Poor drug demand reduction
Lack of evidence-based understanding and strategies to effectively reduce the demand for illegal drugs.
Source spread
Where this theme appears
This theme appears across 11 independent accountability sources, so the source mix matters as much as the headline total.
12 PFD reports
43 committee recs
3 PPO recs
7 NAO recs
48 IMB recs
1 patient safety alert
4 Scottish FAIs
1 Article 2 learning point
10 DHR recs
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(12)
Jason Houghton
Concerns: The coroner raised concerns about the unregulated supply of Class A drugs, specifically Diacetyl Morphine in pill form, through internet sources and its importation via international postal systems, noting a lack of oversight.
Response (Home Office): • The MHRA examined a specific website and liaised with the internet service provider to close it down. • Law enforcement agencies routinely monitor controlled drugs offered for sale online … (AI summary)
Responded
Darren Mindham
Concerns: The coroner noted that Pentobarbital, a drug commonly used in suicide, is not subject to strict control due to its Schedule 3 classification, indicating a potential gap in reducing access to means of suicide.
Overdue
Aaron McCaffrey
Concerns: The coroner noted there is no apparent limit on the amount of loperamide medication that can be purchased from a single store, making it easier to acquire large quantities. This raises concerns due to the potential for misuse and the risk of overdose.
Overdue
Ben Jukes
Concerns: The army's drug-testing regime failed to detect regular illicit drug use over five years, and a serviceman was forewarned of a test, enabling him to evade it. The coroner highlights that testing must be random and unannounced to be effective.
Response (Ministry of Defence): • The Army's drug misuse strategy was revised in November 2016. • An investigation was undertaken to identify how Captain Jukes gained advance notice of a compulsory drug test. • … (AI summary)
Responded
David Travers
Concerns: The coroner noted that despite existing measures, individuals can still too easily access multiple prescriptions from different GP surgeries, which creates risks of excessive intake and diversion of prescription drugs to the illegal market.
Response (Northern Eastern and Western Devon CCG): • The CCG reviewed the Root Cause Analysis and convened a multi-agency meeting to discuss the coroner's concerns. • The CCG will recommend national changes to NHS Digital regarding immediate … (AI summary)
Responded
Benjamin Williamson
Concerns: The coroner identified gaps in integrated care for patients with co-occurring mental health and substance misuse issues, leading to inadequate support. Insufficient communication and feedback between addiction services and the GP, alongside unaddressed consent for disclosure, compromised ongoing care.
Response (Addaction): • Addaction internally reviewed and improved its processes for recording confidentiality and consent reviews, and reinforced communication protocols with staff. • It introduced a monitoring function into its patient management … (AI summary)
Response (Kernow CCG NHS Trust): • NHS Kernow confirmed the existence of a multi-agency Dual Diagnosis Strategy and held meetings with providers to address identified service gaps. • An exceptional Crisis Care Concordat meeting identified … (AI summary)
Responded
Joseph Mochan
Concerns: No specific concerns related to future deaths were detailed in the provided text.
Response (Sussex NHS Commissioners): • Brighton & Hove City Council (BHCC) currently commissions a range of year-round accommodation for rough sleepers, including supported accommodation and short-term shelters. • BHCC is exploring other models of … (AI summary)
Overdue
Claire Richards
Concerns: The coroner noted the widespread availability of illegally dealt prescription drugs to vulnerable individuals and inquired about projected or actual steps to prevent medication diversion from lawful dispensing to criminal hands.
Response (Royal Pharmaceutical Society): • The Royal Pharmaceutical Society (RPS) stated that it transferred its regulatory role to the General Pharmaceutical Council (GPhC) in 2010. • The RPS noted the coroner's concerns regarding the … (AI summary)
Overdue
Holly Chevassut
Concerns: GRS operates vehicles with mirrors and guards positioned less than 2 meters from the road surface and projecting over 20 centimetres from the vehicle's widest point. This configuration is identified as creating a risk of personal injury and death to those overtaken by these vehicles.
