Addiction Support Waiting Times
Excessively long waiting times and delays in accessing addiction support and residential rehabilitation placements.
Source spread
Where this theme appears
This theme appears across 13 independent accountability sources, so the source mix matters as much as the headline total.
78 PFD reports
66 committee recs
2 CQC actions
18 PPO recs
15 IMB recs
10 IMB reports
3 detention investigation recs
22 DHR recs
13 PHSO decisions
9 LGO/SPSO decisions
Browse by source
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.
Prevention of Future Deaths reports(78)— showing 50 strongest matches
Paul Nash
Concerns: The GP surgery did not prioritise an urgent prescription for seizure medication after information about the deceased running out was not fully conveyed. Concerns were also raised about nationwide difficulties for epilepsy patients in obtaining sufficient medication quantities and pharmacy processing delays.
Response (Department of Health and Social Care): • NHS England issued a patient safety incident notification to community pharmacy contractors regarding the importance of supplying time-critical medicines. • NHS England reviewed the Pharmacy First service specification, identifying … (AI summary)
Response (Sundon Medical Centre): • The practice created a Critical Medication List and updated prescribing instructions for epilepsy medications to clearly state the indication and total dose. • A formal process for identifying and … (AI summary)
Responded
Pauline Meredith
Concerns: The coroner identified concerns regarding the lack of a formal medication review process for a patient on long-term, high-dose medication, especially the addition of morphine with alcohol dependence. The report also noted a perceived reluctance by the GP to address family concerns and insufficient engagement with community mental health services.
Response (Browning Street Surgery): • The practice has formally instigated a programme of regular meetings to review all deaths in patients under 50 and will develop criteria to identify complex patients for discussion at … (AI summary)
Overdue
Lee Bonsall
Concerns: The coroner noted that citalopram was given on repeat prescription contrary to guidelines, and questioned if GPs were aware of them. Concerns were also raised about ten-month waiting times for psychotherapy, making it an unviable alternative to medication.
Response (Department of Health): • NICE stated it would review its guidelines on depression (CG90). • The Secretary of State confirmed it would forward the coroner's prescribing concerns to NICE for consideration in their … (AI summary)
Response (Department of Health): • The Department of Health outlined existing guidance and responsibilities for repeat prescribing of medication in England. • The Department of Health and NHS England are committed to developing and … (AI summary)
Responded
Alan Stanfield Browning
Concerns: Mr. Browning was discharged from Somewhere House without his family being informed of accommodation arrangements, and a Friday discharge limited time to secure proper housing. There was also a lack of clarity regarding routine family involvement in discharge planning.
Overdue
Richard White
Concerns: The coroner noted that Hope House lacked a clear and accessible policy or protocol regarding the administration and holding of medication by staff, which was not made known to prescribers or other relevant personnel.
Response (700 Club2): • The organisation stated that it does not store or administer medication to clients as a matter of policy. • The organisation confirmed that if a client voluntarily surrenders medication, … (AI summary)
Responded
Michael Tarratt
Concerns: The coroner raised concerns about the infrequent communication between the Drug and Alcohol team and the GP, and the lack of routine information exchange between services regarding patient prescriptions.
Response (Leicestershire Partnership NHS Trust): • An urgent memo was sent to all Drug & Alcohol team members outlining new standards for GP communication, including initial assessment summaries, quarterly updates, and discharge notifications. • Standard … (AI summary)
Responded
Sindy Woodhall
Concerns: The coroner noted the sale of potentially fatal gases by local retailers to the deceased, despite awareness of her substance use. Concerns were raised regarding the lack of specific legislation or regulatory powers for Trading Standards to prevent such sales.
Response (Trading Standards Institute): • The Trading Standards Institute stated it is a private company and professional body and does not possess powers to intervene in such matters. • It indicated that the matter … (AI summary)
Response (Oldham Council): • The Council stated its officers would visit the trader concerned. • Officers would discuss safety and health implications and moral obligations regarding sales to individuals with addictions. • Officers … (AI summary)
Response (UK Health Security Agency): • The agency has been working with the Department of Health to support efforts to restrict inappropriate access to volatile substances. • The agency has refined the information collected on … (AI summary)
Response (Department of Health): • The Department of Health stated it had been working to support efforts to restrict inappropriate access to volatile substances. • The National Treatment Monitoring System was refined to include … (AI summary)
Responded
Graham Darby
Concerns: A specific threat made by Mr Darby to take his own life if evicted, mentioning a knife and rope, was not sufficiently flagged by other agencies to his housing provider, Family Mosaic. This meant Family Mosaic was unaware of the direct threat when making decisions.
Overdue
Anthony Huggan
Concerns: The coroner noted the absence of an appropriate out-of-hours service for drug addiction, which placed an undue burden on emergency services. Concerns were also raised about the timeliness of follow-up checks for patients self-discharging after an overdose.
Response (Bury Council): • The One Recovery Bury service, implemented in April 2014, provides flexible opening hours, including weekends and evenings. • Plans are being developed for early 2015 to enhance flexible service … (AI summary)
Responded
Sian Armstrong
Concerns: The coroner noted a delay in a child receiving required CBT and sought assurances that this therapy would be available to children in a timely manner from North Bristol NHS Trust.
Overdue
William Maskell
Concerns: The coroner noted concerns regarding the absence of a clear protocol for agency and police involvement in student welfare checks, where student privacy appeared to take precedence over welfare, leading to delayed interventions.
