Custodial medication interaction warnings
Failure to provide clear warnings to prisoners about the critical risks of combining prescribed medications with other substances.
Source spread
Where this theme appears
This theme appears across 8 independent accountability sources, so the source mix matters as much as the headline total.
39 PFD reports
10 PPO recs
1 IOPC rec
32 IMB recs
3 Article 2 learning points
1 detention investigation rec
3 PHSO decisions
1 LGO/SPSO decision
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(39)
Kirk Duboise
Concerns: There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Response (Care UK): Care UK has implemented protocols for summoning ambulances, disseminated to staff via a Governor's notice and staff briefings. NOMS has implemented ACCT training, with further training for healthcare staff commencing …
Overdue
Stephen Farrar
Concerns: There was no formal risk assessment completed when Mr Farrar was first admitted to Woodhill Prison, despite risk factors; there is no formal risk assessment tool available in prisons.
Response (Greater Manchester Police): • Greater Manchester Police stated it agrees that a mental disorder does not absolve individuals of criminal consequences. • Greater Manchester Police confirmed it routinely pursues legal proceedings alongside and …
Overdue
Satheeskumar Mahatheaven
Concerns: Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Response (HM Prison and Probation Service): HMP Pentonville and HMP Thameside have implemented local policies to ensure appropriate information sharing and effective communication between prison staff and healthcare providers. Community GP records are now routinely requested …
Responded
Paul Hardy
Concerns: Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Overdue
Carl Smith
Concerns: Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
Response (Dorset Healthcare University NHS Foundation Trust): Dorset HealthCare NHS Trust implemented new policies and procedures to improve the quality of service in Devon Prisons. An education package has been put in place for all staff regarding …
Overdue
Devinder Seth
Concerns: Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.
Response (Davindar Lal Seth): The Pharmacy department at Barts Health NHS Trust is producing guidance for staff relating to the risk of opiate medications, their side-effects and the signs of opiate toxicity, and a …
Responded
Shalane Blackwood
Concerns: The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
Overdue
Terence Adams
Concerns: Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Response (Care UK): Care UK will remind staff to check they have had sight of the core record and any accompanying information including the PER, relating to history, index offence, sentence status, clinical …
Overdue
Charles Rendell
Concerns: There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.
Response (Bayer PLC): Bayer states that patient safety is taken very seriously. They reviewed reports of psychiatric effects associated with ciprofloxacin and believe the UK product information includes an appropriate warning to advise …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA reviewed the information and considers that the product information for Ciproxin provides up-to-date information on the risk of mental disturbances. They will review all UK Package Leaflets for …
Responded
Jack Portland
Concerns: No specific concerns regarding future deaths were detailed in the provided text, only contact information.
Response (HM Prison and Probation Service): Extensive suicide and self-harm prevention training has been delivered to staff since 2015, new procedures have been introduced to improve ACCT management, prisoners will be able to register with a …
Response (Oxford Health NHS Trust): The Section 17 leave form has been amended, and a new SOP for managing leave includes discussions with family. The Trust also reports on weekly monitoring processes and has introduced …
Overdue
Jonathan Earp
Concerns: Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
Response (Gloucestershire Hospitals NHS Trust): The Trust reviewed the circumstances of fentanyl administration, discussed the case with ward staff and presented it to the Senior Nurse and Midwifery Committee. An action plan confirms work undertaken …
Responded
Michael Folley
Concerns: The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.
Response (Hampshire and Isle of Wight Constabulary): Hampshire Constabulary will mandate electronic self-learning packages on Prisoner Escort Records for Custody Officers and Detention Officers, review the content annually, and raise the issues in the Regulation 28 Notice …
Response (CNWL NHS Trust): CNWL NHS Trust details existing ACCT and SASH training, reception screening processes with standardized training being rolled out, twice-yearly care records audits, and staff supervision policies including discussion of care …
Overdue
Marcus McGuire
Concerns: HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Response (HM Prison and Probation Service): HMP Birmingham has trained additional case managers, monitors compliance with the single case manager model daily, reviews it monthly, and has introduced further quality assurance of every ACCT document.