Response (GRS Recovery): • GRS Recovery removed wing mirror protectors from Vehicle 2. • GRS Recovery rotated the offside and nearside wing mirrors of both vehicles 1 and 2 by 180 degrees, which … (AI summary)
Responded
Joshua Forsdyke
Concerns: The coroner noted the easy and open availability of Ketamine to students, which was being dealt from or by individuals with access to student halls of residence.
Response (Fresh Student Living): • In conjunction with the University of Arts London, room inspections will be reviewed to focus on signs of illegal drug use. • Fresh Student Living and the University of … (AI summary)
Response (UAL): • The university stated it would reduce the availability of illegal drugs in halls of residence by improving identification of drug dealing and strengthening partnerships with police. • The university … (AI summary)
Responded
Benjamin Buckfield
Concerns: The coroner noted concerns regarding the unchecked, open trade of illegal drugs at the festival and a policy allowing entry for individuals caught with drugs unless they are considered dealers, which creates a demand for replacement drugs.
Overdue
Gemma Weeks
Concerns: The coroner raises concerns that the public, particularly young people, do not fully understand the dangers and health risks of acute and chronic ketamine use, partly due to its classification as a Class B drug.
Response (Department of Health and Social Care): • A national campaign is planned to launch in coming months to raise awareness of ketamine's harms, including bladder damage. • The Department cascaded a briefing to local authorities and … (AI summary)
Response (Department for Education): • The Department for Education recently published updated statutory guidance for Relationships, Sex and Health Education (RSHE), which includes curriculum content on drugs, alcohol, tobacco, and vaping. • The department … (AI summary)
Response (Home Office): • The Home Office commissioned the Advisory Council on the Misuse of Drugs (ACMD) in January 2025 to provide an updated harms assessment of ketamine and advice on its classification. … (AI summary)
Responded
Select committee recommendations(43)
#22 — Illegal drug use remains high, underscoring the critical need for effective prevention strategies.
Recommendation: Around 3 million people in England and Wales take illegal drugs each year, around one in 11 adults. Despite attempts in the 2010 and 2017 drugs strategies to reduce long- term demand, this figure has remained largely unchanged since 2010–11.74 …
Response attribution not verified
#15 — Conduct comprehensive review of initiatives reducing demand for sexual exploitation by June 2024.
Recommendation: The Government should conduct a comprehensive review of all legislative, policy and educational initiatives that are underway to reduce demand for sexual exploitation and report on this by June 2024. This review should compare the UK’s approach with Human trafficking …
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
#23 — Government lacks evidence base on effective prevention strategies to stop individuals taking drugs.
Recommendation: The JCDU and Home Office did not have an evidence base about what works in preventing individuals from taking up drug use.77 The drug strategy has a strong focus on the link between criminal activity and drug use, with initiatives …
Response attribution not verified
#6 — Coordinate urgent JCDU work to develop an evidence-based plan for reducing illegal drug demand.
Recommendation: Despite previous attempts to reduce the demand for illegal drugs, the JCDU and departments still do not understand how to change behaviours and prevent people from taking drugs. Reducing the demand for illegal drugs is crucial to mitigating the harms …
Response attribution not verified
#31 — Provide sustainable central funding for national rehabilitation programmes and ring-fenced funds for local services.
Recommendation: We welcome the new funding the Home Office will be providing for drug treatment. However, it is only for one year, when sustainable increased funding is needed for ongoing services. We recommend that the Government makes central funding available for …
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
#23 — Devise and publish a cross-departmental action plan and UK-wide campaign to tackle drug stigma.
Recommendation: We recommend that the Combating Drugs Minister leads on devising a cross- departmental action plan to tackle stigma. In devising the action plan, the Government must engage with people with lived experience of drugs and stakeholders in the drug treatment …
Response attribution not verified
#16 — Set out how Modern Slavery Strategy will combat demand for sexual exploitation.