Response (William Maskell Response2): • The Trust will work with the university to ensure staff are aware of the quickest means for university staff to gain access to a student's room. • The Trust … (AI summary)
Response (William Maskell): • The University conducted a full review of its processes and procedures for students in crisis and emergency entry to student rooms. • The University will clarify and make more … (AI summary)
Overdue
Darren Mindham
Concerns: The coroner noted that Pentobarbital, a drug commonly used in suicide, is not subject to strict control due to its Schedule 3 classification, indicating a potential gap in reducing access to means of suicide.
Overdue
Richard Breatnach
Concerns: The coroner identified gaps in the online prescribing process, including applications allowing false information without prescriber verification with GPs, and the inappropriate prescribing of excessive dihydrocodeine without direct patient assessment.
Response (NHS England): • NHS England raised the issues arising from this case at the Care Quality Commission National Controlled Drugs Group. • NHS England hosted a multi-agency meeting to discuss issues related … (AI summary)
Overdue
Shane Hardy
Concerns: The coroner noted gaps in support for individuals with co-occurring addiction and mental health issues who disengage from referrals. Concerns also included insufficient inter-agency information sharing and no lead communication agency.
Overdue
Robert Lloyd
Concerns: The coroner noted difficulties in providing supportive treatment for alcohol abusers on the Isles of Scilly due to limited face-to-face support. This was exacerbated by reduced transport services, making it challenging for professionals to travel and engage with service users.
Response (The Health Centre): • The Health Centre met with the Drug and Alcohol Action Team of Cornwall Council to discuss future services and undertook training for two pharmacists. • A new Addaction worker … (AI summary)
Response (Drug Alcohol Action Team): • The Drug Alcohol Action Team has appointed an Adults Recovery Co-ordinator who has commenced fortnightly visits to the islands. • The contract with Addaction will require fortnightly island visits … (AI summary)
Overdue
David Read
Concerns: The coroner identified significant delays in Mr. Read's access to the Community Mental Health Team, noting that a re-referral after a cancelled appointment resulted in a waiting time exceeding 16 weeks.
Response (Norfolk and Suffolk NHS Trust): • The Trust reported that the team is currently fully staffed following recruitment to vacancies. • The Trust stated it would implement a policy to make a phone call to … (AI summary)
Responded
Jamie Pashley
Concerns: The coroner raised concerns about post-detoxification care, asking whether individuals should receive fixed appointments, telephone contact between discharge and first review, and increased availability of an alcohol liaison nurse.
Response (Kings College Hospital NHS Trust): • The Trust is participating in a trial of a more assertive follow-up approach for alcohol dependency patients prior to discharge. • The Trust is considering a business case to … (AI summary)
Overdue
Aaron McCaffrey
Concerns: The coroner noted there is no apparent limit on the amount of loperamide medication that can be purchased from a single store, making it easier to acquire large quantities. This raises concerns due to the potential for misuse and the risk of overdose.
Overdue
Thomas Wall
Concerns: The coroner identifies a lack of local in-patient detox facilities, requiring patients to travel and experience long waiting lists. There is also a need for a more collaborative approach to dual diagnosis patients, noting that separating treatment components exacerbates distress.
Response (Susssex Partnership NHS Trust): • The Trust stated it works closely with partner organisations to achieve a collaborative approach for dual diagnosis patients. • The Trust ensured Public Health England guidance was provided to … (AI summary)
Response (Brighton Hove City Council): • The council detailed the arrangements for inpatient detoxification services, explaining that patients are referred to a unit in London following the closure of local facilities in 2016. • The … (AI summary)
Response (Brighton and Hove Clinical Commissioning Group): • A Dual Diagnosis integrated model has been implemented, including the co-location of 3.5 whole-time equivalent Dual Diagnosis workers with mental health services. • Agreed referral and care pathway protocols … (AI summary)
Overdue
Naomi Sourbut
Concerns: The coroner noted it was unclear whether recommendations from a root cause analysis regarding clients expressing suicidal ideation had been implemented by Devon Partnership Trust, and that protective factors should be in place for individuals indicating intent and means to cause harm.
Overdue
Stuart Campbell
Concerns: The coroner noted that an escalation policy between ADS and Pennine Care was not followed, and ADS workers lacked clear guidance and clinical support. There were also concerns regarding the documentation and facilitation of shared care discussions, especially as the GP had not seen the deceased.
Response (Addiction Dependency Solutions): • All shared care staff will receive additional training and re-training on the standard operating protocol, escalation procedures, and multi-disciplinary shared care discussions by 20th December 2017. • Full care … (AI summary)
Responded
Christopher Hutton
Concerns: The coroner noted that the deceased had not commenced an intensive Probation treatment programme, which was part of their sentence, due to high demand and significant backlogs in allocating places.
Response (HM Prison and Probation Services): • HM Prison and Probation Service stated that work was in progress nationally to increase the number of staff delivering sex offender group work. • It noted that the staff … (AI summary)
Responded
Lakhminder Kaur
Concerns: The coroner noted Mrs Kaur's long-term addiction to zopiclone and identified concerns with the decision to abruptly discontinue the medication to prevent self-harm.
Overdue
John Derwent
Concerns: The coroner noted significant waiting times for CBT, reaching 12 months against a 6-week target due to insufficient capacity. The report also described ineffective escalation mechanisms between the commissioning body and service provider to address the increasing waiting list.
