No evidence-based drug policy
Failure to mandate that independent evaluation findings deterministically guide the future of safe drug consumption facilities.
Source spread
Where this theme appears
This theme appears across 12 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
24 PFD reports
29 committee recs
2 HSSIB recs
1 IOPC rec
2 NAO recs
1 IMB rec
1 Article 2 learning point
8 DHR recs
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.
Inquiry recommendations(1)
Prevention of Future Deaths reports(24)
Bradley Cockel
Concerns: The coroner noted that a specific drug and some of its chemical compounds were not controlled by legislation at the time of death, with only a partial temporary ban enacted for some compounds later.
Overdue
Matthew Flatman
Concerns: The process of proscribing MDAI (Gogaine), a "legal high" known to pose a fatal risk, particularly to individuals with cardiac problems, is moving slowly and its proscription should be accelerated.
Overdue
Anthony Garrett
Concerns: The coroner raises concerns regarding the ready availability and legal sale of synthetic cannabinoids, marketed as herbal incense but misused, noting they are dangerous and potentially life-threatening. A review of their status and control is requested.
Overdue
Howard Jeffers
Concerns: The coroner noted concerns that future deaths may occur unless Novel Psychoactive Substances (NPS) can be more accurately analysed and detected by toxicological testing, highlighting a lack of specific evidence presented at the inquest regarding steps to address this risk.
Response (Howard Jeffers): • The Toxicology Unit explained that the analysis of novel psychoactive substances (NPS) is inherently limited and challenging. • This limitation is attributed to the vast number of compounds, their … (AI summary)
Response (Howard Jeffers Response3): • The organisation regularly attends and presents at scientific meetings and publishes on the topic of novel psychoactive substances (NPS). • The organisation is actively engaged in the UK and … (AI summary)
Response (Howard Jeffers Response2): • The unit has conducted and is conducting research to improve in-field methods for identifying novel psychoactive substances (NPS) from seized samples, including the use of handheld Raman spectroscopy. • … (AI summary)
Responded
Bethany Shipsey
Concerns: The coroner raised concerns about the extreme toxicity of DNP, its increasing popularity among young people as a 'diet drug', and its ready availability online, noting that current legislation does not make its possession, sale, or supply illegal.
Response (Department of Health): • The Food Standards Agency's National Food Crime Unit (NFCU) launched Operation Broguish in April 2015, which involved submitting abuse complaints to domain registrars, leading to 21 domain name suspensions, … (AI summary)
Responded
Mohammed Ahmed
Concerns: The coroner noted expert evidence suggesting a combination of Olanzapine and Spice could cause adverse allergic reactions, and raised concerns about whether this potential interaction is sufficiently known to clinicians nationally.
Response (Department of Health): • The Medicines and Healthcare products Regulatory Authority (MHRA) stated it would keep the issue under scrutiny through its Yellow Card scheme and a national pilot for reporting illicit drug … (AI summary)
Overdue
Alexander Boamah
Concerns: The coroner noted a lack of a process for clinicians to inform the Department of Work and Pensions about individuals at risk, especially those without capacity, who receive large sums of money that may be used for illicit substances.
Response (Department for Work and Pensions): • A review of the DWP safeguarding policy and guidance is currently underway. • The review will consider how communication channels between the Department and treating clinicians can be opened. … (AI summary)
Responded
Marc Cole
Concerns: The coroner noted insufficient independent data on Taser lethality, particularly concerning the incremental risk of multiple or sustained activations, raising concerns that police training may be deficient or incomplete.
Response (the College of Policing Redcated): • The College stated its current guidance and learning materials address risks associated with the number and duration of Taser activations, developed in consultation with SACMILL. • The College committed … (AI summary)
Response (Home Office): • The Scientific Advisory Committee on the Medical Implications of Less-Lethal Weapons (SACMILL) provides independent medical advice on less-lethal weapon systems, with recommendations incorporated into the National Taser training curriculum. … (AI summary)
Responded
Samuel Morgan
Concerns: The coroner noted a potential link between SSRIs and suicidal thinking in young adults. They suggested a 'Black Box Warning' on medication packaging could more effectively highlight this increased risk to patients.
