPS faces, and it is a
complex, multi-faceted problem with no simple answer. At the time of Mr Fareed’s death,
HM Inspectorate of Prisons was inspecting High Down. Their subsequent report, published
in November 2023, identified that the availability and use of drugs in the prison threatened
the prison’s stability and contributed to debt, bullying and fear.
High Down has been working hard to tackle the issue of drugs and should continue to
prioritise and undertake the actions required to reduce the availability of drugs within the
prison.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 26 April 2023, Mr Amer Fareed was convicted of harassment without violence.
He was sentenced to four months in prison.
2. After periods at HMP Thameside and HMP High Down, Mr Fareed was transferred
to HMP Peterborough on 10 July, where he was referred to the substance misuse
service because of his history of misusing drugs. He told staff that he was
constantly thinking about cocaine.
3. On 3 August, Mr Fareed returned to High Down. During his initial health screen, he
said he did not have any current issues with drugs. However, it was noted that he
had a history of substance misuse. He was not referred to the prison’s substance
misuse service.
4. On 8 August, Mr Fareed confided to another prisoner that he had bought Spice (a
substance containing one or more synthetic cannabinoids).
5. At approximately 8.36pm, an officer who was conducting the evening welfare check
saw that Mr Fareed was lying on the floor with his head against a pipe. He called
out to Mr Fareed and, when he did not respond, he radioed for assistance.
6. When the officers went into the cell, they found Mr Fareed unresponsive and not
breathing. Staff immediately began chest compressions.
7. At 9.04pm, paramedics arrived on the scene and pronounced Mr Fareed dead
shortly afterwards.
8. The post-mortem report concluded that he died from synthetic cannabinoid toxicity.
Findings
9. Mr Fareed’s death from synthetic cannabinoid toxicity indicates that he was able to
source and use illicit drugs in prison. High Down has appointed a Head of Drug
Strategy who leads on ensuring that their drug strategy remains current and actions
to tackle illicit substances are progressed.
10. Despite having a significant history of substance misuse, Mr Fareed was not
referred to the prison’s substance misuse service when he arrived at High Down.
11. There was a delay in paramedics attending the emergency. The ambulance had to
wait outside the prison for approximately four minutes before they were allowed in.
It then took a further four to five minutes for them to move through the security
checks. We note the ongoing work between HMPPS and health partners to address
the delays in ambulance staff entering prisons and that HMPPS have recently
published a new policy for staff which provides guidance on the items with which
ambulance staff are permitted to enter the prison.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
12. HMPPS notified us of Mr Fareed’s death on 8 August 2023.
13. The investigator issued notices to staff and prisoners at HMP High Down informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
14. The investigator obtained copies of relevant extracts from Mr Fareed’s prison and
medical records, CCTV footage, body-worn video camera footage and prison
telephone calls. The investigator listened to Mr Fareed’s telephone calls but was not
able to understand all of what was said due to strong accents and the use of slang.
15. The investigator interviewed seven members of staff and one prisoner at HMP High
Down on 29 August and 3 October 2023. He carried out one further interview by
Microsoft Teams on 26 October 2023.
16. Another investigator took over the investigation in July 2024.
17. NHS England commissioned a clinical reviewer to review Mr Fareed’s clinical care
at the prison. She was present for six of the interviews with staff.
18. We informed HM Coroner for Surrey of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
19. The Ombudsman’s office contacted Mr Fareed’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not reply.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out a factual inaccuracy, and this report has been amended
accordingly.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP High Down
21. HMP High Down is a category C prison in Surrey. It was re-categorised from a local
to a training and resettlement prison in April 2022. Central and Northwest London
NHS Foundation Trust provide the physical and mental healthcare services at High
Down. Healthcare staff work in the prison between 7.30am and 8.00pm from
Monday to Friday and from 8.00am to 8.00pm on Saturday and Sunday. Forward
Trust provides substance misuse services. The prison has a substance misuse
treatment unit and an incentivised substance-free living unit.
HM Inspectorate of Prisons
22. The most recent inspection of HMP High Down took place in August 2023 and their
inspection report was published in November 2023. One of their priority concerns
was the availability and use of illicit drugs, in particular psychoactive substances
and the threat they posed to the prison’s stability.
