Limited drug harm reduction
The 10-Year Drugs Strategy's insufficient range of harm reduction approaches, with an over-emphasis on abstinence-based recovery.
Source spread
Where this theme appears
This theme appears across 14 independent accountability sources, so the source mix matters as much as the headline total.
29 PFD reports
30 committee recs
2 HSSIB recs
10 PPO recs
2 IOPC recs
8 IMB recs
1 Scottish FAI
1 detention investigation rec
102 DHR recs
1 PHSO 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(29)
Christopher Scott
Concerns: The coroner identified that AMT, a 'legal high', is readily available for purchase online and in the community, and has been linked to several deaths due to its deadly effects.
Overdue
Damion Stanley Joseph Henson
Concerns: 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.
Overdue
Neil Richard Clark
Concerns: 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.
Overdue
Deanne Smith
Concerns: 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.
Response (United Pharmacy): • United Pharmacy pharmacists are working with patient special workers to exchange information on clients using Bromley Drugs and Alcohol services. • United Pharmacy holds regular meetings with Bromley Drugs … (AI summary)
Overdue
Kathryn Sawyer
Concerns: 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.
Response (Roundwell Medical Centre): • The medical centre stated that patients on addictive medication would be assigned to a single GP where possible to ensure continuity of care. • The medical centre committed to … (AI summary)
Responded
Catherine Findlay
Concerns: 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.
Response: • The Psychoactive Substances Bill was introduced to ban the sale, supply, production, and distribution of psychoactive substances for human consumption, including MXP. • A comprehensive action plan on New … (AI summary)
Overdue
Arenijus Nedzelskies
Concerns: 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.
Response (Home Office): • The Psychoactive Substances Act 2016 received Royal Assent, restricting the production, supply, and importation of psychoactive substances. • The government banned over 500 new drugs and established a Forensic … (AI summary)
Overdue
Elvis Snelson
Concerns: The coroner raised concerns about the dangers of acetylfentanyl, a highly potent opioid sold as a 'legal high', noting that users may be unaware they have consumed an opioid with toxic effects like sedation and respiratory depression.
Overdue
Christine Stevenson
Concerns: 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.
Response (Christine Stevenson): • The coroner's letter has been shared with the Local Intelligence Network (LIN). • The issue of volumes and strengths of controlled drugs prescribed will be raised, and guidance will … (AI summary)
Response (Home Office): • Officials consulted with the Department of Health and the Care Quality Commission regarding the prescribing of opiate medicines. • Information from the investigation was added to the Yellow Card … (AI summary)
Responded
Robert Lloyd
Concerns: The coroner noted difficulties in providing supportive treatment for alcohol abusers on the Isles of Scilly due to limited face-to-face support. This was exacerbated by reduced transport services, making it challenging for professionals to travel and engage with service users.
Response (The Health Centre): • The Health Centre met with the Drug and Alcohol Action Team of Cornwall Council to discuss future services and undertook training for two pharmacists. • A new Addaction worker … (AI summary)
Response (Drug Alcohol Action Team): • The Drug Alcohol Action Team has appointed an Adults Recovery Co-ordinator who has commenced fortnightly visits to the islands. • The contract with Addaction will require fortnightly island visits … (AI summary)
Overdue
Anna Phillips
Concerns: 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.
Response (Food Standard Agency): • The National Food Crime Unit (NFCU) submitted 31 abuse complaints to domain name registrars, resulting in 21 domain names being suspended. • The NFCU engaged with a major online … (AI summary)
Responded
Ian Wolstenholme
Concerns: 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.
Response (Department of Health): • The Medicines and Healthcare products Regulatory Agency (MHRA) is undertaking a review of product information for all opioid medicines. • Information relating to the medicines involved in the death … (AI summary)
Overdue
Matthew Hamilton
Concerns: The coroner identified that heroin users released from custody are often unaware of their reduced drug tolerance after abstinence and the fatal risks of consuming pre-custody drug levels.
Response (HM Prison Probation Service): • The Drug and Alcohol Reduction Team (DART) updated its guidance pack, which will be offered to all prisoners on discharge from HMP Durham and to those with potential release … (AI summary)
Responded
George Rimmer
Concerns: 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.
Response (Boehringer Ingelheim): • Boehringer Ingelheim stated it would propose to the Medicines and Healthcare products Regulatory Agency (MHRA) to add a warning to the Patient Information Leaflet (PIL) advising against drinking directly … (AI summary)
Responded
Matthew Fitten
Concerns: The coroner noted that despite a prescription for single daily dosage bottles, large multi-dose methadone bottles were supplied without a measuring device or instructions for accurate daily dosing.
Response (Haverhill Pharmacy): • The pharmacy confirmed its normal and current procedure is to supply methadone in individual containers. • The pharmacy indicated it would inform prescribers in advance if it faces any … (AI summary)
Response (UK Health Security Agency): • PHE reiterated to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements. • PHE strengthened guidance on individualised risk assessments in subsequent … (AI summary)
Responded
Kimberley Smith
Concerns: The coroner identified no clear written policy for informal patients requesting leave from an Acute Care Unit, specifically regarding risk assessments and risk management. Concerns also included outstanding aspects of a protocol for managing alcohol detoxification on mental health wards.
Response (Surrey and Borders Partnership NHS Foundation Trust): • The Trust stated it would develop a standalone written policy for informal patient leave, incorporating risk assessments, monitoring, and reporting missing persons. • The Trust confirmed it had completed … (AI summary)
Responded
Daniel Mervis
Concerns: Oxford University lacks an overarching drug policy for its colleges, and St John's College has a potential conflict between its strict drug misuse policy and the support offered for addiction, which may deter students from seeking help. The college's drug policies also require wider advertisement.