Response (Dept. of Health and Social Care): • The Medicines and Healthcare products Regulatory Agency (MHRA) created a Yellow Card report based on the information provided in the coroner's report. • The government continues to implement the … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) stated that patient information leaflets for SSRIs include bold and bullet-pointed warnings about the risk of suicide, developed with patient input … (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
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
Chester Mossop
Concerns: The coroner notes a lack of national distribution of bath safety advice to healthcare professionals and parents/carers. There are concerns that bath seats may give a false sense of security, as parents may be unaware they are not safety devices.
Response (NHS England): • NHS England stated it would update its ‘Washing and bathing your baby’ website page to include guidance on bath seats, clarifying they are not recommended and are not safety … (AI summary)
Response (OPSS): • OPSS contacted the coroner's office to obtain further details of the product. • OPSS will assess the safety and compliance of similar models of baby bath seats. • OPSS … (AI summary)
Response (Product Safety Standards): • The Office for Product Safety and Standards (OPSS) has contacted the coroner's office to obtain further details of the product involved. • OPSS will assess the safety and compliance … (AI summary)
Responded
Raymond Lee
Concerns: There is limited national guidance and evidence on the optimal treatment for oesophageal strictures, specifically regarding the number of dilatations and the timing for considering stenting, given the associated risks of perforation.
Response (NHS England): • NHS England stated it would work with the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) and NICE to develop national, evidence-based advice/guidelines for managing oesophageal … (AI summary)
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence reviewed evidence and issued new recommendations on palliative management of luminal obstruction for oesophageal or oesophago-gastric junctional cancer. • The National … (AI summary)
Responded
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
Frances Newbury
Concerns: The coroner raised concerns that Naloxone was not administered to Ms Newbury despite paramedics being informed of illicit drug use and her history of opiate misuse. This issue has arisen in previous inquests where other reversible causes were treated.
Response (London Ambulance Service): • The London Ambulance Service requested that its Consultant Paramedics and Associate Clinical Directors, who are members of the JRCALC resuscitation group, request a review of JRCALC guidance concerning opioids … (AI summary)
Responded
Glenn Lockwood
Concerns: Insufficient monitoring for signs of Pregabalin abuse was identified, particularly given the patient's known history of drug abuse. Concerns were also raised that a Serious Event Analysis exploring potential record-keeping and prescribing issues may not have fully explored relevant risks.
Response (ClydeCo): • The Practice appears to accept that there is some confusion and that notes are not clear regarding prescribing and documentation. • A further serious event analysis is required to … (AI summary)
Response (The Limehouse Practice): • The practice completed a further Serious Event Analysis (SEA) with agreed actions. • The practice will implement three-monthly face-to-face reviews for patients on dependence-inducing medications. • New procedures will … (AI summary)
Responded
Sienna Barber
Concerns: The coroner noted the absence of specific NICE guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups. The report also highlighted that a NICE review of rapid antigen testing excluded children under five, where such testing could be beneficial.
Response (Nation Institute for Health and Care Excellence): • NICE stated it had produced several guidelines relevant to children presenting with fever, including NG143, NG51, and NG84. • NICE stated it had published diagnostic guidance on rapid tests … (AI summary)
Response (Manchester University Foundation Trust): • The Trust liaised with the Greater Manchester Sudden Unexpected Death of a Child team, Public Health England, and the Greater Manchester Child Death Overview Panel to raise concerns. (AI summary)
Response (Department of Health and Social Care): • NHS England published interim clinical guidance on the diagnosis and treatment of children with Group A Streptococcus. • A campaign was commenced to inform parents and carers about Group … (AI summary)
Response (Royal College of Paediatrics and Child Health): • The Royal College of Paediatrics and Child Health endorsed the reinstatement of the NICE Sore Throat (Acute) NG84 guideline. • The College will share information and suggestions from the … (AI summary)
Responded
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
Louise Jones
Concerns: The GP practice lacked policies for long-term opioid prescriptions, including patient agreements on treatment strategy and warning flags for addiction risk after three months. There was also no policy regarding the co-prescription of opioids and benzodiazepines.
Response (Petroc Group): • The practice developed a comprehensive policy for opioid prescribing. • The practice stated it would disseminate the new policy to all staff and discuss it at a practice-wide meeting. … (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
Hannah Aitken
Concerns: The coroner noted a lack of central monitoring for poisoning incidents involving certain substances, which are increasingly used for self-harm. There are no restrictions on importing these substances, and no government department appears to be actively considering regulating their access, purity, or quantities sold to mitigate risks.