Recommendation: The Government’s Modern Slavery Strategy, which we have recommended be updated, must set out how the Government will combat the demand for sexual exploitation created by individuals who pay for sex.
Response attribution not verified
#14 — Increase police and CPS use of Section 53A and publish annual prosecution data.
Recommendation: There should be much greater use of section 53A of the Sexual Offences Act 2003 by police forces and the CPS. This should be supported by additional training on the use of section 53A, provided by the College of Policing, …
Response attribution not verified
#13 — Strengthen Section 53A of the Sexual Offences Act 2003 and increase conviction penalties.
Recommendation: Section 53A of the Sexual Offences Act 2003 should be strengthened and penalties upon conviction increased to ensure comparability with other sexual and trafficking offences and to increase the deterrent value.
Response attribution not verified
#1 — Committee gathered evidence on alcohol treatment services from key stakeholders
Recommendation: On the basis of a Report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department) on alcohol treatment services.1 We also took evidence from Alice Wiseman, Director of Public Health, …
Response attribution not verified
#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
#10 — Progress observed in drug worker recruitment, county lines disruption, and police diversion tactics.
Recommendation: There have been signs of progress in some areas.24 For example, local areas have recruited an extra 1,220 drug workers, exceeding the 3-year target already.25 In terms of disrupting the supply of drugs, over 2,000 county lines have been closed …
Response attribution not verified
#30 — Government's response to drug-related retail crime lacks urgency and timely national programme rollout.
Recommendation: The Government has acknowledged that drugs play a significant role in a large number of crimes and with prolific offending in particular. Yet, one year on from the Government’s response to the call for evidence on violence and abuse toward …
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 …
Response attribution not verified
#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
#30 — Concerns raised about new drug possession sanctions' impact on stigma and young people.
Recommendation: We welcome the Government’s ambition to reduce demand for drugs including recreational drugs. However, we have heard concerns that the three-tiered framework of escalating sanctions under the Swift, Certain, Tough: New Consequences for Drug Possession White Paper may have a …
Response attribution not verified
#13 — Prepare a strategy to mitigate increased supply of synthetic opioids across the UK.
Recommendation: We recommend that the Government must prepare a strategy to mitigate the risk of an increase in the supply and availability of synthetic opioids in the UK before the end of this Parliament.
Response attribution not verified
#12 — Increase monitoring of synthetic drug trafficking and prioritise heroin dependency treatment.
Recommendation: To mitigate this risk, we recommend the Government, in partnership with the devolved administrations, increase its monitoring of synthetic drugs being trafficked in, and around, the UK, and prioritise supporting people with a chronic heroin dependency into treatment and recovery.
Response attribution not verified
#11 — Alarm over synthetic opioid harms and potential shift from heroin dependency.
Recommendation: We are alarmed by the health and social harms of synthetic opioids, such as fentanyl. We are concerned that a reduction in the global supply of heroin will have the effect of people with an opioid dependency turning to even …
Response attribution not verified
#12 — Insufficient enforcement of Sexual Offences Act fails to deter those who buy sex.
Recommendation: Enforcement of the current provisions of Section 53A of the Sexual Offences Act 2003 is insufficient to deter those who buy sex.
Response attribution not verified
#30 —
Recommendation: Employment has been shown to reduce reoffending. Getting prisoners into employment therefore makes economic sense for society, easing the current burden on prisons, and allowing former prisoners to re-enter society. The low number of prisoners finding long-term employment following their …
Response attribution not verified
#20 —
Recommendation: It is widely believed across the waste sector that there has been a steady rise in the involvement of organised crime groups over recent years.69 We heard from the Agency and HMRC of the challenges involved in taking such criminals …
Response attribution not verified
#20 — Establish specific drug use reduction targets for young people and other vulnerable cohorts.