23. HMIP identified that 45% of prisoners had said that it was easy to get hold of drugs
(compared to 31% in comparable prisons). They said that mandatory drug testing
had only resumed in February 2023 and that the positive drug testing rate in the
previous three months was very high at 33.73%, with the rate for psychoactive
substances alone at 21.08%. This was among the highest rates in adult male
prisons in England and Wales.
24. HMIP noted that there had been five Governors since 2018, leaders had not
sufficiently prioritised tackling the availability of drugs in their self-assessment report
and staff shortages had led to delays in analysing intelligence, with only a quarter of
suspicion drug tests having been carried out.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to December 2023, the IMB reported
that security intelligence indicated an overwhelming presence of illicit items, with
drugs ‘finds’ increasing from 195 in 2022 to 1,641 in 2023.
26. The IMB said that drones and ‘throwovers’ (where items were thrown over the
prison walls) appeared to be the main source of illicit items entering the prison, as
well as items being passed by visitors. It was noted that towards the end of 2023,
perimeter patrols were undertaken, and the prison had worked with external
partners to deal with the drones.
Previous deaths at HMP High Down
27. Mr Fareed was the tenth prisoner to die at High Down since August 2020. Seven of
the previous deaths were from natural causes, two were self-inflicted and one was
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
drug-related. There are no significant similarities between our findings in this
investigation and those of the previous deaths.
Psychoactive Substances (PS)
28. The term ‘psychoactive substances’ is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazenes) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
29. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
Background
30. Mr Amer Fareed had served a number of previous custodial sentences for drug-
related offences and offences against the person and property.
31. He had a significant history of substance misuse in the community and in custody.
Mr Fareed was involved in the prison drug culture, and on a number of occasions,
he had been found under the influence of illicit substances for which he needed
medical intervention. Throughout his time in prison, Mr Fareed had extensive
substance misuse interventions, he had been advised about relapse prevention and
drug tolerance and had completed detoxification programmes.
32. On 26 April 2023, Mr Fareed was convicted and sentenced to four months in prison
for harassment without violence. He was sent to HMP Thameside.
33. During his reception health screen, Mr Fareed told staff that he had a problem with
drugs, and they identified that he would need to complete a detoxification
programme for pregabalin (a prescribed drug used to treat neuropathic pain,
seizures and generalised anxiety disorder but widely misused). This was completed
on 8 June.
HMP High Down
34. On 23 June, Mr Fareed transferred to HMP High Down. During the first night
reception health screen Mr Fareed’s previous history of substance misuse was
identified, but no referral was made to the prison’s substance misuse team. No
further issues about substance misuse were identified at the secondary health
screen which took place three days later.
35. On 6 July, during a routine check of the condition of Mr Fareed’s cell, staff found a
quantity of “fermenting liquid” hidden behind a bed panel. Mr Fareed was charged
with possession of an unauthorised substance.
36. On 7 July, arrangements were put in place to transfer Mr Fareed to HMP Leeds for
a court appearance a few days later.
HMP Peterborough
37. On 10 July, Mr Fareed was due to be transferred to Leeds. However, because the
escort vehicle was late, Mr Fareed was taken to HMP Peterborough. At the first
night reception health screen, Mr Fareed, who said he had no current substance
misuse problems, was identified as having a significant drug history. The prison’s
substance misuse team offered him support but he declined it. Despite declining, Mr
Fareed was referred to the substance misuse team.
38. On 19 July, the substance misuse service saw Mr Fareed. He said that he had
taken illicit substances since the age of 14 and had also sold illicit substances. Mr
Fareed said that he had stopped using drugs before but that there were triggers
which caused him to relapse, which included smells, places, people and difficult life
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
events. Mr Fareed was given harm minimisation advice and was told about drug
tolerance levels. Mr Fareed said that on release, he wanted to be referred to
community drug support services, to be trained how to use naloxone and given a
naloxone kit. (Naloxone is a life-saving medication which can be self-administered
to reverse opioid overdose rapidly.)
39. On 26 July, the prison’s substance misuse team saw Mr Fareed. He said that
although he was doing well, cocaine was always on his mind. He said that he had
been trying to keep himself busy and had been doing a gym course and praying.
HMP High Down
40. On 3 August, Mr Fareed was transferred back to High Down. A nurse completed the
first night reception health screen and recorded that Mr Fareed was agitated. He
noted Mr Fareed’s history of substance misuse but also noted that Mr Fareed had
said that he had no current substance misuse issues. The nurse recorded ‘N/A’ in
response to whether Mr Fareed had had any substance misuse problems in the last
three months.