Response (G4S): G4S states that actions at HMP Birmingham are not within its remit as the prison is now operated and managed by HMPPS, but they reflect on every death in custody …
Responded
Andrew McCall
Concerns: A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Response (NHS England): NHS England will contact Addiction Dependency Solutions to review processes for collecting/verifying GP data and information sharing. They will also write to all Staffordshire GP practices to highlight risks and …
Responded
Graham Saffery
Concerns: The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.
Response (Bedfordshire CCG): The CCG has shared learning from the incident with other practices and the East of England NHS England, developed a SystmOne search to identify at-risk patients, briefed prescribing leads, and …
Responded
Abdeslam Benelghazi
Concerns: Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.
Response (Department of Health and Social Care): The Department of Health and Social Care plans to publish a White Paper in early 2020 responding to the Independent Review of the Mental Health Act and will consult publicly …
Responded
Marlon Watson
Concerns: Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
Response (Care UK): Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight …
Response (HMP Dovegate): Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight …
Responded
Samantha Gould
Concerns: There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
Response (NHS England): NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing …
Response (RPS): The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health …
Response (GPC): The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share …
Response (CCA): The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, …
Responded
Ian Miller
Concerns: A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Response (HM Prison and Probation Service): The prison updated its prisoner induction process in January 2022 to include information on in-possession medication, the dangers of misusing prescription drugs, and instructions to report concerns. Guidance was issued …
Overdue
Jan Goodliffe
Concerns: Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
Overdue
Sheila Steggles
Concerns: Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Response (Hellesdon Hospital): Hellesdon Hospital is updating the Trust induction for junior doctors to include physical health training, supported by senior consultants and underpinned by the SBAR framework. They will offer "3 Ps" …
Responded
Maria McGauran
Concerns: The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.
Response (Alvaston Medical Centre): Alvaston Medical Centre recruited two clinical pharmacists to conduct patient medication reviews, particularly for controlled drugs, and ensures high-risk scheduled drugs are not part of repeat prescriptions, with a robust …
Responded
Beatrice Dawkins
Concerns: Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.
Response (Portsmouth Hospitals NHS Trust): The Trust is implementing electronic prescribing, reviewing processes for highlighting allergies, developing handheld severe allergy cards for patients, and participating in a national Information Standard for medicine and allergy/intolerance data …
Responded
Susan Gladstone
Concerns: The report identifies a potential interaction between tramadol and warfarin that caused a dangerously high INR level, and that there was no warning to the prescribing doctor about this possible interaction.
Overdue
Steven Bowker
Concerns: The prolonged prescription and use of opiate medication pose significant dangers to patients.
Response (Department of Health and Social Care): The Department acknowledges the concerns regarding prolonged opiate prescriptions, explains the role of clinicians and the MHRA, and highlights existing guidance and monitoring processes, including updates to product information and …
Overdue
Joy Ebanks
Concerns: Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term use, contributed to toxicity.
Response (Kirby Road Surgery): The surgery has developed an action plan, clinical staff have undertaken training courses regarding opioid prescribing for chronic pain, opioid and gabapentinoid prescribing policies have been updated, and information has …
Responded
Stephen Coster
Concerns: Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.
Response (HM Prison and Probation Service): HMP Lewes reviewed record-keeping practices, clarified responsibilities for welfare checks and clinical observations, regularly briefs staff on emergency codes, and reviewed hospital escort procedures. Custodial managers now oversee Code Blue/Red …
Responded
Darren Docherty
Concerns: Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
Response (Stoke on Trent Council): Stoke-on-Trent City Council outlines existing duties to provide advice and accommodation, and says it will continue working with health and social care to support individuals released from prison to access …
Overdue
Marlin Burrows
Concerns: The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Response (Greater Manchester Mental Health NHS Foundation Trust): Healthcare staff at HMP Garth have been instructed to review and sign the welfare checklist document upon arrival at the wing to inform clinical decision making, with monthly assurance checks …
Response (HM Prison and Probation Service): HMPPS is developing national guidance for managing prisoners under the influence of illicit substances, which is currently in the consultation stage. Once agreed, the guidance will be rolled out via …
Responded
Mohammed Azizi
Concerns: Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
Response (Bedfordshire Cambridgeshire and Norfolk Group): The organisation will provide advice and guidance to the staff member involved in the incident, ensure all future support and advice for staff during an inquest will be provided by …
Responded
Kevin McDonnell
Concerns: Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Response (HM Prison and Probation Service): HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality …
Responded
Sean Davies
Concerns: Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Overdue
Thomas Kingston
Concerns: There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.