Overdue
Karl Willis
Concerns: The coroner noted the risks of amitriptyline toxicity and raised concerns about a self-certification process for medication access that allowed inaccurate answers, especially when the patient's GP was not informed.
Response (NHS England): • NHS England stated that work is being done to connect NHS services to patients' summary care records to enable clinicians to access a summary of main conditions. (AI summary)
Responded
Scott Carton
Concerns: The report identifies a lack of appropriate psychological support for Mr Carton's emotionally unstable personality disorder and drug dependence in his hostel and prison placements. It also notes insufficient psychological resources for prisoners with similar conditions upon release, impeding successful reintegration.
Overdue
Jerome Jones
Concerns: The coroner identified a lack of policy for additional checks on prisoners with repeat NPS use, especially when combined with existing medical conditions. There was also no method for drug workers to communicate these risk factors to healthcare or prison officers, and drug workers lacked access to medical records to inform their advice.
Response (Shropshire Community Health NHS Trust): • The Trust described its current practice for additional observations following prisoner substance use and referral to Forward Trust staff. • The Trust stated that the Forward Trust is in … (AI summary)
Response (HM Prison Probation Service): • An updated drug strategy was launched at the establishment, and staff were notified of it, including reminders about healthcare staff's responsibility for determining and communicating additional checks for prisoners … (AI summary)
Overdue
Benjamin Williamson
Concerns: The coroner identified gaps in integrated care for patients with co-occurring mental health and substance misuse issues, leading to inadequate support. Insufficient communication and feedback between addiction services and the GP, alongside unaddressed consent for disclosure, compromised ongoing care.
Response (Addaction): • Addaction internally reviewed and improved its processes for recording confidentiality and consent reviews, and reinforced communication protocols with staff. • It introduced a monitoring function into its patient management … (AI summary)
Response (Kernow CCG NHS Trust): • NHS Kernow confirmed the existence of a multi-agency Dual Diagnosis Strategy and held meetings with providers to address identified service gaps. • An exceptional Crisis Care Concordat meeting identified … (AI summary)
Responded
Paul Gillam
Concerns: The coroner identified gaps in the operation of the Cornwall dual diagnosis policy, particularly concerning the interface and working relationship between Addaction and CMHT. Concerns were also noted regarding the development and implementation of their service level agreement delivery plan.
Response (NHS Kernow Clinical Commissioning Group): • A multi-agency steering group has been established to review the Cornwall and Isles of Scilly Dual Diagnosis Strategy and develop an implementation plan. • Meetings have been held to … (AI summary)
Overdue
Matthew Hamilton
Concerns: The coroner identified that heroin users released from custody are often unaware of their reduced drug tolerance after abstinence and the fatal risks of consuming pre-custody drug levels.
Response (HM Prison Probation Service): • The Drug and Alcohol Reduction Team (DART) updated its guidance pack, which will be offered to all prisoners on discharge from HMP Durham and to those with potential release … (AI summary)
Responded
Conor Crutchley
Concerns: The Early Intervention Team lacks specialist drug and alcohol workers, despite many patients having dual diagnoses, and interaction with external providers relies on self-referral. Significant waiting times for talking therapies are also noted due to recruitment challenges.
Response (Pennine Care NHS Trust): • The team is developing roles for dual diagnosis champions to undertake additional training and cascade skills within the team. • An additional psychological therapist post was recruited to, with … (AI summary)
Responded
Justin Brown
Concerns: The coroner noted concerns regarding the hospital's discharge process for addiction patients, specifically the lack of an agreed protocol and insufficient collaboration with commissioned drug services to monitor referrals and patient outcomes.
Overdue
Joanna Flynn
Concerns: The coroner identified a lack of specialised assistance and referral agencies for General Practitioners to help patients wean off addictive prescription opiates. Concerns were also raised about the sufficiency of training and education for GPs in this area of care.
Response (NHS England): • A review group has been established to address dependence on and withdrawal from prescribed medicines, including opiates. • NHS England continues to provide primary care with additional funding, staff, … (AI summary)
Response (the Department of Health and Social Care): • Public Health England published an evidence review in September 2019 on the scale and causes of prescription drug dependence. • The National Institute for Health and Care Excellence (NICE) … (AI summary)
Response (Mid Essex CCG): • The CCG has developed and is implementing a Local Enhanced Service to provide multi-professional expert support and education for GPs and patients managing prescribed opioid dependence. • The CCG … (AI summary)
Overdue
Ricky Barcock
Concerns: The coroner raises concerns regarding the appropriateness of the client wellbeing checks protocol, specifically concerning physical checks during sleep, after drug use, and the need to rouse clients to confirm their wellbeing.
Response (Oasis Recovery Communities): • Oasis Bradford reviewed and updated its Observation and Client Wellbeing Checks Policy in December 2019, expanding its explanation and explicit instructions. • Related risk assessments, policies, and procedures were … (AI summary)
Overdue
Joseph Gingell
Concerns: The coroner raised concerns regarding the toxic effects of drugs when taken excessively with other medication, and that permitting patient "self-certification" without checks and not informing a GP removes safeguards for vulnerable individuals with addiction.
Response (NHS England): • The Care Quality Commission (CQC) inspected all non-NHS online primary care services in England, publishing findings in March 2018. • NHS England stated it would ensure NHS online consultations … (AI summary)
Responded
Holly Chevassut
Concerns: GRS operates vehicles with mirrors and guards positioned less than 2 meters from the road surface and projecting over 20 centimetres from the vehicle's widest point. This configuration is identified as creating a risk of personal injury and death to those overtaken by these vehicles.