Response (St Johns College Oxford): • A Task and Finish group has been established by the Conference of Colleges to develop a template drug misuse policy for all colleges. • St John's College stated it … (AI summary)
Responded
Amy Ganner
Concerns: The coroner noted the complexity of opioid tolerance and recommended the Department of Health produce a leaflet explaining tolerance and the serious risk of toxicity for patients prescribed opiate medication.
Response (Department of Health and Social Care): • The Medicines and Healthcare products Regulatory Agency (MHRA) updated warnings on opioid product information and packaging to include consistent information on dependence, addiction, and tolerance risks. • The MHRA … (AI summary)
Responded
James Lacey
Concerns: The coroner noted that a substance, easily purchased in relatively small quantities, is classified as a 'reportable poison', which involves less rigorous control measures compared to 'regulated poisons'.
Overdue
Edward Capovila
Concerns: The coroner noted relatively little information is available about more unusual ways fentanyl can be misused or abused, raising concern about future deaths if action is not taken.
Response (Medicines Healthcare products Regulatory Agency): • The MHRA issued a drug safety bulletin in December 2014 warning healthcare professionals and patients of the risk of overdose and death with fentanyl patch exposure to increased heat. … (AI summary)
Responded
Kayleigh Burns
Concerns: The report identifies a need to review the legal framework concerning Nitrous Oxide, given its increasing use by young persons and the associated risk of future deaths.
Overdue
Victoria Storey
Concerns: 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.
Response (Home Office): • The Government committed to control 11 synthetic opioids, including the one in question, under Class A of the Misuse of Drugs Act 1971 and Schedule 1 of the Misuse … (AI summary)
Overdue
Kristopher Tilbury
Concerns: 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.
Overdue
Sean Crawford
Concerns: The coroner noted a lack of specific guidance in academic literature, BNF, NICE, or MHRA regarding the risk of death from the combined effects of clozapine and alcohol. Existing medication leaflets advise against alcohol but do not explicitly state death as a possibility in this scenario.
Response (BNF): • The pharmacodynamic interaction tables have been added to the online versions of the BNF and BNFC. • The organisation plans to review the wording around the use of drugs … (AI summary)
Response (Medicine and Healthcare products Regulatory Agency): • The MHRA stated it would conduct a further assessment of the information provided within the clozapine product information regarding drug-drug interactions. • The MHRA indicated it would consider whether … (AI summary)
Response (Department of Health and Social Care): • Departmental officials shared the report with the National Institute for Health and Care Excellence (NICE) for its consideration of published guidance. • The Medicines & Healthcare products Regulatory Agency … (AI summary)
Responded
James Boland
Concerns: 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.
Response (The Home Office): • The Home Office stated it would commission the Advisory Council on the Misuse of Drugs (ACMD) to conduct an updated harms assessment of ketamine. (AI summary)
Responded
Joseph Forbes Black
Concerns: 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.
Response (NHS England): • NHS England noted that legislative changes now permit community pharmacies to provide take-home naloxone without a prescription. • Regional Patient Safety colleagues engaged with Islington Better Lives, which confirmed … (AI summary)
Response (Department of Health and Social Care): • The Government amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services. • The amendments increased the number of specified services and … (AI summary)
Responded
Joshua Leatham-Prosser
Concerns: 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.
Response (Home Office): • The Minister of State for Policing, Fire and Crime Prevention formally commissioned an updated harms assessment of ketamine from the Advisory Council on the Misuse of Drugs (ACMD) on … (AI summary)
Responded
Frederick Ireland-Rose
Concerns: 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.
Response (Department of Health and Social Care): • The Department of Health and Social Care (DHSC) maintains a surveillance system to track changing drug markets and harms, incorporating toxicology results. • The UK controlled 15 named synthetic … (AI summary)
Response (Advisory Council on the Misuse of Drugs): • The Advisory Council on the Misuse of Drugs (ACMD) published advice on nitazene opioids in July 2022 and has since updated its report five times, with a further addendum … (AI summary)
Responded
Matthew Singh Prevention of future deaths report
Concerns: The coroner noted the continuing availability and use of psychoactive substances at HMP Berwyn, despite ongoing initiatives, posing significant risks to the health of prisoners and the potential for future deaths.
Response (HM Prison Probation Service): • HMPPS is investing over £40 million in physical security enhancements across 34 prisons, including £10 million for anti-drone measures. • Incentivised Substance Free Living Units have been implemented in … (AI summary)
Overdue
Select committee recommendations(30)
#12 —
Recommendation: 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 …
Response attribution not verified
#21 — Work with Scottish Government to create sustainable legal framework for Safer Drug Consumption Facilities.
Recommendation: 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 …
Response attribution not verified
#20 — The Thistle's operational status remains precarious without UK Government approval or legislation.
Recommendation: 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 …
Response attribution not verified
#17 — Urgently complete assessment and support The Thistle's drug checking licence application.
Recommendation: 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 …
Response attribution not verified
#16 — Require UK Government to consider applications for medical equipment exemptions at The Thistle.
Recommendation: 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 …
Response attribution not verified
#15 — The Thistle's full effectiveness is inhibited without key harm reduction equipment and services.
Recommendation: 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 …
Response attribution not verified
#14 — Require the Lord Advocate and Scottish Government to consider future inhalation room applications on their merits.
