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 10 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
2 Scottish FAIs
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: The coroner noted a delay in summoning an ambulance and that relevant forms were not seen by staff assessing the risk of self-harm for a new prisoner.
Response (Care UK): • Care UK introduced and disseminated a colour code system for summoning ambulances and issued a Governor's notice to staff. • Training on ACCT (Assessment, Care in Custody and Teamwork) … (AI summary)
Overdue
Stephen Farrar
Concerns: The coroner noted the absence of a formal self-harm or suicide risk assessment for Mr. Farrar upon his admission to Woodhill Prison, despite clear risk factors, and the general lack of such assessment tools in prisons.
Overdue
Satheeskumar Mahatheaven
Response (HM Prison and Probation Service): • HMP Pentonville and HMP Thameside have implemented local policies and new procedures to improve information sharing between prison staff, healthcare providers, and external agencies. • Staff at both prisons … (AI summary)
Responded
Paul Hardy
Concerns: Healthcare staff did not follow instructions to obtain blood and urine samples for a possible cancer investigation, nor did they act on recommendations for INR monitoring samples. There was also a failure to conduct a Significant Event Analysis regarding the death, as recommended by the Clinical Reviewer.
Overdue
Carl Smith
Concerns: The quality of custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing regarding these checks appeared deficient.
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust implemented joint reviews for patients on drug treatment programmes, with shared access to caseload details and clear communication of observation level decisions. • An education package on … (AI summary)
Overdue
Devinder Seth
Concerns: Ward staff did not recognise the side effects of opiate medication on an orthogeriatric patient, and there was no clear, easily accessible guidance available to staff on the risks and side effects of opiate medications for this patient group.
Response (Davindar Lal Seth): • The Trust discussed the report at its Quality and Safety Committee and Hospital Management Board. • The Pharmacy department is producing guidance and a 'share the learning' bulletin on … (AI summary)
Responded
Shalane Blackwood
Concerns: The coroner identified a lack of provision for prisoners with complex health needs and insufficient staff for segregation unit regimes. Additionally, concerns were raised about an unclear documentary tool for assessing fitness for segregation and healthcare staff's awareness of physical symptoms masked by mental health issues.
Overdue
Terence Adams
Response (Care UK): • Care UK allocated an additional healthcare assistant to the reception process to review prisoner information, including risk assessments. • Care UK committed to rolling out refresher training to all … (AI summary)
Overdue
Charles Rendell
Concerns: The coroner raised concerns that the potential side effect of Ciprofloxacin, which can cause depression or psychosis leading to suicidal ideation, is not clearly communicated to patients or sufficiently emphasized to prescribing clinicians.
Response (Bayer PLC): • Bayer stated that the UK product information for Ciproxin, including the Summary of Product Characteristics (SmPC) and Patient Information Leaflet (PIL), contains warnings regarding the possibility of psychiatric effects, … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) considered the statutory information for Ciproxin and stated that the product information provides up-to-date details on the risk of mental disturbances, … (AI summary)
Responded
Jack Portland
Concerns: The practical implementation of Section 17 leave, particularly concerning the mandatory provision of 'Records of Grant' copies to patients and an additional party, was identified as a concern.
Response (HM Prison and Probation Service): • The prison implemented extensive training, new procedures, and quality checks for ACCT management. • A new database system was introduced for managing complex discharge cases, with plans for a … (AI summary)
Response (Oxford Health NHS Trust): • The Trust implemented a new standard operating procedure for managing patient leave, clarifying responsibilities and simplifying documentation. • Responsibilities for ensuring patient return from leave and informing the shift … (AI summary)
Responded
Jonathan Earp
Concerns: The coroner noted no clear evidence that all unspent Fentanyl patches were returned or discarded appropriately. Staff also did not fully consider the potential impact of a patient taking additional prescribed medication alongside illicit drugs.