Response (National Institute for Health and Care Excellence): NICE is working collaboratively with the MHRA on the issues raised and will provide a further response once that work has concluded; the outcome will inform any action NICE may …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA outlined existing warnings and guidelines related to SSRIs and suicidal behavior, referencing NICE guidance, and added the adverse reaction report to the Yellow Card database.
Response (Royal College of GPs): The Royal College of GPs provides general comments on GP curriculum, shared decision making, NICE guidance and its Mental Health toolkit, but notes no specific changes it will make.
Responded
Chloe Burgess
Concerns: The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing a significant toxicity risk.
Response (National Institute for Health and Care Excellence): NICE acknowledges the coroner's concerns regarding drug interactions in the death of Chloe Elizabeth Burgess, but states that the British National Formulary (BNF) is best placed to address these concerns, …
Response (Royal College of Physicians): The Royal College of Physicians notes the concerns and will discuss this case at their next Patient Safety Committee and Joint Medicines Safety Working Group to explore whether further action …
Responded
Abu Rahman
Concerns: Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks in patients with kidney impairment.
Response (Royal Free Hospital): The Trust acknowledges the process of initiating Naloxone was not in line with guidance and will share awareness amongst medical teams. They also outline an action plan including safety huddle …
Responded
Aaron Atkinson
Concerns: There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Response (National Institute for Health and Care Excellence): NICE clarifies that the Clinical Knowledge Summaries (CKS) are not NICE guidance, and that NICE guidance and prescribing information for risperidone does not include a requirement for continued ECG monitoring. …
Response (NHS Derby and Derbyshire Integrated Care Board): The ICB will review the investigation from the practice, await the NICE response, update the JAPC guideline and medicines management webpage, and share lessons learned and guidance updates with primary …
Responded
Josh Tarrant (3)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Response (HMP Elmley): HMPPS is consulting with clinical experts to develop and issue new written guidance for staff on recognising signs of Acute Behavioural Disturbance (ABD). This guidance aims to ensure officers identify …
Responded
Edward Hands
Concerns: Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.
Response (Northamptonshire Healthcare NHS Foundation Trust): • A common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford has been agreed and implemented with the Prison Governor …
Response (HM Prison Probation Service): • HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place, resulting in the removal of any previous conflicting guidance and implementation of …
Response (HMP Bedford): • HMP Bedford implemented a new local protocol for managing prisoners suspected of being under the influence of unknown substances. • The protocol outlines steps for staff, including activating body-worn …
Responded
Rajwinder Singh
Concerns: HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Responded
PPO death in custody recommendations(10)
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff follow a clear and robust process when they find prisoners with illicit prescription drugs, including that they record, communicate and address it appropriately.
Manx Care
Manx Care should ensure that patients who come in with complex and high-risk medication (as per the RCGP guidance) have a medication review when they arrive at the prison.
The Head of Healthcare
The Head of Healthcare should ensure that staff completing medication in-possession risk assessments consider all relevant information, including recent drug or alcohol use.
The Head of Healthcare
The Head of Healthcare should ensure that when high or medium risk medications such as amitriptyline are prescribed, the prescriber ensures that a further in-possession risk assessment takes place in line with local and national policy.
The Head of Healthcare, lead GP and lead pharmacist at …
The Head of Healthcare, lead GP and lead pharmacist should review the ‘homely remedies’ protocol to ensure that it makes reference to checking a prisoner’s prescribed medication to ensure no contraindications before the provision of a ‘homely remedy’.