Recommendation: 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 …
Response attribution not verified
#13 — Legal barriers prevent The Thistle from operating effective drug inhalation rooms.
Recommendation: 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 …
Response attribution not verified
#7 — Addressing Scotland's severe drug crisis requires significant, commensurate investment due to high fatalities.
Recommendation: 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 …
Response attribution not verified
#5 — Establishing multiple safer drug consumption facilities requires a clear, common UK legal framework.
Recommendation: 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 …
Response attribution not verified
#4 — The Thistle's current legal position creates risks for operators and users lacking a full framework.
Recommendation: 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. …
Response attribution not verified
#174 — Mandate universal rollout of take-home naloxone kits and training for all leaving custody.
Recommendation: The MoJ and NHS England, or its successor, must mandate the immediate, universal rollout of take-home naloxone kits for all individuals leaving custody. This must be coupled with comprehensive, compulsory training for all prisoners and staff. This public health measure …
Response attribution not verified
#59 — Mandate all police forces to roll out voluntary naloxone provision, including funding and training.
Recommendation: 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 …
Response attribution not verified
#58 — Non-universal naloxone provision by English police forces creates a dangerous postcode lottery.
Recommendation: The efforts of UK police forces to roll out this life saving treatment is welcome. However, provision of naloxone across English forces is not universal, which risks creating a postcode lottery on the availability of this potentially life-saving treatment in …
Response attribution not verified
#57 — Establish a national naloxone programme in England and rapidly expand provision to at-risk groups.
Recommendation: 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 …
Response attribution not verified
#56 — National naloxone programme absent in England despite clear evidence of lifesaving effects.
Recommendation: 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 …
Response attribution not verified
#13 —
Recommendation: 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 …
Gov response: The government has a strong track record on investing to tackle drug misuse through the Home Office. No illicit drug can be assumed to be safe and there is no safe way to take illicit …
Accepted
#19 — Demonstrate an evidence-based approach and consider The Thistle's independent evaluation for policymaking.
Recommendation: 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, …
Gov response: The Government is committed to an evidence-based approach towards drug policy within the law, ensuring we are following the evidence and taking account of any relevant considerations when providing measures to tackle substance misuse. This …
Rejected
#18 — Require UK Government to seriously consider evaluation of The Thistle and merits of SDCFs.
Recommendation: 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 …
Response attribution not verified
#55 — Increase provision of essential equipment and additional services for needle and syringe programmes.
Recommendation: 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 …
Gov response: The Government partially accepts this recommendation. 20 Injectable opioid treatment: commissioning and developing a service - GOV.UK (www.gov.uk) Needle and syringe programmes are already embedded into, or work alongside, drug and alcohol services, commissioned by …
Accepted in Part
#54 — Ensure needle and syringe programmes reach wider populations to prevent blood-borne virus transmission.
Recommendation: We are concerned by the effect the Covid-19 pandemic has had on the provision of needle and syringe programmes. The UK must continue its efforts in preventing the spread of blood-borne viruses by ensuring needle and syringe programmes reach as …
Response attribution not verified
#21 — Update the 10-Year Drugs Strategy to increase available harm reduction approaches for treatment.
Recommendation: 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.
Response attribution not verified
#20 — 10-Year Drugs Strategy needs to expand its range of harm reduction approaches.
Recommendation: 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 …
Response attribution not verified
#10 — Local community concerns regarding The Thistle's impact require serious attention despite ongoing evaluation.
Recommendation: Community support and the impact of the SDCF on the local community is of paramount importance to the success of The Thistle. While we are reassured that the ongoing independent evaluation is monitoring the levels of discarded paraphernalia and the …
Response attribution not verified
#8 — Safer drug consumption facilities are complementary tools, not substitutes for recovery services.
Recommendation: 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, …
Response attribution not verified
#160 — Widespread illicit substance availability normalises drug use and addiction within prisons.
Recommendation: The widespread and increasing availability of illicit substances has fostered a culture of acceptance that normalises drug use in prisons. This makes the presence of drugs inescapable for many prisoners. The situation is made worse by two key factors: the …
Response attribution not verified
#34 — Implement report recommendations on harm reduction, especially expanding drug diversion schemes for offenders.
Recommendation: 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.
Gov response: The Drug Strategy already provides strong support for harm reduction approaches and expansion of measures to reduce drug use. We recognise that a system wide approach is required to deliver interventions that support those caught …
Position Not Stated
#48 — Commit to establishing long-acting buprenorphine as first-line treatment for opioid dependence in England.
Recommendation: 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 …
Gov response: The Government accepts this recommendation and is already supporting the further rollout of long-acting buprenorphine. 126 local authorities provide long-acting buprenorphine as a treatment option to their population. From the end of 2021–22 to the …
Accepted
#12 — Drug strategy requires rapid adaptation to emerging synthetic opioid threats, with ongoing government preparedness.
Recommendation: 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 …
Response attribution not verified
#47 — Long-acting buprenorphine shows encouraging results for opioid treatment in Wales.
Recommendation: We welcome the 10-Year Drug Strategy’s recognition of the potential positive impact of long-acting buprenorphine. We think that the use of Buvidal in Wales has provided a very encouraging UK evidence base and proved that it is an effective form …
Response attribution not verified
HSSIB safety recommendations(2)
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.
Area of Improvement
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
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.
Area of Improvement
NCEPOD recommendations(3)
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
PPO death in custody recommendations(10)
The Head of Healthcare at HMP Exeter
The Head of Healthcare at HMP Exeter should ensure that prisoners who are assessed as being at risk of opioid overdose are provided with naloxone training at the earliest opportunity and given a naloxone kit when they leave prison.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who are assessed as at risk of opioid overdose are provided with a naloxone kit when they leave prison.