Response (Department of Health and Social Care): • The Department of Health and Social Care (DHSC) published the Suicide Prevention Strategy for England in 2023 and leads a Concerning Methods Working Group, which has implemented over 30 … (AI summary)
Response (Home Office): • The Poisons Act was amended in October 2023 to strengthen controls and enhance suspicious activity reporting requirements for listed substances. • The Home Office has engaged with online platforms … (AI summary)
Responded
Edward Barnard
Concerns: The coroner expressed concern regarding a vulnerable young adult illicitly obtaining and using a veterinary-only licensed substance for a suicidal purpose. This identifies a potential emerging risk, prompting reports to veterinary bodies to consider preventive measures.
Response (Royal College of Veterinary Surgeons): • RCVS committees will consider additional requirements for practices to have individualised suicide prevention plans. • The RCVS Standards Committee will review legislative requirements for Schedule 2 Controlled Drugs and … (AI summary)
Overdue
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
Stella LeClaire
Concerns: The coroner noted an increase in toxicological requests for a specific substance, highlighting the need for specialist analysis to aid potential prosecution of suppliers. The report suggests the Chief Coroner consider guidance on routine toxicological analysis in poisoning investigations.
Response (Department of Health and Social Care): • The Department monitors concerning trends through the Concerning Methods Working Group, which includes coroner community representation. • More than 30 targeted actions have been taken to reduce opportunities to … (AI summary)
Responded
Select committee recommendations(29)
#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
#2 — Mandate independent evaluation findings determine future of The Thistle safe drug consumption facility.
Recommendation: We recognise that the opening of The Thistle on a pilot-basis presents an opportunity to test the effectiveness of SDCFs in Glasgow’s unique context. We believe the evidence provided by the independent evaluation panel should be determinative in discussions about …
Response attribution not verified
#1 — Adopt a balanced, evidence-based approach to tackling problem drug use.
Recommendation: We call on both Governments to adopt a balanced, evidence-based approach to problem drug use. (Conclusion, Paragraph 35)
Response attribution not verified
#4 — Review the application of Neither Confirm Nor Deny in all legacy related cases
Recommendation: The Government should review, in consultation with MI5 and the PSNI, the application of NCND in all legacy related cases, considering specifically the principles outlined in this Report. (Recommendation, Paragraph 21) 11
Response status not verified
#10 — Revise fuel poverty definition to include homes meeting minimum energy efficiency standards
Recommendation: In the forthcoming Fuel Poverty Strategy, we recommend that the Government revise the official definition of fuel poverty to reflect the fact that those living in homes compliant with the new Minimum Energy Efficiency Standard may still struggle to heat …
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
#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
#43 — Support Glasgow safe consumption facility pilot, creating legislative pathway and ensuring joint funding.
Recommendation: In particular, we recommend the Government support a pilot in Glasgow by creating a legislative pathway under the Misuse of Drugs Act 1971 that enables such a facility to operate legally. The pilot in Glasgow must be jointly funded by …
Gov response: The Government does not accept the Committee’s recommendation and does not support the introduction of drug consumption rooms in England and Wales due to the risk of these facilities condoning illicit drug use and encouraging …
Rejected
#41 — Evidence base required for safe consumption facilities across the United Kingdom.
Recommendation: An evidence base for a safe consumption facility in the UK is needed.
Response attribution not verified
#12 — Inconsistent outcome measures for prisoners with substance misuse needs hinder effective evaluation.
Recommendation: We asked MoJ and HMPPS about how successful outcomes for prisoners with substance misuse needs are measured. HMPPS told us there is range of things that could 18 Committee of Public Accounts, Mental health in prisons, Eighth Report of Session …
Response attribution not verified
#17 — Paramilitary groups are fragmented; sub-group transition concept requires further development and consideration.
Recommendation: Paramilitary groups do not resemble cohesive units, rather they are composed of sub-groups that vary in location, strength of affiliation and level of criminal activity. We have heard that some sub-groups are readying themselves for transition, whilst others show little …
Response attribution not verified
#12 — Extend multi-year funding period for Tackling Paramilitarism Programme Phase Three to five years.