Response (Gloucestershire Hospitals NHS Trust): • The Trust reviewed the circumstances of fentanyl administration to Mr Earp. • The case was discussed with ward staff and presented to the Senior Nurse and Midwifery Committee. • … (AI summary)
Responded
Michael Folley
Concerns: The coroner identified issues with the police's paper-based Person Escort Record (PER) system, including officers lacking access to previous self-harm risk data from other agencies. Concerns were also raised about Detention Officer training and deficiencies in the PER's completion, checking, and secure handover processes.
Response (Hampshire and Isle of Wight Constabulary): • Hampshire Constabulary will mandate that all Custody Officers and Detention Officers complete an electronic self-learning package on Person Escort Records (PERs). • The force will review its policies and … (AI summary)
Response (CNWL NHS Trust): • The Trust confirmed mandatory ACCT and SASH training for staff, with compliance monitored monthly, and stated it would address any outstanding SASH training. • The Trust has implemented policies … (AI summary)
Overdue
Marcus McGuire
Concerns: The coroner identifies deficiencies in ACCT plans from the absence of a single case manager, affecting care and follow-up. Concerns were also raised about a disparity between evidence and inspection findings on implementing single case management at HMP Birmingham.
Response (HM Prison and Probation Service): • HMP Birmingham has trained additional case managers to improve consistency in single case management and reduce caseloads. • The prison has introduced daily monitoring and monthly reviews of single … (AI summary)
Response (G4S): • G4S stated that decisions regarding actions at HMP Birmingham are not within its remit, as the prison is now operated and managed by HMPPS. • G4S indicated that it … (AI summary)
Responded
Andrew McCall
Concerns: The coroner noted that a system dependent on patient self-declaration meant GPs were often unaware their patients were on opiate replacement therapy, risking the prescription of unsuitable medications.
Response (NHS England): • NHS England will ask Addiction Dependency Solutions to review and verify processes for collecting and sharing GP data. • NHS England will share this communication with the Local Authority … (AI summary)
Responded
Graham Saffery
Concerns: The British National Formulary (BNF), a resource regularly consulted by GPs, does not appear to include advice for caution and monitoring when prescribing amitriptyline and oxycodone simultaneously, unlike other pharmacological guidance.
Response (Bedfordshire CCG): • The CCG discussed the case at its Prescribing Committee and shared the learning across all practices. • A SystmOne search was developed and published to identify patients on high-strength … (AI summary)
Responded
Abdeslam Benelghazi
Concerns: The coroner noted concerns regarding the concurrent prescribing of clonazepam with methadone. This combination can cause central nervous system and respiratory depression, increasing the risk of sudden death, particularly given clonazepam's long half-life.
Response (Department of Health and Social Care): • The Medicines and Healthcare products Regulatory Agency (MHRA) is contacting marketing authorisation holders to update product information for clonazepam and methadone, and will remind healthcare professionals of co-prescribing risks. … (AI summary)
Responded
Marlon Watson
Concerns: The coroner noted concerns that healthcare staff at HMP Dovegate do not have a full and proper understanding of the ACCT process, requesting details on appropriate training and auditing.
Response (HMP Dovegate): • Care UK confirmed that initial ACCT and SASH training is provided during staff induction, with refresher training completed annually or every three years. • Care UK stated that additional … (AI summary)
Response (Care UK): • Care UK offered additional refresher ACCT training to all staff. • Care UK requested the prison to provide this training, which is scheduled to take place within 12 weeks. … (AI summary)
Responded
Samantha Gould
Concerns: The coroner raises concerns about the lack of national guidance for pharmacies to be involved in medication safety plans for mental health patients aged 16-17, noting this poses a risk of future fatalities.
Response (NHS England): • A local protocol has been introduced for CAMHS to advise pharmacies and GPs of relevant care plans for 16-17 year old patients. • This local protocol is now part … (AI summary)
Response (RPS): • The Royal Pharmaceutical Society (RPS) stated it continues to campaign for improved access and sharing of patient health records for community pharmacies. • The RPS has published a policy … (AI summary)
Response (GPC): • The General Pharmaceutical Council stated it would proactively look for opportunities to share the learnings from this case with key stakeholders. • The General Pharmaceutical Council stated it would … (AI summary)
Response (CCA): • The Community Pharmacy Patient Safety Group will discuss the incident to identify learnings and share best practice. • A summary of this discussion will be shared nationally via internal … (AI summary)
Responded
Ian Miller
Concerns: Concerns were raised about medication management at HMP Usk, where prisoners self-manage drugs that are not securely stored. This contributes to widespread trading of prescribed medication among prisoners, risking future deaths.
Response (HM Prison and Probation Service): • The prisoner induction process was updated in January 2022 to include information on in-possession medication, misuse dangers, and reporting concerns. • Guidance was issued to staff in January 2022 … (AI summary)
Overdue
Jan Goodliffe
Concerns: The coroner raised concerns that non-medically qualified social workers conducted home assessments, missing opportunities to obtain expert medical advice on medication interactions for the deceased.
Overdue
Sheila Steggles
Concerns: The coroner identified gaps in VTE risk assessment for patients with reduced mobility, insufficient detail in clinical notes and care plans, and a need for improved junior staff consultation on medication interactions.
Response (Hellesdon Hospital): • The Trust will update its induction for medical trainees and the Doctor handbook to include physical health emergencies, VTE assessment, and escalation guidance. • The physical health team is … (AI summary)
Responded
Maria McGauran
Concerns: A requested review of the patient's multiple medications was not undertaken, and the Surgery could have considered alternative pain management earlier to prevent overdose risks.
Response (Alvaston Medical Centre): • Alvaston Medical Centre recruited two clinical pharmacists to conduct structured patient medication reviews. • The centre implemented a practice to ensure high-risk scheduled drugs do not form part of … (AI summary)
Responded
Beatrice Dawkins
Concerns: The coroner identified that critical information regarding the deceased's chloramphenicol sensitivity, documented since 1997, was not accessible or flagged to clinicians during a later hospital admission, resulting in the medication being prescribed.
Response (Portsmouth Hospitals NHS Trust): • An Electronic Prescribing and Medicines Administration (EPMA) system has been rolled out across medicine and is scheduled for full implementation across all wards by the end of 2022. • … (AI summary)
Responded
Susan Gladstone
Concerns: The coroner noted a lack of information for prescribing doctors regarding the known interaction between tramadol and warfarin, as this interaction is not listed in the British National Formulary.
Overdue
Steven Bowker
Concerns: The coroner raises concerns about the potential dangers to patients associated with the prolonged prescription and use of opiate medication.
Response (Department of Health and Social Care): • NHS England published a framework for action in March 2023 for Integrated Care Boards (ICBs) to reduce inappropriate prescribing of dependence-forming medicines. • The NHS Business Services Authority provides … (AI summary)
Overdue
Joy Ebanks
Concerns: The coroner noted prolonged prescribing of two dependency-forming drugs without a clear plan for dose reduction, despite the practice's own guidance highlighting the hazards of long-term opioid and gabapentinoid use for chronic pain.
Response (Kirby Road Surgery): • The surgery conducted a significant event analysis and discussed the case at organisational meetings. • A specialist prescribing pharmacist was recruited, and patients on opioid and gabapentinoid medications were … (AI summary)
Responded
Stephen Coster
Concerns: The coroner identified inadequate record keeping, healthcare staff failures in observation and assessment, and a lack of care plans and communication protocols between healthcare and prison staff. There was insufficient understanding among prison staff of emergency procedures, leading to delays in hospital transfer.
Response (HM Prison and Probation Service): • HMP Lewes implemented an agreed system clarifying responsibilities for welfare checks and clinical observations between prison and medical staff. • Staff received regular briefings, training, and pocket guides on … (AI summary)
Responded
Darren Docherty
Concerns: The coroner raised concerns that individuals released from prison often lack accommodation, which prevents them from accessing necessary GP and community mental health services.
Response (Stoke on Trent Council): • The Council completed a review of the Duty to Refer process to ensure all referrals receive a response within three days. • The Council will continue to work with … (AI summary)
Overdue
Marlin Burrows
Concerns: The coroner identified that a welfare sheet for monitoring prisoner health lacked clear purpose and completion guidance. Entries by prison staff were not consistently made known to medical staff, and its operation had not been jointly considered by prison and healthcare.
Response (Greater Manchester Mental Health NHS Foundation Trust): • Healthcare staff have been informed that they must request, review, and sign welfare checklist documents upon arrival, with this review noted in clinical records. • Monthly assurance checks will … (AI summary)
Response (HM Prison and Probation Service): • HM Prison and Probation Service is developing national guidance for staff managing prisoners under the influence of illicit substances. • The coroner's concerns have been shared with the Substance … (AI summary)
Responded
Mohammed Azizi
Concerns: The coroner identified issues with documents bearing signatures that witnesses denied, retrospective alteration of records, and incomplete disclosure of documents which hampered the investigation and risk accurate record-keeping.
Response (Bedfordshire Cambridgeshire and Norfolk Group): • Systems for ACCT documentation have been changed to ensure concerns are identified and addressed, and regional assurance support visits have increased. • Operational staff briefings are now more targeted … (AI summary)
Responded
Kevin McDonnell
Concerns: Prison staff misunderstood the need for meaningful ACCT observations, treating them as superficial checks, and did not share risk-pertinent information. The coroner also noted failures in securing and retaining accurate documentary evidence after the death.
Response (HM Prison and Probation Service): • HMP Nottingham increased delivery of SASH/ACCT awareness and upskilling training. • HMP Nottingham introduced a ‘trigger’ database for sharing pertinent risk information. • ACCT books are no longer removed … (AI summary)
Responded
Sean Davies
Concerns: The coroner raised concerns about the incomplete implementation of risk formulations for prisoners with IPP sentences. Welfare checks by prison officers did not adhere to national guidance, and some operational support group officers lacked or did not follow essential training.
Overdue
Thomas Kingston
Concerns: The coroner raises concerns about the adequacy of communicating suicide risks associated with SSRI medications. Additionally, concerns are noted regarding the appropriateness of guidance for persisting with or switching SSRIs when no benefit or adverse side effects are experienced.
Response (National Institute for Health and Care Excellence): • NICE's patient safety leads discussed the report and relevant guidance. • NICE is working collaboratively with the Medicines and Healthcare products Regulatory Agency (MHRA) on the issue. • The … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) convened an Expert Working Group (EWG) in 2022 to review the communication of suicide risks in patient leaflets, with its first … (AI summary)
Response (Royal College of GPs): • The GP curriculum includes guidance on effective communication, risk assessment, and suicide prevention in mental health care. • The Royal College of General Practitioners has developed a Person-Centred Care … (AI summary)
Responded
Chloe Burgess
Concerns: The coroner notes that the dangers of combining amitriptyline, paroxetine, and ivabradine are not widely appreciated and do not trigger prescribing software alerts, and prescribers may lack full understanding of these interactions.
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence (NICE) stated it could not comment on the concerns raised regarding drug interactions. • NICE indicated that responsibility for the content … (AI summary)
Response (Royal College of Physicians): • The Royal College of Physicians consulted cardiovascular and pharmacology experts and liaised with the Royal Pharmaceutical Society. • The Royal College of Physicians will discuss this case at its … (AI summary)
Responded
Abu Rahman
Concerns: Concerns were raised about delays in administering Naloxone due to frequent stock shortages, and a lack of awareness regarding opioid toxicity risks in patients with kidney impairment.
Response (Royal Free Hospital): • Safety huddle sessions will be conducted for two weeks to clarify the process for accessing Naloxone, including out of hours. • Pharmacy will increase Naloxone stock levels on ward … (AI summary)
Responded
Aaron Atkinson
Concerns: Concerns were raised about the lack of annual ECGs during GP reviews for individuals prescribed long-term anti-psychotic medication. This appears to stem from a lack of clarity and consistency in national and local guidance regarding the recognised cardiac risks.
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence (NICE) shared the Prevention of Future Deaths report with Agilio Software. • Agilio Software will add wording to the Clinical Knowledge … (AI summary)
Response (NHS Derby and Derbyshire Integrated Care Board): • The Integrated Care Board (ICB) stated it would amend its local Joint Area Prescribing Committee (JAPC) guidance to advise annual electrocardiogram (ECG) monitoring for all patients on antipsychotics after … (AI summary)
Responded
Josh Tarrant (3)
Concerns: The coroner identified a lack of training for healthcare and prison staff in recognising Acute Behavioural Disturbance (ABD), leading to Mr Tarrant's condition not being identified. This absence of training persists despite ABD being a known condition referenced in a 2005 Prison Service Order.
Response (HMP Elmley): • HMPPS has taken steps to support staff in recognising and responding to behavioural and physiological indicators associated with Acute Behavioural Disturbance (ABD). • HMPPS is consulting with clinical experts … (AI summary)
Responded
Edward Hands
Concerns: The coroner noted conflicting policies between the prison healthcare provider and prison staff regarding prisoners suspected of being under the influence of illicit substances. This resulted in confusion, a lack of awareness, and a prisoner's clinical deterioration not being recognised or escalated due to missed observations.
Response (Northamptonshire Healthcare NHS Foundation Trust): • A common local protocol for managing prisoners suspected to be under the influence of illicit substances has been agreed and implemented at HMP Bedford. • The UTI protocol and … (AI summary)
Response (HM Prison Probation Service): • HMP Bedford and Northamptonshire Healthcare Foundation Trust (NHFT) conducted a joint review of Under the Influence (UTI) policies and protocols. • A single, standardised UTI protocol has been implemented … (AI summary)
Response (HMP Bedford): • HMP Bedford implemented a local protocol outlining procedures for managing prisoners suspected of being under the influence of substances. • The protocol provides detailed guidance on staff response, welfare … (AI summary)
Responded
Rajwinder Singh
Concerns: The coroner noted a lack of mandatory ACCT refresher training for prison officers at HMP Wandsworth and no procedures to ensure agency staff receive equivalent ACCT training. Furthermore, ACCT induction training does not include principles of risk formulation.
Response (NHS England): • Oxleas NHS Foundation Trust implemented a process to ensure all staff, including temporary and agency, undertake mandatory ACCT training. • Oxleas NHS Foundation Trust commissioned a two-day ACCT Plus … (AI summary)
Response (HM Prison and Probation Service): • HMP Wandsworth has appointed three safety floorwalker officers to provide coaching and targeted ACCT refresher training to staff. • HMP Wandsworth will extend ACCT support to non-operational colleagues, including … (AI summary)
Response (Oxleas NHS): • Mandatory ACCT training for temporary healthcare staff has been implemented and is recorded. • A series of training modules on risk formulation has been commissioned, with a two-day module … (AI summary)
Responded
NCEPOD recommendations(1)
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
Scottish Fatal Accident Inquiries(2)
Richard Hugh McGhie
However I wish to make it clear to Sedexo that such record keeping is not acceptable and in the case of another prisoner suffering from epilepsy might have disastrous consequences for that prisoners care. One hopes that appropriate corrective measures will be taken to ensure all such logs are fit for purpose in the future and it may well be …
Mar 2012
Jason Ritchie
For the Medical in Possession Policy to be effective and efficient, the prison staff must be alert continuously to the dangers inherent in the self administration of drugs in line with the IP policy. I nonetheless consider that it is a matter that should be, if not already, addressed by the prison authorities.
Oct 2006
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 complained about inappropriate stopping of medications without detox in prison, delays in new prescriptions, and inadequate management of his physical pain and mental health.
NHS in England
Not Upheld
Dec 2024
P-003508 — Black Country Healthcare NHS Foundation Trust
Miss U complained Black Country Trust reduced her father's medication and ignored requests for antipsychotics, causing a relapse. She also alleged Wolverhampton Trust inappropriately prescribed medication and placed him on a COVID-19 ward, contributing to his death.
NHS in England
Apr 2025
P-004363 — An independent provider in the Wychavon area
Mr F complained he was denied A&E access for a hand injury, refused pain medication, and received inadequate aftercare, leading to severe pain, depression, and self-harm.
NHS in England
Nov 2025