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.
The Head of Service Delivery for substance misuse
The Head of Service Delivery for substance misuse should satisfy themselves that the local policy on the offer and issue of naloxone on release captures prison leavers with previous opiate use and other relevant risk factors.
The Head of Healthcare
The Head of Healthcare should work in partnership with Practice Plus Group, the regional Health and Justice Leads and regional drug providers to satisfy themselves that: • the local policy on the offer and issue of naloxone on release captures …
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.
The National Probation Service
The National Probation Service should review the position on the use of naloxone and make a decision about whether it should be made available for use by AP staff
The Manager of Peterborough AP
The Manager of Peterborough AP should update the Head of the National Approved Premises Team on measures taken to ensure that staff discuss residents’ reduced tolerance to drugs during induction.
The Head of Service Delivery (Substance Misuse)
The Head of Service Delivery (Substance Misuse) will wish to review the circumstances of Mr Wood’s release to ensure that the processes for issuing naloxone to prisoners on release are robust.
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.
IOPC learning recommendations(2)
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 …
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, can recognise the signs and symptoms of toxicity for commonly encountered drugs (as …
IMB individual recommendations(8)
Portland (2020)
The ingress of illicit drugs into Portland needs to be addressed. It is having an impact on the health and well-being of prisoners and staff, and is linked to debt, bullying, violence, isolation and overall stability in the prison.
Governor / Director
Swaleside (2020)
The efforts to prevent the ingress of weapons, phones and drugs are well appreciated and must continue unabated in order to improve this problem. The continued ingress of mobile phones is particularly worrying as a major route through visits has been cut off during the COVID-19 lock-down (see section 4).
Governor / Director
Dartmoor (2020)
There continues to be a serious level of substance misuse at HMP Dartmoor. What additional measures are planned to address this, particularly in the absence of capital investments such as portals and itemisers?
HMPPS
Wayland (2024)
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 pains of …
Governor / Director
Rochester (2020)
The Board retains the view that to enable a better outcome for prisoners and reduce re-offending, increased funding for resources should be allocated across the entire prison estate for tackling drug-use by prisoners. This includes improvements in security technology and intervention programmes.
Ministry of Justice
In Progress
Norwich (2020)
Is the Prison Service analysing the repercussions of the replacement of tobacco by vapes, and what are the conclusions?
HMPPS
Implemented
Wayland (2021)
The Board hopes, in addressing the scourge of drugs and intoxicants in prison, that innovative use of modern technology, including the use of targeted sobriety testing or tagging, and an enlargement of official ways of sourcing permitted items, could be researched as a policy initiative by the Prison Service and so recommends (see section 4.6).
HMPPS
Partially Accepted
Bullingdon (2022)
There continues to be a problem with the availability and use of drugs. This is despite the strenuous efforts which were made in the reporting year on the part of the prison. What further steps can the Prison Service take to address the availability and use of drugs in the prison?
HMPPS
Health investigations(88)
Independent investigation: Katie Kazmi, Reading (1999) — Rec 1
The Department of Health and the Home Office in conjunction with the relevant professional bodies should formulate guidelines for the testing for substance misuse with restricted patients.
south_east
Independent investigation: Brian Cherry, Walthamstow (2004) — Rec R3
Although objectively drug free for many years relapse prevention in terms of substance misuse should be undertaken.
london
Independent investigation: Lenny Leak, Gateshead (2001) — Rec 4
Drug and alcohol misuse is a problem which presents itself to all agencies. The Panel recommends that the Drug Action Team reviews the policy and procedures of all agencies to ensure that there are pro-active and resilient services available for those with drug and alcohol problems. This review should include …
north_east_yorkshire
Independent investigation: Laura Sturla, Gillingham (2003) — Rec 10
The trust should review its policy on the management of patients with substance misuse problems admitted to an acute inpatient ward. This should include a clear policy on the use of behavioural contracts, breathalysing and urine drug screening.
south_east
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 38
Psychiatric trainees should receive training in the management and treatment of patients with mental illness and co-existing substance misuse, and how such complex cases can pose further management difficulties in cases where there is also personality disorder and/or violence.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 34
When dealing with offenders who are mentally disordered and/or habitual drug users, the Probation Service should always consider applying for a Condition of any Licence, requiring the offender to undergo psychiatric and/or drug treatment following their release from prison.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 33
The Drug Action Team should ensure that substance misuse services develop interventions which attempt to maintain engagement with chaotic and risky patients, irrespective of whether the patient is committed to the therapeutic process (e.g. outreach services targeted at such people).
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 32
No-one referred by a GPor CMHTshould be discharged from the drug service without a risk assessment being carried out.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 31
The Drug Action Team should ensure that substance misuse services are adequately assessing the risks posed by those referred to them.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 22
As part of their continuing professional development, consultants in general psychiatry should be trained in the management and treatment of patients with mental illness and co-existing substance misuse, and how such complex cases can pose further difficulties in management in cases where there is also personality disorder and/or violence.
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 9
The trust should, in partnership with the police, exercise consider the use of acute wards as training areas for police sniffer dogs, to reduce the supply of illicit substances.
north_west
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 8
The trust should support the care team in dealing with inpatient substance misuse by producing a robust policy to deal with the issue. The policy should recognise that: a. previous substance misuse or excessive alcohol consumption, should always act as an indicator of a potential for disturbed behaviour and be …
north_west
Independent investigation: Wendy Pashley, Rotherham (2006) — Rec 3
Although it is not uncommon for mental health service users to have a higher alcohol intake than is recommended, the Trust needs to develop a more proactive approach to the education of its service users about excessive drinking and also information about local support groups if the service user and/or …
north_east_yorkshire
Independent investigation: Vincent Francis, Wells (2009) — Rec 1
The development of standardised tools which specifically measure alcohol/substance dependency should be promoted for common use in services when risk assessment indicates a problem with alcohol and substance misuse.
south_west
Independent investigation: Robert Lewis, Sutton (2010) — Rec One
It is recommended that the Trust considers how future services and clinical care pathways are established for adolescent substance misusers to address their needs, and that a report outlining appropriate plans to address this issue is presented to the executive committee.
london
Independent investigation: Paul Taylor, Jarrow (2019) — Rec 6
Specialist substance misuse services or staff must be requested to advise on, or to assess and contribute to, care and treatment plans where there are substance misuse issues and associated risk to others.
north_east_yorkshire
Independent investigation: John Speakman, Wigan (2006) — Rec 1
Where service users with substance misuse problems are engaged for assessment and/or treatment delivery by general adult services, rather than specialist dual diagnosis services, it is important that a thorough exploration of the service user’s substance misuse is undertaken, recognising that this can be challenging and some service users will …
north_west
Independent investigation: John Hall, West Rainton (2013) — Rec 4.7.2
Community teams should seek specialist advice as required in relation to treatment strategies when managing patients with a history of drug and/or alcohol abuse who do not engage with the service.
north_east_yorkshire
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R17
Drug screening must be systematically and routinely carried out on any patient suspected of using illicit drugs.
london
Independent investigation: Hugh McCaffrey, Willesden — Rec 5.87
Care Plans prepared for clients needing to use the drug and alcohol rehabilitation services should clearly identify users’ assessed needs and the availability of the services which will need to be accessed and such should be noted on an accessible database available to all relevant agencies.
london
Independent investigation: Ian Dollery, Lytham St Annes (2015) — Rec 2
Lancashire Health and Wellbeing Board should assume responsibility for the coordination of a forum to develop and implement a local dual-diagnosis protocol that provides: - A coordinated and collaborative whole system integrated pathway to support individuals who misuse substances so that they have access to high-quality physical and mental healthcare, …
north_west
Independent investigation: Brian Dodd, Prestatyn (2003) — Rec c)
There should be a low threshold for tolerance of substance mis-use in the community, where it has any impact on the risk of dangerousness and a clear management plan where substance misuse occurs, should be specified in the care plan.
wales
Independent investigation: Brian Dodd, Prestatyn (2003) — Rec b)
That all patients discharged from secure care with a history of alcohol or drug abuse/misuse should be routinely, regularly and randomly tested for illicit drugs and alcohol use. This could be applied with urine testing, hair testing and breathalysing. It should be considered and specified in the care plan.
wales
Independent investigation: Ben Cargill (Mr D), Chesham, Bucks (2004) — Rec five
The inquiry panel recommends that the inpatient unit review their processes to ensure that: • Where a person continues to misuse substances then a more active management of these problems should be undertaken either by a referral to specialist services or through the adult service with support from the specialist …
south_east
Independent investigation: Beatrice Hughes, Harrow (1997) — Rec d.
develop joint strategies in conjunction with primary care and voluntary agencies to overcome the cycle of short-term in-patient admissions followed by a return to Drug and/or alcohol misuse for certain individuals like WM.
london
Independent investigation: Antonio Tommaso, New Barnet (2014) — Rec 4
The Trust should ensure that all service users with psychosis who misuse alcohol and/or illicit substances are considered for referral to substance misuse services. If the decision is to not make a referral, the rationale for the decision should be recorded.
london
An assessment of a mental health trust’s internal investigation of … — Rec R4
The trust should ensure that staff preparing medicines management care plans take into account the risk of non-compliance where this is indicated. Where drug dependency is a factor alongside a diagnosed mental health condition, a co-occurring mental health and substance misuse assessment should be conducted.
north_east_yorkshire
Independent investigation into the care and treatment of patient M … — Rec 99
Interventions utilising a health model, for example, adopting a harm reduction approach and viewing substance misuse as a psychological disorder, are more likely to promote the alliance between prisoners and staff which is necessary for the prison community to address widespread use of NPS.
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 97
Various methods of information sharing have been adopted, such as prison radio, poster campaigns and distributing leaflets and promotional materials. This should be a priority because prisoners report only patchy access to information, with particularly low levels of information on harm reduction such as keeping safe if using, and keeping …
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 96
Education is the main preventative health intervention, especially in preventing the proportion of users who use NPS for the first time in prison. Topics include drug refusal skills, risks to physical and mental health, and the unpredictable effects of NPS compounds as they are composed of different types of substances …
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 95
Preparation for release should include specific advice about the risk of relapse, emphasizing that cannabis is a less risky choice than the synthetic cannabis in NPS.
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 94
Once the person is accepting of the need for change, evidence-based interventions include an individual assessment of treatment need, and both educational and therapeutic groups. This can include group work led by prisoners. Other self-help initiatives are the establishment of users’ forums, and the use of peer mentors to offer …
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 92
Prison services have considerable expertise in delivering clinical and psychosocial treatments to substance misusers. Users of NPS can be offered the same range of interventions.
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 90
It is difficult to be sure what has been used, so each situation must be managed according to the presenting problem. The most common adverse effects of NPS use – nausea, increased heart rate and agitation – will respond to simple interventions, such as encouraging fluids, a calm and reassuring …
east_of_england
*Independent investigation into the care and treatment of Mr L: … — Rec 7
Ward staff should provide information on treatment and support options to people who experience drug and alcohol problems as a routine intervention and a system should be in place to support this.
Mr. L. At the time of the incident (2011) Mr L had three brief episodes of care with South West Yorkshire Partnership NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr B: … — Rec 4.7.2
Community teams should seek specialist advice as required in relation to treatment strategies when managing patients with a history of drug and/or alcohol abuse who do not engage with the service.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Ms … — Rec 6
Specialist substance misuse services or staff must be requested to advise on, or to assess and contribute to, care and treatment plans where there are substance misuse issues and associated risk to others.
north_east_yorkshire
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 1
Given the changes in access to Specialist Drug and Alcohol Services the Trust should put in place mechanisms to demonstrate and monitor this improvement. • The Trust should develop a reliable and valid methodology for monitoring: o access to the service; o commencement of treatment. In the first instance this …
south_west
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 10
Where there is recognition of a substance misuse problem then there should be a clear and continuing strategy of intervention.
north_east_yorkshire
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 6
The panel recommends to the Trust that a policy on screening for the use of illicit substances by patients is developed as a matter of urgency within three months. (Paragraph 5.12)
east_of_england
Independent investigation: Janet Frost, Meadowfielsd – County Hospital Durham (1999) — Rec 8.4
The trust and social services should review the inter relationship of substance misuse services across their organisations.
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 21
The Trusts should develop a protocol with the local police regarding the possession and use of illegal drugs by an in-patient on hospital premises.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 10
The case of DN has highlighted a number of training issues which are pertinent today. There is a need to address: (cid:2) risk assessment and management training across the whole Mental Health Trust (cid:2) the particular problems associated with substance misuse in conjunction with mental illness, which in some cases …
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 10
The police should be requested to consider formal warnings to patients found to be in possession of illicit substances.
north_west
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 5
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people with a dual diagnosis of mental illness and substance misuse.
midlands
Independent investigation: William Kean, Canning Town (2004) — Rec Three
It is recommended that the Trust provides Dual Diagnosis training to all clinical staff and that this training is audited as to its effectiveness.
london
Independent investigation: Richard James, Northwood (2007) — Rec 6
The Independent Investigation Panel recommend the continued provision of Dual Diagnosis expertise for people with serious mental illness. Given the prevalence and impact of substance misuse on patients within core psychiatric services, the Trust must ensure the continued provision of Dual Diagnostic expertise for this client group. It should seek …
london
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 17
For patients with an identified risk factor of drug use, testing should not only be random but an expected part of their care. This should be clearly explained. Patients should also be told that an adverse inference will be drawn if they fail to give a sample, or otherwise circumvent …
london
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 1
A joint protocol should be agreed between substance misuse services and mental health services outlining joint working procedures and lead responsibility for dual diagnosis clients. (AA)
london
Independent investigation: Miriam Poulin, Macclesfield (2005) — Rec 1
The Trust should issue a clinical update reminding staff that drug use in young people is fairly common. It should be a matter of routine to consider carefully the role of illicit drug use in a patient's presentation.
north_west
Independent reviews(10)
Shaw Detention Review — Rec 53
Recommendation 53: I recommend that the Home Office, in association with service providers, consider what can be done to reduce the use of new psychoactive substances and to advise detainees on the effects of their misuse.
Immigration
Carol Black Drugs Review (Part 2) — Rec 11
We recommend that local authorities commission a full range of evidence-based harm reduction and treatment services to meet the needs of their local population in line with the new national Commissioning Quality Standard.
Health & Social Care
Carol Black Drugs Review (Part 2) — Rec 2
We recommend that the government invests, by the end of year 5 of this programme, an additional £552 million in the treatment system through DHSC and an additional £15 million in employment support through DWP. MHCLG will also need to bid for additional funds for housing support at the next …
Health & Social Care
Leveson Criminal Courts Review — Rec 8
I recommend implementing Out of Court Resolutions alongside restorative justice for low-tier offences such as some thefts, public order offences and drug misuse.
Justice & Legal
Leveson Criminal Courts Review — Rec 6
I recommend further investment in and greater use of rehabilitation programmes for drug and alcohol misuse and other health intervention programmes. This must adhere to a national framework to ensure consistent provision across the country.
Justice & Legal
Gauke Review — Rec 6.3
Ensure female offenders receive appropriate support by (1) expanding the use of liaison and diversion and (2) considering a women’s specific pathway as part of Drug and Alcohol treatment requirements
Justice & Legal
Acheson Report — Rec 26.5
We recommend policies which reduce alcohol-related ill health, accidents and violence, including measures which at least maintain the real cost of alcohol.
Health & Social Care
Gauke Review — Rec 6.10
Continue to monitor emerging medications to treat drug and alcohol dependency
Justice & Legal
Corston Report — Rec 20
Women must never be sent to prison for their own good, to teach them a lesson, for their own safety or to access services such as detoxification.
Justice & Legal
Gauke Review — Rec 2.3
Increase investment in providers of Community Sentence Treatment Requirements to increase accessibility for offenders with substance misuse or mental health issues
Justice & Legal
Domestic Homicide Reviews(102)— showing 50 strongest matches
Sheffield — recommendation 18
STHFT should ensure patients are signposted for specialist support when they are exhibiting evidence of alcohol and drug misuse.
STHFT
Sheffield — recommendation 17
SYP should ensure any person arrested for a ‘trigger’ offence should be the subject of a mandatory drug test and assessment, we well as being offered the support of a drug referral worker.
SYP
South Yorkshire Police
Norfolk — recommendation D
Registration form to be explicit in asking about illicit use of substances and offering onward referral to local services.
Hackney ICB for General Practitioner (GP)
Coventry — recommendation 2
The agencies of Coventry Police and Crime Board should consider how they can increase take-up of substance misuse services for individuals with multiple needs
Coventry Police and Crime Board
Swindon — recommendation 16
Operational officers will be reminded of Force Policy that if either drugs or alcohol are key factors in an offence for which an individual has been arrested, the arrested person should be signposted to a substance abuse support service and this should be recorded on the Custody Record.
Wiltshire Police
Wiltshire Police
Somerset — recommendation 5
To keep abreast of research being undertaken in relation to the misuse of NPS substances with a view to sharing this learning across the partnership to prevent harm.
Somerset Drug and Alcohol Service
Haringey — recommendation 1
Substance misuse services should: (a) Include in their domestic abuse policy a response to non-engagement with services by those on licence. This case shows the link between non-engagement and increasing risk. (b) Engage with multi-agency approaches to addressing victim safety and perpetrator behaviour.
Substance Misuse Agencies
St Helens — recommendation 33
Learning from this review should be cascaded to drug and alcohol treatment services who will consider when developing plans for the outreach elements of their service.
Public Health
St Helens — recommendation 32
Public Health will explore the Borough offer in relation to providing appropriate support for the children of parents with drug and alcohol problems. Support should be available even if parents are unwilling or unable to change their use of drugs or alcohol.
Public Health
St Helens — recommendation 24
Review advice/pathways in place relating to substance misuse issues
St Helens and Knowsley Teaching Hospitals …
St Helens — recommendation 19
That the MARAC consider and document support available to both victim and perpetrator where alcohol abuse is prevalent.
Community Safety Partnership
Buckinghamshire — recommendation GP1-2
To develop practice responses so that individuals presenting with problematic alcohol use are advised about, and encouraged to use, alcohol treatment services
GP Practice 1
Gloucester — recommendation Gloucestershire Hosp
Provide signposting information to Alcohol Services for all patients who attend our Emergency Departments with alcohol-related presentations.
Gloucestershire Hospitals NHS Foundation Trust
Gloucestershire Hospitals NHS Foundation …
Gloucester — recommendation Gloucestershire Cons
That Gloucestershire Constabulary, in conjunction with CGL, should continue to recognise and assist persons presented in custody with alcohol and substance abuse to try and reduce offending and rehabilitate them.
Gloucestershire Constabulary | CGL
Gloucestershire Constabulary
Milton Keynes — recommendation 2
Methods should be found to publicise ways in which people using illegal drugs can approach agencies about domestic abuse without fear of disclosures about illegal drugs being reported. This may involve local voluntary/ third sector groups.
Milton Keynes Community Safety Partnership | …
Basildon — recommendation 7
That a tailored drug and alcohol treatment programme is delivered to those clients who present for treatment and are identified as having been childhood witnesses of serious domestic abuse.
Drug and alcohol treatment agencies
Basildon — recommendation 1
That the appropriate Essex-wide partnership / board monitors; • the number of patients in drug treatment services in south Essex who are also being treated for a personality disorder and / or a diagnosed mental health illness; and • the number of patients in drug treatment and who have an …
Essex-wide partnership / board
New Forest — recommendation 18
A review should be undertaken of alcohol support provision in the New Forest to see if the needs of binge drinkers can be more effectively treated.
Hampshire Public Health
Southend-on-Sea — recommendation 10
The provision of services for drug and alcohol users needs to be driven by risk to others and themselves as much as their willingness to engage. A review should take place to establish whether drug and alcohol services meet the needs of those who are resistant to change or who …
Drug & Alcohol Commissioning
North Devon and Torridge — recommendation Case 2 R8
Implement further training and initiatives to improve the response by all agencies to alcohol abuse in line with the Devon alcohol strategy.
Safer Devon Partnership
Devon Partnership NHS Trust
Isle of Wight — recommendation 6.12
That the commissioners and providers of Isle of Wight drugs and alcohol treatment services examine the feasibility of ensuring that multiple offers of service are made in varied ways based on the hypothesis that some clients may respond to different types of approach thereby increasing the likelihood of engagement.
Isle of Wight drugs and alcohol …
Isle of Wight — recommendation 6.6
That Hampshire Constabulary strengthen its guidance surrounding the impact of substance misuse in relationships, the nature of co-dependence of those who suffer from disorders related to addiction and effective interventions to support them so as to protect vulnerable people in such settings.
Hampshire Constabulary
Hampshire and Isle of …
Cannock Chase — recommendation 2
The alcohol screening tool should be completed in all relevant cases at the report stage to ensure the correct targeting of provision takes place.
National Probation Service
National Probation Service
Tower Hamlets — recommendation 2
that LBTH re-procure it’s contract(s) for substance misuse treatment services with a view to simplified referral processes, and enhanced psychosocial interventions for non-opiate users, including extensive publicity and an ongoing communications strategy embracing the full range of its stakeholders.
LBTH
Durham — recommendation 2
There is currently an initiative in custody suites where each individual identified in an alcohol related incident is subject to screening. The Alcohol Harm Reduction Group to evaluate the effectiveness of the current initiative, in custody suites in County Durham.
The Alcohol Harm Reduction Group
Nottingham — recommendation 2
EMAS to explore creating Pathways to drug and alcohol services for referrals with consent.
EMAS
East Midlands Ambulance Service …
Stoke-on-Trent — recommendation D1.3
Work to address alcohol use should be undertaken with all offenders where it is identified as linked to risk, even if there is no evidence of current use. This should help relapse prevention in the future.
National Probation Service
National Probation Service
Walsall — recommendation 8.6
The Black Country and West Birmingham CCG and Black Country Healthcare Foundation Trust should ensure practitioners are aware of the heightened risks when they identify co-morbidities of adult ADHD and alcohol or drugs misuse and that they respond appropriately.
Black Country and West Birmingham ICB …
NHS Black Country ICB
Dudley — recommendation 4
Emergency Department staff to receive bespoke training in regard to alcohol misuse and local services available to give advice and support.
Dudley Group NHS Foundation Trust
The Dudley Group NHS …
Dudley — recommendation 3
Domestic abuse training to continue to emphasise the connection between domestic abuse and substance misuse.
Dudley Group NHS Foundation Trust
The Dudley Group NHS …
Pendle — recommendation 4
That Pendle Community Safety Partnership ensures information is available on the effect and impact of using illicit drugs.
Pendle Community Safety Partnership
West Cumbria — recommendation 8
All clinicians to be advised to ensure consistency in using clinical templates and system prompts. The practice will request that prompts contain reference to drug and alcohol misuse.
Primary Care Practice
West Cumbria — recommendation 1
Safer Cumbria (Combatting Drugs Partnership) to ensure that the 2022 drug needs assessment considers the profile of New Psychoactive Substances to assist in informing the design of local strategies to support the reduction of serious violence and associated harms.
Safer Cumbria (Combatting Drugs Partnership)
North East Lincolnshire — recommendation 7.1.4
That officers are reminded to provide details of alcohol support services.
Humberside Police
Humberside Police
Cumbria — recommendation 7.1.2
System-wide training regarding upskilling practitioners on substance misuse, to be delivered by Recovery Steps Cumbria.
Recovery Steps Cumbria
Recovery Steps Cumbria
Carmarthenshire — recommendation 13
Improve the knowledge and confidence of practitioners working in Tier 1 services to have conversations with individuals about their substance use and options for support and interventions
West Wales Area Planning Board
Carmarthenshire — recommendation 12
Improve the consistency of GPs and wider agencies identification and referrals for specialist substance use services
West Wales Area Planning Board
Carmarthenshire — recommendation 11
Develop a regional substance use, domestic abuse and mental health pathway for individuals who present with multiple needs
Regional Partnership Board
Cardiff — recommendation Recommendation Four
The Cardiff Public Services Board reviews both its strategic and tactical management and support to victims of mental health especially those victims currently being supported for substance and alcohol addiction.
Cardiff Public Services Board
Manchester — recommendation GMMH 4
Safeguarding Adults Level 3’ training module to include information on ‘Chemsex’ as a complexity factor to raise staff awareness and to inform them of specialist advice available.
GMMH
Greater Manchester Mental Health …
Manchester — recommendation GMMH 3
Level 3 Safeguarding Adults/Domestic abuse training module to be updated to include specific information on same sex intimate partner violence and other complexity factors such as polysubstance use.
GMMH
Greater Manchester Mental Health …
Manchester — recommendation 4
The Manchester CSP, supported by the LGBT+ Foundation and the Northern Centre for Sexual Health, should: Develop a programme to determine the most effective way to promote the service and raise awareness of the pathways to access the service; Encourage partners on the CSP to reflect in their safeguarding updates …
Manchester Community Safety Partnership | LGBT+ …
Gloucester — recommendation 1
Gloucestershire Criminal Justice Board to use this case to review with multi-agency partners how people in Scott’s situation – in and out of prison, with mental ill health, using substances, a history of homelessness and domestic abuse -- get identified and supported by the system, including getting consistent proactive support …
Gloucestershire Criminal Justice Board
Gloucester — recommendation 1
The National Criminal Justice Board use this case to review with multi-agency partners how people in Scott’s situation – in and out of prison, with mental ill health, using substances, a history of homelessness and domestic abuse -- get identified and supported by the system, including getting consistent proactive support …
National Criminal Justice Board
Cheshire West and Chester — recommendation 3
Statutory partners to provide reassurance to the CSP that where appropriate and possible agencies should signpost relatives of those who misuse drugs and or alcohol to appropriate support, for example Alanon.
Cheshire West and Chester Community Safety …
Somerset — recommendation 1
The practice should access training to improve awareness of domestic abuse and the potential impact of the combination of alcohol abuse, misuse of drugs and the mental ill health. Two suggested e-learning packages can be accessed on the AVA website www.avaproject.org.uk
Canterbury and Coastal Clinical Commissioning Group
St Helens — recommendation 28
Ensure that reducing harm to children from parental problem drug and alcohol use is a priority aim of the Borough’s Alcohol Strategy 2016 – 2017 onwards.
Public Health
St Helens — recommendation 22
Review advice/pathways in place relating to alcohol related attendances/admissions
St Helens and Knowsley Teaching Hospitals …
North Worcestershire — recommendation WMPercia IMR 4
Warwickshire and West Mercia Police to consider further training input for staff with regards the side affects of cocaine/drug use.
Warwickshire Police | West Mercia Police
Warwickshire Police
Chorley and South Ribble — recommendation 2.2
The Chorley and South Ribble CSP should receive assurance that specialist substance misuse services are able to link into appropriate care and support services across the partnership area.
Chorley and South Ribble Community Safety …