Response (GRS Recovery): • GRS Recovery removed wing mirror protectors from Vehicle 2. • GRS Recovery rotated the offside and nearside wing mirrors of both vehicles 1 and 2 by 180 degrees, which … (AI summary)
Responded
Daniel Mervis
Concerns: Oxford University lacks an overarching drug policy for its colleges, and St John's College has a potential conflict between its strict drug misuse policy and the support offered for addiction, which may deter students from seeking help. The college's drug policies also require wider advertisement.
Response (St Johns College Oxford): • A Task and Finish group has been established by the Conference of Colleges to develop a template drug misuse policy for all colleges. • St John's College stated it … (AI summary)
Responded
Natasha Crabb
Concerns: The coroner noted that inhaling butane is lawful with no powers to intervene, and there are no restrictions on the amount that can be purchased, making it easy for addicted individuals to obtain large quantities.
Response (Dept. of Health and Social Care): • Departmental officials made contact with the Home Office regarding powers applicable under the Psychoactive Substances Act 2016. • Information about the dangers of inhaling butane is available on the … (AI summary)
Overdue
Helen Spicer
Concerns: The coroner noted the absence of restrictions on the import, export, possession, or administration of oral morphine, and that safe custody requirements and signing for collection from pharmacies do not apply.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated it works closely with the Home Office and the Advisory Council on the Misuse of Drugs to inform decisions on controlled … (AI summary)
Response (ACMD): • The ACMD's Secretariat developed a standard operating procedure and a watch-list for medicines misuse. • The ACMD agreed to gather further information on the scale of the issue. • … (AI summary)
Responded
Jade Rayner
Concerns: Concerns included Greater Manchester Police not recording or investigating a sexual offence allegation, which affected victim support. There was also an absence of a clear multi-agency strategy for complex cases and insufficient alcohol misuse support for trauma-driven needs.
Response (Greater Manchester Health and Social Care Partnership): • Two multi-agency task and finish groups would be set up to review Section 42 and Multi Agency Adults at Risk System (MAARS)/TAA processes. • Learning from the case would … (AI summary)
Response (Greater Manchester Police): • A central Crime Recording and Resolution Unit has been introduced to ensure crimes are recorded for relevant incidents. • The management of district vulnerability e-mail accounts has been reviewed, … (AI summary)
Responded
Parys Lapper
Concerns: The coroner noted that individuals can easily manipulate the current prescription system due to a lack of a central record for issued prescriptions. This allows people to obtain excess medication from multiple NHS and private providers acting in isolation.
Response (NHS England): • NHS England is supporting the adoption of electronic prescribing solutions across NHS Trusts, with funding provided for over 80% of Trusts. • Work is underway to define common information … (AI summary)
Responded
Steven Allen
Concerns: The coroner noted concerns regarding the prescribing of oxycodone and other medications to an individual with a history of addiction, especially when prescriptions were issued via telephone consultations and replacement prescriptions were given with little challenge.
Response (Stockport Clinical Commissioning Group): • The practice undertook a review of the case and its processes for managing prescribing for vulnerable patients. • The Medicines Management Team is discussing with Primary Care Network Leads … (AI summary)
Responded
Elaine Inns
Concerns: The coroner noted concerns regarding the continued prescription of powerful painkillers, including liquid morphine, to a patient known to consume significant alcohol and not adhere to medication dosage instructions.
Response (Stockport Clinical Commissioning Group): • The practice updated its medication review template to include specific inquiries about alcohol use and other medications for patients on opiates. • Patients identified as drinking while prescribed opiates … (AI summary)
Responded
Jane Bush
Concerns: The report highlights delays in accessing mental health assessments and psychological therapy due to challenges in balancing service capacity with increasing demand, and difficulties in recruiting and retaining skilled staff within the Trust.
Response (Hellesdon Hospital): • The Trust increased assessment capacity by supplementing existing clinicians with agency nurses and extended their contracts. • It secured additional funding for six staff for the Central Youth Team, … (AI summary)
Responded
Nicholas Spooner
Concerns: The coroner identified a need for specialist dual diagnosis services, including outreach and drop-in centres, to support individuals experiencing mental health crises alongside substance abuse, who are often denied mental health care.
Response (BHCC CCG SPFT and CGL): • The CCG commissions a crisis cafe service and is commissioning a new crisis house for 24/7 support, with substance misuse recognised as a priority group. • BHCC and the … (AI summary)
Response (Dept. of Health and Social Care): • The Department has allocated additional funding for addiction treatment and public health grants, and Public Health England has developed guidance for dual diagnosis services. • The Government published an … (AI summary)
Response (NHS Social Care): • Procurement processes for a new crisis house and mental health supported accommodation services have been completed, with contracts awarded and services scheduled to start on 01 November 2022. • … (AI summary)
Overdue
Daniel Hall
Concerns: The coroner identified lengthy delays for students at the University of South Wales in accessing mental health support services, even when suicidal ideation was expressed and risk factors like ASD were known.
Response (University of South Wales): • The University increased the number of staff in its Wellbeing and Disability Service by 37% and introduced new specialist Wellbeing practitioner roles, which reduced student waiting times. • The … (AI summary)
Responded
Daniel France
Concerns: The coroner identified a significant gap in support for vulnerable young people awaiting substantive mental health treatment, exacerbated by long waiting lists for psychological therapies and difficulties meeting urgent intervention criteria. This situation poses risks for individuals at chronic risk of impulsive acts.