41. The nurse told us that during the first reception screen, it was not always possible to
get the prisoner to engage fully as they could be tired and preoccupied with other
issues. He said that when he carried out the health screen with Mr Fareed, he
completed the template questions but did not review his history. He also said that
there was not always time to talk through issues, and instead, these would be
considered (and referrals made) at a later stage.
42. The nurse told the investigator that Mr Fareed was impatient to sort out his property
and get to the wing and was not willing to engage. He recorded that Mr Fareed had
a history of heroin, cocaine and methadone misuse. He did not refer him to the
prison’s substance misuse team and was unable to clearly explain during his
interview why he did not do this.
43. Mr Fareed was taken to the induction wing and, that evening, he told his sister by
telephone that he had moved back to High Down.
44. On 4 August, Mr Fareed completed his secondary induction. He told staff that he
had been in contact with his family and wanted to take part in education or work as
this might stop him reoffending on release. Mr Fareed said he was preparing for his
release and felt okay.
45. During the afternoon, Mr Fareed telephoned his sister. He asked her to transfer
money because he wanted to buy a box of vapes. Mr Fareed gave his sister the
account details of a woman. Mr Fareed’s sister asked him if he was going to spend
the money on drugs. He denied that he would. Mr Fareed’s sister transferred the
money to the woman’s account while they spoke on the telephone.
46. On 5 August, shortly after midnight, Mr Fareed spoke to one of his brothers, brother
A. Mr Fareed told his brother that he had returned to High Down.
47. Later that day, a nurse completed Mr Fareed’s secondary health screen, which
focused on his mental health and wider healthcare needs. There were no questions
about his substance misuse. She told the investigator that unless the person was
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
undertaking opiate substitution therapy, she would not normally discuss drug issues
at the secondary screen. She said that this should happen at the initial reception
screen.
48. On 6 August, Mr Fareed spoke to a second brother, brother B. They talked about
general domestic matters, other people’s bank accounts and various people owing
money.
49. At 2.35pm on 7 August, Mr Fareed phoned a male friend and asked him to transfer
money into another person’s account by the end of the night. Mr Fareed appeared
to talk about “deals” and gave a woman’s bank details. Mr Fareed told his friend
that he could buy canteen with the money and asked his friend to use a particular
reference, a male name, when making the transfer. The person told Mr Fareed that
he would transfer the money.
50. At 6.36pm, Mr Fareed spoke to his male friend again. The person told Mr Fareed it
would be “done” in five minutes, and they talked further about other transactions
and the woman whom they had previously discussed was mentioned again.
51. Mr Fareed spoke to brother B twice that evening. In the second call, he gave him
the details of the woman they had previously discussed. He asked for the money to
be transferred before midnight.
52. At 8.37pm, Mr Fareed spoke to his male friend who told Mr Fareed that it had been
“done”. They referred to a male name in their conversation.
Events of 8 August 2023
53. At 11.55am on 8 August, Mr Fareed spoke to brother B and asked him if he had
transferred the money as requested. The conversation that followed indicated that
Mr Fareed intended to use drugs and that his brother understood this. Mr Fareed
told his brother that he was running out of telephone credit and would call back
later.
54. At approximately 4.55pm, CCTV footage shows that Mr Fareed returned to his cell
with his evening meal. Shortly afterwards, he was seen walking around the wing,
engaging with prisoners.
55. At 5.19pm, CCTV footage shows that Mr Fareed walked along the wing landing with
another prisoner, Prisoner A. They both went into Mr Fareed’s cell. The prisoner
was in the cell for approximately one minute before he left and walked along the
landing to the stairs.
56. Prisoner A told the investigator that he had met Mr Fareed for the first time that day.
He said he went to Mr Fareed’s cell to give him a vape capsule and Mr Fareed had
offered him Spice. Mr Fareed told him that he had got it from someone in house
block two. He said that he had refused, and, after a short conversation, he left and
returned to his cell.
57. CCTV footage showed that a short while later, Mr Fareed left his cell and spoke to
another prisoner. At approximately 5.29pm, Mr Fareed returned to his cell and an
officer locked his door.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
58. The officer said he completed the routine roll check at around 5.30pm and at the
time, Mr Fareed was standing in his cell, reading a letter which had been given to
him earlier that day. He said that he did not speak to Mr Fareed, and he saw
nothing to suggest he was under the influence.