Recommendation: We welcome the announcement in the 2023 Budget of an additional £3 million for 2024/25 to extend the Tackling Paramilitarism Programme in Northern Ireland. The Programme is carrying out vital work to develop strategies to tackle paramilitarism systematically. Paramilitarism is …
Response attribution not verified
#44 — Establish a national drug checking service in England for anonymous postal sample submission.
Recommendation: We recommend that the Home Office and Department of Health and Social Care jointly establish a national drug checking service in England to enable people to submit drug samples by post anonymously. We recommend the Home Office consult stakeholders on …
Response attribution not verified
#42 — Support piloting of safe consumption facilities in areas of demonstrated local need.
Recommendation: We recommend that the Government support the piloting of safe consumption facilities in areas across the UK where there is deemed to be a need by local government and stakeholders.
Response attribution not verified
#14 — Home Office selectively adopts ACMD advice on drug classification changes.
Recommendation: The ACMD seeks to provide scientific, evidence-based recommendations to support the development of evidence-based drug policy. We note that the Home Office appears more likely to adopt advice to increase the classification of a controlled drug than it is to …
Response attribution not verified
#11 — Cross-Government Reducing Reoffending Board lacks clear departmental roles and governance for substance misuse.
Recommendation: Substance misuse is the only area where the Cross-Government Reducing Reoffending Board—made up of senior representatives from 12 central government bodies, and with a remit to identify opportunities to reduce reoffending—has not set out the main departments which have a …
Response attribution not verified
#16 — Conduct a scoping exercise to assess public support for a paramilitary group transition process.
Recommendation: We have heard evidence both for and against the establishment of formal process of Group Transition. On the one hand, we are concerned that a Group Transition process aimed at the disbandment of paramilitary groups could inadvertently risk reinforcing the …
Response attribution not verified
#11 — Undertake updated analysis of paramilitary activity to inform national security strategy scope in Northern Ireland.
Recommendation: There is a live debate as to whether the current scope of national security, as it relates to Northern Ireland, should be revised to include threats other than those to democracy and the state, such as paramilitary activity like drug …
Response attribution not verified
#24 — Investment in research for drivers of substance misuse behaviours remains inadequate
Recommendation: Dame Carol and Ms Wiseman told us that there was little investment in research into the behaviours and factors that lead to substance misuse.80 The JCDU pointed to the £5 million investment in the ‘innovation fund’ which is looking at …
Response attribution not verified
#1 — Evidence gathered from Home Office, DHSC, and key drug strategy stakeholders.
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Home Office and the Department for Health and Social Care.2 We also took evidence from Dame Carol Black, author of the government’s independent …
Response attribution not verified
#9 — Set online slots stake limits to match land-based machines and not exceed £5
Recommendation: The high degree of accessibility of online slots negates the additional protection provided by account-based play. Setting a limit for online slots at the same level as Category B gaming machines, at between £2 and £5, takes account of the …
Response attribution not verified
#15 — Embed a standard code of practice for community groups receiving public funding to tackle paramilitarism.
Recommendation: We are concerned to hear claims that paramilitary organisations act as gatekeepers within some communities and masquerade as community organisations to receive public money. The Government must embed a standard code of practice and behaviour that all community-level organisations availing …
Response attribution not verified
#10 — Prioritise ending paramilitary harm as a strategic commitment in the Programme for Government.
Recommendation: Tackling paramilitarism in Northern Ireland requires a whole of Government approach. While we are mindful that it is ultimately a matter for any newly formed Executive to decide its priorities for government, we urge the next administration in Northern Ireland …
Response attribution not verified
#2 — Urge Executive to support communities addressing paramilitary murals and flags
Recommendation: Memorials, commemorative artefacts and flags glorifying paramilitary groups serve as a visual signifier of the coercive control that such groups attempt to have over communities and can retraumatise the victims and survivors of paramilitary violence. The PSNI does not always …
Response attribution not verified
#18 — Government lacks evidence on optimal prosecution levels needed for fraud deterrence.
Recommendation: On the deterrence effect of convictions and whether there is a sufficient level of convictions to create a suitable deterrent, the PSFA told us that it was not aware of any evidence to indicate what the right level of prosecutions …
Response attribution not verified
#8 — Require Government to consider point-of-sale risk information for online gambling products
Recommendation: We support the White Paper’s proposals to make online gambling products safer by design. Improving understanding of what affects products’ risk of harm should be a priority, and Government should keep its position on a safety testing regime under review …
Response attribution not verified
#1 — Terminology for paramilitarism in Northern Ireland is complex, contested and risks misrepresentation
Recommendation: The term ‘paramilitarism’ is complex and contested in Northern Ireland. We heard how use of the term can risk romanticising the presence of gangs who engage in overt criminality and attempt to exercise coercive control over the communities they seek …
Response attribution not verified
#55 — Insufficient evidence on stop and search effectiveness undermines public confidence and policy decisions.