Overdue
Claire Copeland
Concerns: Concerns were raised regarding arrangements for delivering physical prescription documents, which lack effective mechanisms to confirm delivery, detect failure, or remedy non-delivery, thereby risking discontinuity of medical treatment.
Response (HumanKind): • Humankind implemented a standard operating procedure for prescription delivery, requiring direct handover to pharmacy staff, obtaining a signature, and recording receipt details. • The standard operating procedure includes a … (AI summary)
Responded
Robyn Skilton
Concerns: Insufficient resourcing and provision within mental health services for young people led to long waiting times for assessments by child psychiatrists, delaying diagnosis and treatment. The increased demand for CAMHS services without corresponding resource increases is noted as unsustainable.
Response (department of Health and Social Care): • The Department stated that the NHS Long Term Plan commits to investing an additional £2.3 billion annually into mental health services by 2023/24. • The Department reported an increase … (AI summary)
Responded
Colin Smith
Concerns: The coroner noted a lack of structured training for all hostel workers regarding identifying risks of alcohol intoxication and recognising signs indicating a need for urgent medical intervention.
Overdue
Select committee recommendations(66)— showing 50 strongest matches
#120 —
Recommendation: We also heard about deferred sentences. Dr Graham told us that Scottish sheriff courts can decide to âdefer sentence for approximately six monthsâ during which the offender is supported and supervised, and to âsentence at the end of thatâ, giving …
Response attribution not verified
#110 —
Recommendation: Justin Russell said that to reduce the criminal activity of low-level, âprolificâ offenders, their rehabilitation âwould need to involve a residential elementâ and âtreatment for mental health and/or drug and alcohol problemsâ, which âwould probably need to involve someone consentingâ …
Response attribution not verified
#107 —
Recommendation: Lord Justice William Davis explained that, according to sentencing guidelines: âThe seriousness of the offence should be the initial factor in determining which requirements to include in a community order.â He added, âif, in the individual case, there is a …
Response attribution not verified
#102 —
Recommendation: Women entering the Criminal Justice System in England and Wales are often the victims of abuse and discrimination, or suffering from trauma, addiction, and mental health issues. Many of them have caring responsibilities. These issues, acknowledged by the Government in …
Response attribution not verified
#91 —
Recommendation: Current efforts to improve treatment services and increase their availability should be sustained. Further investment in Community Sentence Treatment Requirements is required and should be a priority. CSTRs are key to reducing reoffending, putting offenders on a path away from …
Response attribution not verified
#89 —
Recommendation: Many people on probation suffer from mental health issues and from addiction to alcohol or drugs, which fuels their offending behaviour. Few of them are referred to a Community Sentence Treatment Requirement (CSTR). And yet, referrals exceed the availability of …
Response attribution not verified
#85 —
Recommendation: Chris Jennings also told us he was determined to see an increase in the availability of treatment services: âThe Community Sentence Treatment Requirements are the area where I want to see most progress. If we cannot address peopleâs mental health …
Response attribution not verified
#84 —
Recommendation: In the face of such challenges regarding the availability of treatment, Damian Hinds MP told us that âthe Government made a commitment in the 10-year drugs strategy paper From Harm to Hope to making sure that there is a treatment …
Response attribution not verified
#81 —
Recommendation: Referrals exceed availability for drug treatment, too. Justin Russell told us waiting lists âare not hugeâ for community-based drug treatment services commissioned by local authorities. 150 He added that there had been âa big dropâ in the availability of such …
Response attribution not verified
#74 —
Recommendation: For instance, we were told that Alcohol Treatment Requirements âare aimed at those with alcohol dependence, who are thought to require an alternative approach comprising (residential or non-residential) rehabilitative treatmentâ, and that âin such cases, treatment is thought to tackle …
Response attribution not verified
#73 —
Recommendation: Three âCommunity Sentence Treatment Requirementsâ (CSTRs) exist to support offenders on their path away from crime: âthe Drug Rehabilitation Requirement (DRR), the Mental Health Treatment Requirement (MHTR), and the Alcohol Treatment Requirement (ATR)â. 123 Speaking about DRRs specifically, Damian Hinds …
Response attribution not verified
#13 —
Recommendation: A greater proportion of people on probation should be served one or more treatment requirement(s). This could be achieved by implementing our recommendations on Pre-Sentence Reports (see paragraphs 255â259) and on âintegratedâ sentences (see paragraphs 123â127), and through a greater …
Response attribution not verified
#12 —
Recommendation: Many people on probation suffer from mental health issues and from addiction to alcohol or drugs, which fuels their offending behaviour. Few of them are referred to a Community Sentence Treatment Requirement (CSTR). And yet, referrals exceed the availability of …
Response attribution not verified
#94 —
Recommendation: Rebecca Robson, from Womenâs Community Matters, explained that âa lot of the mental health difficulties we see are the result of experiences of domestic and sexual abuse in childhood, and then ongoing domestic abuseâ. She went on to explain that …
Response attribution not verified
#90 —
Recommendation: A greater proportion of people on probation should be served one or more treatment requirement(s). This could be achieved by implementing our recommendations on Pre-Sentence Reports (see paragraphs 255â259) and on âintegratedâ sentences (see paragraphs 123â127), and through a greater …
Response attribution not verified
#87 —
Recommendation: Chief Probation Officer Kim Thornden-Edwards told us about âa new national partnership agreement on health and social careâ, agreed in February 2023. This new partnership, between the Ministry of Justice and the Department of Health and Social Care, âfunds some …
Response attribution not verified
#86 —
Recommendation: To enact such changes, witnesses told us about the âCommunity Sentence Treatment Requirement (CSTR) protocolâ between the Ministry of Justice and HMPPS, on the one hand, and NHS England and Public Health England, on the other hand. 164 The protocol …