59. At approximately 8.36pm, an Operational Support Grade (OSG) began carrying out
prisoner welfare checks (when the officer opens the cell observation panel to check
that the prisoner is present and safe).
60. At 8.38pm, the OSG arrived at Mr Fareed’s cell and looked through the cell
observation panel. He told the investigator that the television was on, and Mr
Fareed was lying on his front on the floor, with his head leaning against a pipe on
the wall. He said that it was not unusual for prisoners to lie on the floor. He knocked
on the door several times, but Mr Fareed did not respond. He said he then looked
more closely to see if Mr Fareed was breathing and radioed for assistance at
8.39pm.
61. CCTV footage shows that at 8.41pm, the OSG radioed again. He told us that when
he could not see any signs of breathing, he called an emergency code blue (which
triggers the control room to call an emergency ambulance). The control room
recorded that a code blue was heard at 8.40pm and that they were on hold to the
ambulance service at 8.43pm.
62. At 8.42pm, two officers arrived at Mr Fareed’s cell. Officer A opened the door and
went in, followed by Officer B, who switched on his body-worn camera. Officer A
spoke to Mr Fareed but there was no response. The officers moved Mr Fareed
away from the pipe and rolled him onto his back. Officer A then checked to see if he
was breathing and asked the OSG, who was standing outside the cell, to collect the
emergency bag. He then began chest compressions.
63. At 8.43pm, the OSG arrived with the emergency bag. Officer B called through to the
control room to tell them that they had started chest compressions. The control
room confirmed that they were on hold for the ambulance service. The ambulance
records show that the call connected at 8.45pm and was answered at 8.46pm.
64. At 8.46pm, Officer A asked for two response officers to let the ambulance in at the
gate.
65. At 8.53pm, the ambulance arrived at the prison gate, but no one was there to
provide access. The paramedics remained outside until 8.57pm. At 9.02pm, the
ambulance was still waiting to complete the prison’s security procedures.
66. CCTV showed that the ambulance crew arrived at the cell at 9.04pm and Mr Fareed
was pronounced dead at 9.23pm.
67. At 2.05am on 9 August, the police attended and searched Mr Fareed’s cell. They
seized a vape pen, the tip of a vape pen, part of a vape and a ripped up playing
card. Following a forensic test on 29 September, the police identified that the vape
contained residue which tested positive for MDMB-4en-PINACA (a synthetic
cannabinoid).
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contact with Mr Fareed’s family
68. The Deputy Head of Safer Custody was appointed as the family liaison officer
(FLO). Records indicate that the prison asked the police to visit Mr Fareed’s next of
kin, but they did not receive a response. At 10.33am on 9 August, the FLO and a
colleague visited Mr Fareed’s sister, but no one was at home. They subsequently
notified her of Mr Fareed’s death by phone and a short while later, they met her at
her home.
69. In line with national policy, the prison contributed to the costs of Mr Fareed’s
funeral.
Support for prisoners and staff
70. After Mr Fareed’s death, the Head of Safer Custody debriefed some of the staff
involved in the emergency response to ensure they had the opportunity to discuss
any issues arising, and to offer support. The staff care team also offered support.
71. The prison posted notices informing other prisoners of Mr Fareed’s death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Fareed’s death.
Post-mortem report
72. A post-mortem examination was carried out on 15 August 2023 and samples of Mr
Fareed’s organs and bodily fluids were sent for toxicological analysis. The
toxicologist identified a synthetic cannabinoid, MDMB-4en-PINACA (or its
metabolite) in Mr Fareed’s blood and urine samples. Synthetic cannabinoids are
substantially more toxic than natural cannabinoids, as found in the cannabis plant.
In view of this, the pathologist concluded that the cause of death was MDMB-4en-
PINAC toxicity.
Outcome of inquest
73. The inquest into Mr Fareed’s death was held on 23 June 2025 and a verdict of
death as a consequence of taking synthetic cannabinoid MDMB-4en-PINACA whilst
in custody was recorded.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Clinical Findings
Clinical care
74. The clinical reviewer found the care Mr Fareed received was of a good standard
and was equivalent to that which he could have expected to receive in the
community. However, she identified a lack of clarity about the role of the reception
screen in relation to historic substance misuse and harm reduction and that the
details captured at previous prisons were not reviewed effectively.