Recommendation: The lack of evidence available about the effectiveness of stop and search in reducing serious violence crime has contributed to scepticism about the basis for using the powers and therefore a lack of confidence in them. The Home Office should …
Response attribution not verified
HSSIB safety recommendations(2)
The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period
It may be beneficial if future research or funding is directed towards identifying the evidence base for the prescribing of low-molecular-weight heparin for venous thromboembolism risk in pregnancy and the first 6 weeks after birth. This will support the production …
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
Further research into possible interactions between propranolol and Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants in overdose would be beneficial.
Safety Observation
NAO audit recommendations(2)
Childhood obesity
The Department should establish a robust evidence base, commissioning further research if necessary, of what works to establish which interventions in the programme and actions by local authorities work best to reduce childhood obesity.
Accepted
Support for vulnerable adolescents
We recommend that those central government departments involved should, through formal governance, work together to: b) address the gaps in the evidence base of what interventions work to support vulnerable adolescents;
Accepted
Health investigations(13)
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 46
There needs to be a national policy on the issue of the legal liability of the occupiers or managers of premises such as a hospital on whose premises cannabis or heroin are prepared and/or smoked and/or dealt by an in-patient. As the law presently stands (Section 8 of the Misuse …
london
*Independent investigation into the care and treatment of Mr W: … — Rec 1
The commissioners of substance misuse services together with service providers should put in place mechanisms to ensure themselves that best practice guidance on the delivery of substance misuse services is being implemented. Commissioners and providers of substance misuse should put in place mechanisms to ensure that information on the quality …
Merseycare NHS Foundation Trust
north_west
An independent investigation into the care and treatment of mental … — Rec Recommendation 1
TEWV must develop an agreed set of local policies and procedures to be regularly reviewed by key strategic partners in line with the November 2016 NICE8 guidance on coexisting severe mental illness and substance misuse: community health and social care services.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
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: Terrance Hall, Weston Super Mare (2008) — Rec 2
Commissioners should ensure that they are commissioning services in a manner that is consonant with the latest NICE Guidance on the commissioning of alcohol services253
south_west
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 1
TEWV must develop an agreed set of local policies and procedures to be regularly reviewed by key strategic partners in line with the November 2016 NICE8 guidance on coexisting severe mental illness and substance misuse: community health and social care services.
north_east_yorkshire
*Mental health homicide investigation legacy report into the care and … — Rec Recommendation Two
The Trust will examine all extant clinical policies and procedures to ensure that NICE guidance is embedded within them. The Trust training and development needs analyses will be constructed to ensure that an explicit link is made to the requirements of the NICE guidance with particular reference to substance misuse …
Mr X This is the report of the independent investigation into the care and treatment of Mr X . Mr X was a former patient at Sussex Partnership NHS Foundation Trust
south_east
Independent investigation into the care and treatment of Mr N — Rec National recommendat
NHS England & NHS Improvement should work with NICE to consider including in existing guidance information about the prescribing of injectable anti-psychotics for the treatment of psychosis in under 18s.
london
Independent investigation into the care and treatment of Mr N — Rec 7
Trust medicine management policies for long acting antipsychotic injections should provide guidance for their use in young people.
london
Accepted
Independent investigation: Katie Kazmi, Reading (1999) — Rec 4
The Home Office and the DofH in conjunction with the relevant professional bodies should formulate guidelines for the testing for substance misuse with restricted patients.
south_east
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 into the care and treatment of Mr W: … — Rec 2
The Trust and its commissioner should ensure that the Best Practice guidance on the co-ordinated treatment of individuals with a dual diagnosis of mental health problems and substance misuse problems is implemented. The Trust should ensure that when an individual with a substance misuse problem is admitted to hospital for …
Merseycare NHS Foundation Trust
north_west
*Independent investigation into the care and treatment of Mr P: … — Rec 6
With respect to the future management of people with substance misuse problems and psychosis the Trust should ensure its staff are able to support the competencies outlined in the NICE guidance for working with people with psychosis and substance misuse, and work with commissioners to develop appropriate commissioned pathways for …
south_east
Independent reviews(12)
Carol Black Drugs Review (Part 2) — Rec 32
We recommend that the government promote greater innovation in research, for example in pharmaceuticals, by offering incentives or rewards to companies or organisations whose developments prove beneficial in practice in the addiction field.