Response attribution not verified
#82 —
Recommendation: Even when treatment is available, witnesses told us about delays before it starts. Justin Russell said that âas with services for others living in the community, there are huge waiting lists at the moment for things like mental health treatment, …
Response attribution not verified
#80 —
Recommendation: Witnesses told us that referrals exceed availability and that increasing availability âwould save livesâ, especially in respect of mental health. 145 Tom Franklin told us that âlocal services may not be availableâ to deliver treatment requirements, such that the Probation …
Response attribution not verified
#79 —
Recommendation: Justin Russell argued that treatment requirements âare not used as widely as they could beâ. 137 Speaking specifically about drug treatment, Justin Russell told us that there is a âhuge gapâ between the âneed for specialist treatmentâ and the number …
Response attribution not verified
#72 —
Recommendation: The Government acknowledges that helping people on probation face their addictions or mental health issues helps reduce crime. Damian Hinds MP told us that: âDrug addiction is the fuel, the driver, behind acquisitive crime and all manner of other crimes …
Response attribution not verified
#71 —
Recommendation: We heard that âmany offenders experience mental health and substance misuse problemsâ. 113 His Majestyâs Inspectorate of Probation (HMIP) estimated that, in 2021, âabout 75,000 people being supervised in the community by Probation had a drugs problem linked to their …
Response attribution not verified
#70 —
Recommendation: Of all the reasons why community orders are a key sentencing option, one stands out: they can be tailored to the circumstances of individual offenders. In this chapter, we reflect on how best community orders can fit the individual. We …
Response attribution not verified
#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, …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#10 —
Recommendation: The Government should invest in the services that underpin community orders to satisfy sentencers of their efficiency and availability. The emphasis should be put on intensive treatment, the effectiveness of which is established.
Response attribution not verified
#83 —
Recommendation: And when treatment is nominally available, it is not always completed. Justin Russell said that HMIP had âfollowed an entire quarterly cohort of peopleâ who had been given a Drug Rehabilitation Requirement. They found that âonly half of them had …
Response attribution not verified
#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
Response attribution not verified
#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 …
Response attribution not verified
#10 —
Recommendation: We recommend that, with immediate effect, all National Lottery products should carry GambleAware branding.
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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% …
Response attribution not verified
#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 status not verified
#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 this recommendation, as it echoes the expectations of local delivery of the Drug Strategy as outlined in the guidance for local delivery partners and the Commissioning Quality Standard. Guidance for local partners …
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.
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 this recommendation. In 2023–24 local authorities earmarked over £10 million from the SSMTR grant to improve integrating responses to physical and mental health for people receiving drug and alcohol treatment in the …
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
Response attribution not verified
#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. …
Response attribution not verified
#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
Response attribution not verified
CQC inspection actions(2)
Liverpool Walk in Centre
Review the waiting times for patients for initial assessment/triage to treatments. The provider should improve these waiting times so that services are responsive to the needs of children and young people across each of the Walk in Centre locations.
Should Do
No. 3
The provider must ensure staff have training on detoxification and supporting clients through recovery.
Must Do
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 individual 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
In Progress
Norwich (2021)
Will the recognition of local need carry through to priority allocation of drug rehabilitation services in HMP/YOI Norwich?
Ministry of Justice
Noted
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
In Progress
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
In Progress
Health investigations(9)
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 1
Given the changes in access to Specialist Drug and Alcohol Services the Trust should put in place mechanisms to demonstrate and monitor this improvement. • The Trust should develop a reliable and valid methodology for monitoring: o access to the service; o commencement of treatment. In the first instance this …
south_west
Independent investigation: Hugh McCaffrey, Willesden — Rec 4.81
Many patients with psychiatric disorders also have significant problems with drugs and alcohol. Appropriate specialist services should be accessible and provided locally.
london
Independent investigation: Hugh McCaffrey, Willesden — Rec 4.78
Patients who are unwilling or unable to comply with a care plan should be given special consideration and care. Patients who have, in addition to a mental disorder, problems with drugs or alcohol dependency should be able to access appropriate specialist services, and these should be provided as part of …
london
Independent investigation: Vincent Douglas, Lewisham (2017) — Rec 3
We recommend that the Trust provide training for staff working with patients with complex needs and co-morbid substance misuse problems. This should be designed to ensure that those staff can themselves provide support to such patients, and/or to ensure that they know how, and to whom, to refer.
london
Independent investigation: Vincent Douglas, Lewisham (2017) — Rec 2
Our team recommends that a care pathway be developed by the Trust for submission to the CCG to elaborate treatment and onward referral for patients with complex mental ill health and comorbid substance misuse. The purpose would be to ensure that it is clear to all Trust staff how and …
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.
Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
*Independent investigation into the care and treatment of Mr F: … — Rec R1
The trust should conduct annual audits of NICE quality standards. The board should be provided with evidence that all community mental health teams have access to specialist addiction practitioners and know how to refer to them. We recommend that the trust conducts annual audits to review patient pathways from referral …
Lancashire Care NHS Foundation Trust
north_west
Accepted
Independent investigation into the care and treatment of patient M … — Rec 92
Prison services have considerable expertise in delivering clinical and psychosocial treatments to substance misusers. Users of NPS can be offered the same range of interventions.
east_of_england
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.
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
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
Independent reviews(8)
Carol Black Drugs Review (Part 2) — Rec 2
We recommend that the government invests, by the end of year 5 of this programme, an additional £552 million in the treatment system through DHSC and an additional £15 million in employment support through DWP. MHCLG will also need to bid for additional funds for housing support at the next …
Health & Social Care
Gauke Review — Rec 2.3
Increase investment in providers of Community Sentence Treatment Requirements to increase accessibility for offenders with substance misuse or mental health issues
Justice & Legal
Mental Health Taskforce 2016 — Rec 4
The Cabinet Office should ensure that the new Life Chances Fund of up to £30 million for outcome-based interventions to tackle alcoholism and drug addiction through proven approaches requires local areas to demonstrate how they will integrate assessment, care and support for people with co-morbid substance misuse and mental health …
Health & Social Care
Carol Black Drugs Review (Part 2) — Rec 18
We recommend that MoJ ensure that everyone leaving prison has identification and a bank account and that those who cannot claim benefits online get the opportunity, from the day of release, to access DWP's telephony service. MoJ and its partners should make sure that prisoners with drug dependence can access …
Health & Social Care
Carol Black Drugs Review (Part 2) — Rec 12
We recommend that DHSC, NHSE and the Office for Health Promotion review by the end of 2021 to 2022 the commissioning and funding mechanisms for high-cost but low-volume services such as inpatient detoxification and residential rehabilitation. DHSC should introduce a regional or sub-regional approach to commissioning these services to ensure …
Health & Social Care
Prison Capacity Review — Rec 4
I recommend that both the Chief Inspector of Probation and the third sector should be involved in discussing the design, as well as the delivery, of community services. This should include the engagement and resourcing of essential non-criminal justice support such as addiction, health, housing, and employment services.
Justice & Legal
Carol Black Drugs Review (Part 2) — Rec 16
We recommend that DHSC and NHSE expand their CSTR programme to 100% of the country by the end of this Parliament. NHSE and HMPPS should work closely with local commissioners of substance misuse treatment to seize the opportunity presented by the recently announced increase in funding for such treatment in …
Health & Social Care
Leveson Criminal Courts Review — Rec 6
I recommend further investment in and greater use of rehabilitation programmes for drug and alcohol misuse and other health intervention programmes. This must adhere to a national framework to ensure consistent provision across the country.
Justice & Legal
PHSO casework decisions(13)
P-002701 — Leeds and York Partnership NHS Foundation Trust
Mr L complained about long waiting times for ADHD assessment, failure to inform him of alternative pathways, and lack of coping advice, negatively impacting his mental health and employment.
NHS in England
Jun 2024
P-004213 — Mersey Care NHS Foundation Trust
Mr D complained Mersey Care NHS Foundation Trust's resolution for his C-PTSD support was inadequate, citing delays in starting and lack of ongoing talk therapy.
NHS in England
Nov 2025
P-002804 — Torbay and South Devon NHS Foundation Trust
Mr E and Mrs O complained their father was not adequately monitored or reviewed, and was inappropriately given sedative medication, potentially leading to his unexpected death.
NHS in England
Upheld
Jul 2024
P-003489 — Humber Teaching Hospitals NHS Foundation Trust
Mrs H complained the Trust significantly delayed offering treatment and support, and arranging a specialist psychiatrist, for her son following his ADHD and autism diagnosis, leaving him unsafe.
NHS in England
Apr 2025
P-003476 — Psychiatry UK
Mr A complained Psychiatry UK removed him from their ADHD medication titration waitlist due to an incorrect reason, causing anxiety and a longer wait for medication.
NHS in England
Apr 2025
P-003806 — County Durham and Darlington NHS Foundation Trust
Ms M complained the Trust delayed a referral and funding application for her son to see an eating specialist, causing significant distress and a long-term detrimental impact.
NHS in England
Partly Upheld
Aug 2025
P-004241 — A practice in the Tameside area
Mr C complained the Practice refused him diazepam, failed to explore pain treatment options, and acted hostilely, prolonging his pain and causing stress.
NHS in England
Oct 2025
P-004699 — A practice in the Wealden area
Mr K complained a GP Practice would only prescribe low-dose antidepressants, refused sleeping medication, and sent his wife to A&E instead of mental health services, worsening her condition.
NHS in England
Jan 2026
P-001630 — Oxford Health NHS Foundation Trust
Mx U complained about delays in ADHD assessment, medication, and lack of preparation for monthly sessions by the Trust, which worsened their mental health.
NHS in England
Nov 2022
P-001708 — South East London Integrated Care Board
Mr O complained the ICB refused to prescribe fentanyl lozenges for his ongoing back pain, causing him difficulty walking and severe pain episodes.
NHS in England
Jan 2023
P-003614 — A practice in the Wigan area
Mr B complained the Practice would not prescribe rescue packs, insisted he attend, and removed him from its patient list, causing severe anxiety and depression.