The Head of Drug Strategy and the Lead Pharmacist
The Head of Drug Strategy and the Lead Pharmacist should develop officer training on monitoring medication and the risks associated with prisoners using unprescribed medication and ensure it is delivered.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should review the disclosure of DNACPR instructions to custodial staff. Custodial staff should be aware of those who wish not to be resuscitated and have access to a DNACPR instruction form (which can …
The Head of Healthcare
The Head of Healthcare should review the GP medication review waiting times and if a patient has had a number of incidents of self-harm, triage of their needs is undertaken, and an urgent medication review is facilitated.
The Head of Healthcare
The Head of Healthcare should ensure that staff understand and follow NICE guidelines for the management of head injuries and develop a protocol so that prisoners prescribed anticoagulants have a formal medical assessment after a head injury including recording a …
The Head of Healthcare
The Head of Healthcare should ensure that the falls assessment includes a procedure for patients who are prescribed blood-thinning medication based upon the NICE Head Injury guidance.
IMB individual recommendations(32)
North West and Midlands STHF (2023)
For the fifth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding rooms and …
Ministry of Justice
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that Home Office policy be immediately amended to enable staff in STHFs to continue removing medicine from the possession of those detained but to allow them to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk …
Home Office
North and Midlands STHF (2020)
For the third year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detainees with access to their prescribed medication. The Board continues to note that detainee welfare has been adversely affected by this situation. This occurs particularly in holding rooms and reporting centres. The Board …
Home Office
Heathrow and City airports Short Term Holding Facilities (2021)
The Home Office should ensure that the new system for giving detainees access to their prescription and over-the-counter medication is designed and implemented without further delay.
Home Office
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
We would urge the Minister to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would be that …
Other
North and Midlands Short Term Holding Facilities (2022)
For the fourth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding rooms and …
Home Office
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
We reiterate our previous recommendation regarding the provision of prescription medication. We repeat our urge for the Minister to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications and design a practical strategy for ensuring that detained people receive their medication. We repeat …
Other
North West and Midlands STHF (2024)
For the sixth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding rooms and …
Other
North East Midlands, Yorkshire & Humber STHF (2024)
We repeat our recommendation that the policy be immediately revised to allow staff in STHFs to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk of health deterioration and for being fair and humane, while minimising any adverse …
Home Office
Cardiff (2024)
The Board again wishes to highlight applications about medication/ prescriptions continue to be received at a very high level and recommends further consideration be given to addressing this.
NHS / Healthcare Provider
In Progress
London short term holding facilities (STHF) (2025)
Eaton House and London City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now, including at Ministerial level.
Ministry of Justice
Heathrow Short Term Holding Facility (2020)
The Home Office should ensure that the new system is provided as quickly as possible to ensure that people in detention can access their own prescription medication and common non-prescription medication (paras. 9.2 - 9.5; 18.2 – 18.3; 26.2; 34.2).
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
That the administration of detainees’ personal prescribed medication, in airport HRs be resolved forthwith.
Home Office
Bedford (2020)
Request that the Head of Safety (or other nominated officer) be kept informed of any prisoner who has been subject to the protocol for anyone missing more than three doses of medication.
Governor / Director
Wayland (2022)
The Board suggests there may be a need to review how the medication periods are managed and supervised, especially considering instances of violence in the drug dependency medications queue and policy of prescription reduction.
Governor / Director
London Heathrow and City Airports (2022)
[London City Airport and Eaton House] The Board recommends that a workable solution can be found for those detained to have access to their prescribed medication. (See paragraphs 6.4.6 and 8.4.3)
Home Office
Gatwick, Stansted, Luton and Lunar House (2022)
As stated above, at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available, on a 24/7 basis to, where appropriate, authorise the taking of their own medication by detained individuals, or where there is an urgent need, to prescribe medication.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2022)
at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available, on a 24/7 basis to, where appropriate, authorise the taking of their own medication by detained individuals, or where there is an urgent need, to prescribe medication.
Other
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Minister is urged to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would be that the …
Other
Rye Hill (2023)
The Board is concerned that processes designed to ensure prisoners have sufficient prescribed medication with them when transferring to Rye Hill are not being consistently applied across the prison estate.
HMPPS
Dovegate (2023)
It is important there is a medical prescriber in Reception for out of standard hours arrivals, to ensure prisoners get the medication they need on their first night.