Health & Social Care
Carol Black Drugs Review (Part 2) — Rec 31
We recommend that DHSC and BEIS encourage more research into what works to combat substance misuse, across supply, prevention, treatment and recovery.
Health & Social Care
Carol Black Drugs Review (Part 2) — Rec 30
We recommend that the government (either HO or DHSC) establish an innovation fund to research which interventions are most effective at changing the behaviour of recreational drug users.
Health & Social Care
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 1
The government should establish a central Drugs Unit with strong analytical capacity which would develop a National Outcomes Framework and hold departments to account. The sponsoring minister should report annually to Parliament on progress in tackling drug misuse, including publication of relevant data.
Health & Social Care
Sewell Commission — Rec 12
Prevent harm, reduce crime and divert young people away from the criminal justice system The Commission wants to urgently address the disproportionate number of ethnic minority young people going into the criminal justice system as a result of low-level Class B drug possession. The Commission is not advocating or endorsing …
Other
Gauke Review — Rec 6.9
Build a comprehensive evidence base around the use of chemical suppression for sex offenders and explore options for continued funding of services in this area
Justice & Legal
O'Neill AMR Review — Rec 9
Better incentives to promote investment for new drugs and improving existing ones 9.1 Institute a system of 'market entry rewards' to provide lump-sum payments to the successful developers of new antibiotics that meet a specified unmet medical need. In principle, this should be administered and funded on a supra‑national basis, …
Health & Social Care
O'Neill AMR Review — Rec 8
Establish a Global Innovation Fund for early-stage and non-commercial research 8.1 Governments, and public and philanthropic research funding organisations, to collaborate on a global basis to develop a Global Innovation Fund for R&D into new antimicrobials and other related products (including vaccines and diagnostics.) This fund should build on existing …
Health & Social Care
Carol Black Drugs Review (Part 2) — Rec 7
We recommend that DHSC introduce, for 2022 to 2023 and beyond, a Local Outcomes Framework to increase transparency and local authorities' accountability for their treatment and recovery outcomes. DHSC should consider introducing incentive payments for local authorities to deliver improved outcomes.
Health & Social Care
Harrington WCA Review (Year 2) — Rec 23
Similar advice should be sought by Atos for their Mental Function Champions and the UK Drug Policy Commission and other relevant experts could be involved in updating the relevant sections of the Atos Guidance Manual for their healthcare professionals (see also Chapter 3).
Employment & Work
Harrington WCA Review (Year 2) — Rec 22
DWP Operations should consider seeking, and using, advice and guidance from the UK Drug Policy Commission and other relevant experts in order to improve and enhance the knowledge and capability of Decision Makers and Personal Advisers in managing these cases (see also Chapter 3).
Employment & Work
Domestic Homicide Reviews(8)
Leeds — recommendation LCH2
Guidelines for urine screening for drugs & alcohol.
Leeds Community Health – York Street …
Leeds — recommendation 3
Leeds health agencies will put in place a strategy for delivering holistic services for women with substance misuse issues that address experiences of violence and abuse.
Leeds health agencies
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
Sefton — recommendation 15
The Trust has no Policy/ Pathway for Alcohol Use Disorders – Quality standards need to be adopted
Southport and Ormskirk Hospitals NHS Trust
Basildon — recommendation 8
That a review is undertaken into drug testing protocols to ensure that the most effective methods are being used in south Essex, and that results are shared between agencies in accordance with the current contract arrangements.
Relevant agencies in south Essex
Leeds — recommendation CSWS1
Children’s Social Work Service to review with drugs and alcohol agencies the thresholds for when a pregnancy should be referred for substance misusing parents.
Leeds Children’s Social Work Service
Rochdale — recommendation 2
That Rochdale Community Safety Partnership recommend to the Home Office that there is a need to conduct national research that looks at the story of perpetrators of abuse and why they behaved in the way they did.
Rochdale Community Safety Partnership
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)