NHS in England
Jun 2025
P-003733 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr E complained the Trust failed to act on concerns about his son Mr A's flat being 'cuckooed,' a call for help, update risk assessments, or communicate with other agencies, leading to his death.
NHS in England
Partly Upheld
Jul 2025
P-003163 — South Central Ambulance Service NHS Foundation Trust
Ambulance crews failed to provide treatment or clinical observations for her son, despite several attendances, not considering his compromised capacity, which Mrs X believes led to his death.
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
Domestic Homicide Reviews(22)
Buckinghamshire — recommendation 3
Buckinghamshire Integrated Care Board to consider the pathway between GP Practices and One Recovery Bucks in order that there is a more seamless route between the two services than merely signposting patients.
Buckinghamshire Integrated Care Board
NHS Buckinghamshire, Oxfordshire and …
Shropshire — recommendation 8.4b
Highlight patients with combination of alcohol / drug abuse and poorly controlled mental health and look at flagging – adding a note or code to the electronic record – that highlights patients at higher levels of concern.
GP Practices
Shropshire — recommendation 8.4a
Increase awareness about alcohol abuse on the wider family - encourage clinicians to keep their view wide when considering management and assessing risk.
GP Practices
Croydon — recommendation 6.1.3.a
AIR Network to ensure that referrals to Turning Point are made as soon as possible after engagement has started. Outcome: An individual’s substance misuse and other complex needs are assessed and treatment and support delivered as soon as possible.
AIR Network
Harrow — recommendation 5
London North West Healthcare NHS Trust to improve increased capability for community alcohol teams to deliver rapid assessment and treatment for difficult to reach patients who attend hospital in a crisis
London North West Healthcare NHS Trust
London North West University …
Harrow — recommendation 3
Harrow Public Health to agree clear guidance in relation to patient choice access issues for the cross boundary provision of local drug and alcohol services
Harrow Public Health
Preston — recommendation 4
The waiting times for MAS should decrease as a result of reviewed care pathways and efficient working practices.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Cannock Chase — recommendation 7
To review referral pathway for addiction services due to non-attendance closing the referral; consideration should be built into the pathway for referral to other services e.g. social care.
South East Staffs & Seisdon Peninsula …
East and Mid Devon — recommendation R9
Make information about support groups for families of substance misusers more widely available, recognising that not all will be in contact with treatment services.
Safer Devon Partnership
Devon Partnership NHS Trust
East and Mid Devon — recommendation R6
Ensure effective communication to all front line professionals of what services addressing alcohol misuse, drug misuse and domestic abuse are available, and of how to refer or signpost clients to them.
Safer Devon Partnership
Devon Partnership NHS Trust
Portsmouth — recommendation 13
Review of processes/policies/training in relation to patients requiring support with drug and alcohol misuse to ensure potential safeguarding issues are considered for all GPs surgeries in Portsmouth.
GPs – Surgeries Portsmouth
Portsmouth — recommendation 7
The CSP would like to receive confirmation that the DA Matters training includes the impact of substance misuse in cases of domestic abuse. (see recommendation 8 below)
Hampshire Constabulary
Hampshire and Isle of …
Shropshire — recommendation 1
The Partnership to examine the early help offer specifically considering educational and preventative interventions with young people who commit offences, and who have complex needs based on a) earlier childhood adversity, b) presenting mental health difficulties, c) presenting with substance misuse, d) are involved with multiple agencies.
Shropshire Safeguarding Community Partnership
Gateshead — recommendation 5
Home Office to review the effectiveness of 101 single non-emergency contact number and implement measures to reduce call waiting times and abandoned calls;
Home Office
Home Office
Northampton — recommendation 1
For NCC Public Health and CCG commissioner to review the potential for current Drug and Alcohol pathways and consider how this is better integrated with Mental Health Services for future service delivery including options for full alignment and integration.
NCC Public Health | ICB commissioner
Central Bedfordshire — recommendation 14
Public Health Commissioners to develop a programme to raise awareness of best practice in relation to the identification and offer of brief advice by local services in relation to alcohol use
Public Health Commissioners
Lincoln — recommendation 10.6.1
Housing Tenancy Management staff should be provided with advice and training to raise awareness of the impact of drug and alcohol abuse on families and in particular older members of the household. Details should be provided on how to sign post those families to other Agencies to consider appropriate levels …
Lincoln City Council Housing
Cardiff — recommendation 4
The Cardiff Public Services Board reviews both its strategic and tactical management and support to victims of mental health especially those victims currently being supported for substance and alcohol addiction.
Cardiff Public Services Board
Cannock Chase — recommendation 5
To audit current caseload of patients with recorded alcohol abuse to ensure appropriate referrals to addiction services have been offered or made.
South East Staffs & Seisdon Peninsula …
Stoke-on-Trent — recommendation 2
The Stoke-on-Trent Clinical Commissioning Group should seek assurance that providers of health services for the medical consequences of alcohol abuse have in place pathways which encourage patients to access specialist services to address their future alcohol consumption.
Stoke-on-Trent Clinical Commissioning Group
Salford — recommendation 6
Frequent attenders with substance misuse and mental health problems should have a safeguarding referral where appropriate.
Salford Royal Hospitals NHS Foundation Trust
Northern Care Alliance NHS …
Buckinghamshire — recommendation 3
That the Ministry of Justice reviews the resources available for Building Better Relationships courses in order that domestic abuse perpetrators are able to access the course in a more-timely fashion.
Ministry of Justice
Ministry of Justice