Governor / Director
Berwyn (2023)
Prisoners from England are not allowed to access medication which has not been approved by Betsi Cadwaladr (Betsi Cadwaladr University Health Board), the local healthcare provider. Regarding medication for mental health issues in particular, this causes distress.
HMPPS
Thorn Cross (2025)
What is being done to reduce the number of men who arrive without their medication? (6.1.8)
HMPPS
Implemented
Styal (2025)
What progress is being made to ensure adequate and secure ‘in-possession meds’ lockers in the houses and on the wing?
Governor / Director
North West and Midlands STHF (2025)
For the seventh year in succession, the Board repeats its concern at the lack of proper procedures that would allow the Home Office or its contractors to routinely provide detained individuals with access to their own medication. The Board considers the welfare of some of those who have been detained may have been adversely affected by this situation, depending on …
Home Office
North East Midlands, Yorkshire & Humber STHF (2025)
We repeat our recommendation that the policy be immediately revised to allow staff in STHFs to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk of health deterioration and for being fair and humane, while minimising any adverse …
Ministry of Justice
Erlestoke (2025)
What plans are being considered to ensure that prisoners arriving at HMP Erlestoke will have access to their essential medicines without a period of delay?
NHS / Healthcare Provider
In Progress
Elmley (2020)
The Board has raised the issue of medication under restraint, and received confirmation that the Governor is the ultimate authority in such interventions. This needs to be more firmly established, for the sake of the prison officers who carry out the restraint, and in terms of the fair treatment of the prisoner involved.
Governor / Director
Charter Flight (2020)
A supply of compression socks must be available on the plane and offered to returnees under the guidance of the paramedics (see paragraph 5.1.1, first bullet).
Other
Buckley Hall (2021)
Provide secure medication in-cell facilities (6.1.14)
HMPPS
In Progress
Cardiff IMB (2025)
Sut bydd y Bwrdd Iechyd yn sicrhau bod archwiliadau presgripsiynu yng Ngharchar Caerdydd yn cael eu datrys yn gyflym, o ystyried bod trefniant rhannu swydd y fferyllwyr yn atal archwiliadau yn y carchar?
NHS / Healthcare Provider
Cardiff (2025)
How will the Health Board ensure that prescribing checks at HMP Cardiff are resolved quickly, given that the pharmacists’ job-sharing arrangement prevents in-prison checks?
NHS / Healthcare Provider
Implemented
Article 2 learning points(3)
— LP F
Drug Dependence Reviews of dual diagnosis patients should consider the range of medication prescribed to a patient.
PPG
— LP 2
If a prisoner comes into prison on mirtazapine, he/she should have a full review, following confirmation of that prescription from the community GP. This should happen quickly. If an alternative to mirtazapine prescription is appropriate, the person should be reduced slowly from mirtazapine and the new drug introduced gradually, as …
HMP Altcourse and HMPPS
Accepted
— LP 1
There needs to be much speedier medicines reconciliation, post reception. In prisoners, like Mr Everest, who are prescribed drugs like antidepressants, this needs to be within 24 hours to avoid withdrawal symptoms. There needs to be a robust administration process whereby a summary is acquired from the GP in the …
HMP Altcourse and HMPPS
Partially Accepted
Detention investigations(1)
PHSO casework decisions(3)
P-003565 — Oxleas NHS Foundation Trust
Mr R complains about the care and treatment he received from two prisons. Mr R says he did not receive appropriate pain management or care in relation to his mental health.
NHS in England
Not Upheld
Dec 2024
P-003508 — Black Country Healthcare NHS Foundation Trust
Miss U complains about the way Black Country Healthcare NHS Foundation Trust and The Royal Wolverhampton NHS Trust managed her father’s mental health medication.
NHS in England
Apr 2025
P-004363 — An independent provider in the Wychavon area
Claimed failings: Mr F complains between 13 June 24 to 24 June 24 he was refused access to healthcare as the prison would not transport him to A&E after sustaining an injury to his hand. Mr F also tells us he was not given the pain medication he required and …
NHS in England
Nov 2025