75. The nurse who conducted the initial health screen told the investigator that he
completed the questions in the template on the system and that it was sometimes
difficult to get prisoners to engage fully as they were tired or distracted. Neither of
the two nurses involved in the first and second health screen identified that historic
drug use was a reason to refer Mr Fareed to the substance misuse team.
76. The Head of Healthcare carried out an internal review following Mr Fareed’s death.
The prison has subsequently sent a notice to all healthcare staff to inform them that
they should refer all prisoners who report a history of substance misuse to the
Forward Trust Substance Misuse Service. The Head of Healthcare will want to
ensure there is a robust quality assurance process in place to monitor referrals.
Head of Healthcare to note
77. 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
substance misuse.
Non-clinical findings
Drug strategy at HMP High Down
78. The use of psychoactive substances is a concern across the prison estate and has
a profoundly negative impact on the physical and mental health of prisoners, as well
as being associated with debt and bullying. Mr Fareed’s death is an example of the
dangers of illicit drugs and illustrates why prisons must do all they can to eradicate
their use.
79. The availability of drugs at High Down was identified as a significant issue by HMIP
when they inspected the prison in August 2023. As part of our investigation, we
spoke to the Head of Security and the Deputy Head of Residence. We were also
given a copy of the prison’s drug strategy and the data that they collect and review
at the monthly drug strategy meeting.
80. They told us that PS was the most commonly used drug in the prison and that this
was coming in on paper, clothes and in liquid form. They said that they had
identified that the main route for drugs entering the prison was via drones and
throw-overs.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
81. They told us about a number of actions that they had taken to tackle the problem of
drugs entering the prison, which included photocopying all mail coming into the
prison. They said that there were ongoing initiatives in collaboration with Surrey
police and the local council. They had identified their ‘high risk areas’ where drugs
were coming in and how they were being moved around the prison. As a result,
they were targeting their patrols and searches to these areas and prisoners working
in the designated high-risk areas were subject to enhanced security intelligence
checks.
Action taken since Mr Fareed’s death
82. In January 2024, the prison appointed a Head of Drug Strategy, who leads on
ensuring that the prison’s drug strategy remains current and that the actions are
progressed. In February 2024, HMPPS’ Substance Misuse Group visited High
Down to help them better understand the scale and nature of the problem at a local
level and to make recommendations to help them effectively deal with the issue.
83. As a result of their visit, the Substance Misuse Group gave the prison five key areas
on which to focus. This now forms part of the prison’s action plan. The prison is also
in the process of delivering against the seven actions HMIP identified following their
visit to tackle substance misuse.
84. The prison told us that they have increased their rate of mandatory drug testing and
suspicion-based testing by 10%. From October 2024, the mandatory drug testing
team will not form part of the resource management plan. This means that they will
be able to dedicate even more time to frequent drug testing.
85. Drugs in prison is an ongoing issue facing the prison service and while there are
measures that can be taken to reduce the supply of illicit substances into secure
settings, we are realistic that those intent on supplying drugs will continue to find
ways of doing so. While drug use remains a significant problem, there is evidence
that High Down is continuing to tackle it through a concerted focus and wide-
ranging actions.
Delay in ambulance entering the prison
86. Ambulance records show that the ambulance arrived at the prison at 8.53pm.
87. At 8.54pm, Officer A told one of the other officers at the scene to arrange for
someone to go to the gate to provide access. However, access was not provided
until 8.57pm.
88. Once inside the prison, the ambulance was then held in the vehicle waiting area for
a further four to five minutes. (We have not been able to establish the reason for the
delay.) This meant that the paramedics only reached Mr Fareed’s cell at 9.04pm.
89. While we recognise the importance of maintaining the prison’s security, particularly
during the night state, we are concerned that the ambulance had to wait outside for
four minutes and there was a further delay as they moved through security.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
90. We welcome HMPPS’ updates to the policy framework covering emergency
services’ access (Managing Conveyance of unauthorised and illicit items) in
September which contains guidance for staff on ensuring the swift entrance and exit
of emergency vehicles, including what items emergency service personnel are
permitted. As a result, we make no recommendation.
Good practice
91. Officer A led the prison’s response to the medical emergency very well. CCTV and
body-worn video camera footage showed he had a good command of the situation
and provided clear instructions to his colleagues. He has suggested that staff need
updating on where to find the equipment in the emergency bag.
Adrian Usher
Prisons and Probation Ombudsman March 2025
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE