Themes | Healthcare & Patient Safety | The Accountability Index

Limited drug harm reduction

The 10-Year Drugs Strategy's insufficient range of harm reduction approaches, with an over-emphasis on abstinence-based recovery.

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Committee recommendation

#21 - Update the 10-Year Drugs Strategy to increase available harm reduction approaches for treatment.

Home Affairs Committee

We recommend that the Government update the strategy to increase the range of harm reduction approaches available to support a person’s treatment and recovery from drugs in line with the approaches outlined in this report.

Matched on terms: drug, harm, reduction

Committee recommendation

#20 - 10-Year Drugs Strategy needs to expand its range of harm reduction approaches.

Home Affairs Committee

The 10-Year Drugs Strategy recognises some harm reduction approaches but could go further. Abstinence-based recovery may not be an effective form of treatment for everyone. A broader range of harm reduction treatments are therefore required to help as many people into recovery as possible.

Matched on terms: drug, harm, reduction

Committee recommendation

#15 - The Thistle's full effectiveness is inhibited without key harm reduction equipment and services.

Scottish Affairs Committee

Having access to equipment such as single-use tourniquets, testing drugs onsite, and allowing visitors to inhale drugs have all been highlighted as key to The Thistle achieving its maximum effectiveness. Without these, a full and fair evaluation of The Thistle will be inhibited. (Conclusion, Paragraph 126) 50

Matched on terms: drug, harm, reduction

Committee recommendation

#34 - Implement report recommendations on harm reduction, especially expanding drug diversion schemes for offenders.

Home Affairs Committee

We recommend the Government build on the harm reduction measures within the strategy by implementing the recommendations on harm reduction outlined in this report, particularly our recommendations on expanding diversion schemes.

Matched on terms: drug, harm, reduction

Committee recommendation

#13 - Legal barriers prevent The Thistle from operating effective drug inhalation rooms.

Scottish Affairs Committee

Drug trends in Scotland have changed and are changing. For The Thistle to be effective, it must be able to meet the needs of the population it is trying to help, which it cannot do without an inhalation room. As well as making the facility accessible to those who inhale drugs, encouraging visitors to change their method of...

Matched on terms: drug, harm, reduction

Committee recommendation

#14 - Require the Lord Advocate and Scottish Government to consider future inhalation room applications on their merits.

Scottish Affairs Committee

The Lord Advocate believes that widening the statement of prosecution policy to allow an inhalation room to operate is undesirable and we understand the reasons she has given. However, given that expert medical advice suggests that allowing the inhalation of drugs would increase opportunities for harm reduction, any future application for an inhalation room should be considered on...

Matched on terms: drug, harm, reduction

Committee recommendation

#5 - Establishing multiple safer drug consumption facilities requires a clear, common UK legal framework.

Scottish Affairs Committee

There has been interest in establishing SCDFs in other parts of Scotland, and the Lord Advocate has indicated that she will consider any such applications on their merits. Rather than having multiple facilities with individual 48 prosecution policy arrangements, it would be more appropriate for them to operate on a clear, legal basis, common to all. This would...

Matched on terms: drug

Ian Wolstenholme

Aug 2018 · Manchester (North)

The coroner noted a lack of national guidance for clinicians on the co-prescribing of multiple highly addictive and potentially harmful drugs. This absence of guidance increases the risk of combined drug toxicity, which the coroner believes could be mitigated by specific guidance.

Matched on terms: drug, harm

Kristopher Tilbury

Sep 2023 · Hertfordshire

The coroner identified persistent issues with the widespread availability of illicit drugs, including synthetic cannabinoids, at HMP The Mount. Reports from inspections and monitoring boards consistently noted weak drug supply reduction efforts and easy access to substances, impacting prisoner safety.

Matched on terms: drug, reduction

Joseph Forbes Black

Jan 2025 · Inner North London

The coroner identifies limited availability of naloxone kits for illicit drug users, as access is primarily through substance misuse services that many do not engage with. This risk is heightened by the increased presence of potent synthetic opioids in illicit drugs.

Matched on terms: drug, limited

Joshua Leatham-Prosser

Feb 2025 · Dorset

The coroner noted concerns regarding the highly addictive and harmful nature of ketamine, a Class B drug, and the increasing number of young people presenting with potentially fatal health problems linked to its use.

Matched on terms: drug, harm

Committee recommendation

#21 - Work with Scottish Government to create sustainable legal framework for Safer Drug Consumption Facilities.

Scottish Affairs Committee

If the independent evaluation of The Thistle deems the pilot a success, and the Scottish Government proceeds to make The Thistle permanent, and perhaps to open further SDCFs, the UK Government should work with the Scottish Government to make the necessary changes to reserved legislation to ensure there is a full, sustainable legal framework for Safer Drug Consumptions...

Matched on terms: drug

Committee recommendation

#59 - Mandate all police forces to roll out voluntary naloxone provision, including funding and training.

Home Affairs Committee

We recommend that the Home Office requires all 43 police forces in England and Wales to roll out the voluntary provision of naloxone by operational officers. Volunteer officers must be provided with adequate training in the carrying and administration of naloxone before they can carry it on duty. The Home Office must provide additional funding to all 43...

Matched on terms: harm, reduction

Committee recommendation

#17 - Urgently complete assessment and support The Thistle's drug checking licence application.

Scottish Affairs Committee

The Home Office should urgently complete its assessment of The Thistle for a drug checking licence and should ensure any necessary support is provided to ensure The Thistle is successful in its application. The Home Office should provide an update on the progress of the drug checking license in its response to this report. (Recommendation, Paragraph 128) The...

Matched on terms: drug

Committee recommendation

#7 - Addressing Scotland's severe drug crisis requires significant, commensurate investment due to high fatalities.

Scottish Affairs Committee

However, any discussion of the cost of The Thistle must be considered in the context of Scotland’s drugs crisis, with 1,172 people having died from drugs in 2023 alone. While it is right that the cost of The Thistle is properly considered, it must be recognised that the scale of Scotland’s emergency inevitably requires a commensurate response that...

Matched on terms: drug

Christine Stevenson

Mar 2016 · Manchester (South)

The coroner raised concerns about the lack of control over the amount of Oramorph medication prescribed. While its morphine content falls below the threshold for controlled drug requirements, large quantities present a serious risk to health and are subject to abuse.

Matched on terms: drug

Matthew Hamilton

Feb 2019 · County Durham and Darlington

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.

Matched on terms: drug

Aug 2019 · West Sussex

The coroner noted insufficient counselling regarding the risks of exceeding a prescribed medication dose, with warnings on the drug leaflet and bottle also deemed inadequate.

Matched on terms: drug

Feb 2021 · Inner West London

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.

Matched on terms: drug

Victoria Storey

Jun 2023 · Surrey

The coroner notes that the potent illicit synthetic opiate RT4563 is not currently controlled under the Misuse of Drugs Act 1971, despite recommendations to classify it. This creates a high risk of fatal overdose, as users cannot know the actual contents of the illicit substance.

Matched on terms: drug

Frederick Ireland-Rose

Jun 2025 · Inner North London

The coroner raises concerns about the lesser-known presence of nitazenes in vaping fluids and the significant overdose risk this poses. Cannabinoid vape users, often not known to drug services, may be unaware of these risks and have difficulty accessing Naloxone.

Matched on terms: drug

Committee recommendation

#8 - Safer drug consumption facilities are complementary tools, not substitutes for recovery services.

Scottish Affairs Committee

It is also clear to us that SDCFs must not come at the cost of funding current recovery services. It is not an ‘either/or’. Rather, SDCFs are just one tool available to combat problem drug use, which is complementary to, and works in tandem with, recovery services. (Conclusion, Paragraph 84)

Matched on terms: drug

Damion Stanley Joseph Henson

Dec 2013 · Cumbria (South & East)

The coroner raised concerns about multiple deaths at the premises and the lack of 24-hour supervision at a homeless unit. This allows drug users residing there to introduce others out of hours, creating risks for all present.

Matched on terms: drug

Mar 2014 · London (South)

The coroner raised concerns about the policy of dispensing several days' supply of methadone to drug-dependent individuals during public holidays, noting the risk of future deaths when usual provision methods are suspended.

Matched on terms: drug

Apr 2014 · Norfolk

The coroner raised concerns regarding the lack of a timely medication review for a patient with known addiction issues, and the absence of a detailed record of the medication discussion or a future plan for its reduction.

Matched on terms: reduction

Arenijus Nedzelskies

Jan 2016 · South Lincolnshire

Concerns included that 5F AKB-48 and SF PB-22 are not controlled under the Misuse of Drugs Act 1971, and that the deceased had not reported his chronic misuse of cannabinoid receptor agonists to the DVLA.

Matched on terms: drug

Nov 2016 · Cornwall and Isles of Scilly

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.

Matched on terms: limited

Feb 2017 · Cornwall and Isles of Scilly

The coroner notes the ease with which an unlicensed and fatal weight loss drug (2,4 Dinitrophenol) could be obtained online from Turkey and delivered via Royal Mail.

Matched on terms: drug

Nov 2024 · Manchester South

Maintaining ketamine's classification as a Class B drug risks encouraging its use under the false impression it is safer than Class A drugs, with users often unaware of the significant long-term health problems it causes.

Matched on terms: drug

Committee recommendation

#20 - The Thistle's operational status remains precarious without UK Government approval or legislation.

Scottish Affairs Committee

Without the UK Government’s approval or a change in legislation, The Thistle and potential other Safer Drug Consumption Facilities could, theoretically, continue to operate in Scotland indefinitely but this is not a desirable situation as their status would be precarious and uncertain. (Conclusion, Paragraph 137)

Matched on terms: drug

Committee recommendation

#16 - Require UK Government to consider applications for medical equipment exemptions at The Thistle.

Scottish Affairs Committee

If an application for exemptions from the Misuse of Drugs Act 1971 to enable the provision of medical equipment at The Thistle were made by Glasgow City HSCP or the Scottish Government, the UK Government should consider such an application on its merits, as evidence suggests this could enable The Thistle to maximise its effectiveness. (Recommendation, Paragraph 127)

Matched on terms: drug

Committee recommendation

#57 - Establish a national naloxone programme in England and rapidly expand provision to at-risk groups.

Home Affairs Committee

We recommend that the Government establish a national naloxone programme in England to bring it in line with the devolved nations. We also recommend that the Government speed up its work on expanding the provision of naloxone following the UK-wide consultation in 2021. Expanding provision must include any service and person who may come into contact with people...

Matched on terms: harm

Committee recommendation

#56 - National naloxone programme absent in England despite clear evidence of lifesaving effects.

Home Affairs Committee

The evidence on the lifesaving effects of naloxone in counteracting opioid- related overdose is clear. We welcome the national naloxone programmes in the devolved nations but are concerned that no such programme exists in England. We also welcome the joint working between the Government and the devolved Drugs 79 administrations to expand access to naloxone. However, progress is...

Matched on terms: drug

Committee recommendation

#19 - Demonstrate an evidence-based approach and consider The Thistle's independent evaluation for policymaking.

Scottish Affairs Committee

The UK Government must demonstrate that it has an evidence-based approach to policy making and will consider the independent evaluation of The Thistle. Any intervention found to be effective at saving lives and reducing harm should not be dismissed. (Recommendation, Paragraph 136)

Matched on terms: harm

PPO recommendation

The Head of Healthcare

The Head of Healthcare should ensure that all prison leavers with a history of substance misuse are offered naloxone and harm reduction advice on release in line with Practice Plus Group’s policy.

Matched on terms: harm, reduction

PPO recommendation

The Head of Healthcare and the Substance Misuse Service Lead

The Head of Healthcare and the Substance Misuse Service Lead should ensure that prisoners with a history of substance misuse are offered harm reduction advice before their release.

Matched on terms: harm, reduction

PPO recommendation

The Director of HMP Parc

The Director should ensure that Parc’s drug supply and demand reduction strategy: • is up-to-date and properly implemented to help reduce the availability and misuse of illicit substances; and • includes measures to address the diversion of prescribed medication.

Matched on terms: drug, reduction

Committee recommendation

#12 - First Report - The future of UK music festivals

Digital, Culture, Media and Sport Committee

We are highly concerned that a compressed festival season, the likely circulation of high-strength, adulterated drugs and increased risk-taking after lockdown will lead to a spike in drug-related deaths at festivals this summer. We heard compelling 34 The future of UK music festivals arguments that drug checking saves lives, but in many cases service providers and police forces...

Matched on terms: drug

Committee recommendation

#4 - The Thistle's current legal position creates risks for operators and users lacking a full framework.

Scottish Affairs Committee

The current Lord Advocate’s statement of prosecution policy has been pivotal in enabling The Thistle to open. However, the Lord Advocate’s prosecutorial discretion is not a substitute for a considered legal framework to enable and regulate safer drug consumption facilities. The Thistle’s current legal position creates potential risks for people operating and using the facility. While the operators...

Matched on terms: drug

HSSIB recommendation

Mental health: attempted suicide while under the care of community services

Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.

Matched on terms: drug

Committee recommendation

#160 - Widespread illicit substance availability normalises drug use and addiction within prisons.

Justice Committee

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 high number of people entering prison with an existing addiction, and the worrying trend of prisoners who had...

Matched on terms: drug

Committee recommendation

#13 - First Report - The future of UK music festivals

Digital, Culture, Media and Sport Committee

We recommend that, before festivals take place this summer, the Home Secretary should make regulations under section 7 of the Misuse of Drugs Act 1971 that allow organisations conducting drug checking to operate lawfully. Thereafter, the Government should introduce a dedicated licensing scheme for drug checking to set a clear legal framework and minimum standards that service providers...

Matched on terms: drug

Committee recommendation

#18 - Require UK Government to seriously consider evaluation of The Thistle and merits of SDCFs.

Scottish Affairs Committee

The Minister has stated that the UK Government will consider the evidence emerging from the pilot. However, it was clear from the Minister’s evidence that the Home Office will not make legislative changes, even if the evaluation finds that the facility has been effective in meeting its aims. The UK Government should not approach the evaluation having already...

Matched on terms: drug

Committee recommendation

#12 - Drug strategy requires rapid adaptation to emerging synthetic opioid threats, with ongoing government preparedness.

Public Accounts Committee

Mr Trace told us that changes in drug markets can happen rapidly, and that if synthetic opioids became more prevalent in the UK, the strategy would need to adapt rapidly.35 Mr Lay told us that there had been a synthetic opioid (isonitazenes) outbreak in London in 2021 and that policing was undertaking significant work on this threat.36 The...

Matched on terms: drug

Committee recommendation

#48 - Commit to establishing long-acting buprenorphine as first-line treatment for opioid dependence in England.

Home Affairs Committee

We recommend that the Government go further than its commitment under the 10- Year Drugs Strategy to explore the rollout of long-acting buprenorphine and commit to establishing it as a first-line treatment option in England for people with an opioid dependence.

Matched on terms: drug

IOPC learning recommendation

Recommendations - Norfolk Constabulary, August 2023

The IOPC recommends that Norfolk Constabulary takes steps to ensure that response officers, who come into contact with a person who is believed to have consumed drugs, consider the possibility of whether the person has consumed different drugs. Drugs taken in combination may increase the risk of harm or death and should be considered an additional risk factor...

Matched on terms: drug, harm

IMB recommendation

whether there could not be a greater emphasis on alternative strategies than ones of prohibition and interdiction of the actual supply and the provision of treatment options for those caught up in its effects. We mean by this a strategy which counters the reasons that prisoners find drug-taking either attractive as a way of dealing with their personal...

Matched on terms: drug

Neil Richard Clark

Sep 2013 · Birmingham and Solihull

The coroner noted concerns regarding hotel security leaving the deceased unattended on a landing for six hours without subsequent checks. He was rediscovered by a guest the next day, not a staff member, despite staff awareness of his presence.

Matched on classifier match

Catherine Findlay

Oct 2015 · Manchester (West)

The coroner raised concerns about the free availability and misuse of dangerous "research chemicals" like MXP, which are sold over the internet yet are not controlled substances. A review of MXP's status and control was requested to prevent future deaths.

Matched on classifier match

Committee recommendation

#55 - Increase provision of essential equipment and additional services for needle and syringe programmes.

Home Affairs Committee

The Combating Drugs Minister must work with the Department of Health and Social Care, the devolved administrations, and health partners to ensure that the provision of equipment—particularly low dead space syringes and safe water—is increased to reduce the transmission of blood-borne viruses and other illnesses. The Combating Drugs Minister must work to ensure that needle and syringe programme...

Matched on terms: drug

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