Recommendation: In the year ending June 2022, 9.2% of 16–59-year-olds in England and Wales reported having taken drugs at least once within the past year, with 2.7% having taken Class A drugs. These proportions are higher for younger adults, with 19% …
Response attribution not verified
#5 — Ensure JCDU and departments understand barriers for diverse drug user cohorts, enabling targeted local authority action.
Recommendation: The JCDU and departments have not put sufficient emphasis on the importance of addressing the specific needs of different cohorts of people who use drugs. It is unacceptable that drug-related deaths in England increased by 80% between 2011 and 2021, …
Response attribution not verified
#4 — Acquisitive theft, organised crime, and police failures fuel violence against retail workers.
Recommendation: There are several factors driving the increase in violence and abuse towards retail workers over the last 5 years. However, the primary factor appears to be increasing levels of acquisitive theft which are linked to both organised crime and prolific …
Response attribution not verified
#32 — Drug strategy requires further action to prevent exploitation of children by county lines.
Recommendation: We welcome the 10-Year Drug Strategy’s commitment to rolling up county lines but increasing law enforcement efforts is only one part of the solution. We therefore welcome the strategy’s commitment to reducing demand for drugs and to re- building the …
Response attribution not verified
#31 — Explain identification of drug-dependent individuals, youth impact, and costs for new sanctions policy.
Recommendation: Though we await the outcome of the consultation on this White Paper, we ask that the Home Office further explain: (Paragraph 113) a) How people with a drug dependency—to whom this policy will not apply—will be identified and directed into …
Response attribution not verified
#17 — Consider including strategy for reducing demand for sexual exploitation in Commissioner's Strategic Plan.
Recommendation: The new Independent Anti-Slavery Commissioner should actively consider including a strategy for reducing demand for sexual exploitation in the Independent Anti-Slavery Commissioner Strategic Plan.
Response attribution not verified
#19 —
Recommendation: HMPPS launched alcohol monitoring services in October 2020 for offenders sentenced in the community. In November 2021 and June 2022, it extended the scheme to include those leaving prison, in Wales and in England respectively. Alcohol tags measure alcohol concentration …
Response attribution not verified
#2 — Assess the next drug strategy phase to embed system-level focus, address barriers and threats.
Recommendation: Achieving the long-term aim of reducing drug-related harms will only be possible if departments work collaboratively and adapt their approach to the evolving threats. The government has created new national and local structures to enable a co-ordinated response to implementing …
Response attribution not verified
#71 — Further support Northern Ireland officials and communities responding to drugs during political stalemate.
Recommendation: In the absence of an operational Northern Ireland Executive and Assembly, the Government must further support officials and communities in Northern Ireland to respond to drugs. This must include support to develop and sustain early intervention and prevention initiatives under …
Response attribution not verified
#69 — Concerns about harms of non-medical cannabis use, rejecting legalisation for youth safety.
Recommendation: We are concerned by the harms that cannabis for non-medical use may pose, particularly in relation to young people. We do not believe that cannabis should be legalised and regulated for non-medical use. (Paragraph 243) Drugs 81 Northern Ireland
Response attribution not verified
#2 — Balance criminal justice response to drugs with increased public health initiatives.
Recommendation: We recommend that the Government balances its criminal justice response to drugs with an increased public health response that seeks to prevent and treat drug use and tackle the root causes of drug use through, for example, a broad range …
Response attribution not verified
#19 —
Recommendation: The Agency told us how current sanctions often have limited deterrent effect. It considers that the only penalty that makes a difference to many waste criminals, particularly one from an organised crime group, is a custodial sentence, but even when …
Response attribution not verified
#70 — Paramilitary drug crime and political stalemate hinder Northern Ireland's drug response.
Recommendation: We are deeply concerned by the role paramilitary groups play in organised drug crime in Northern Ireland, and the impact that this has on local communities, children and young people. We are also deeply concerned by the effect the current …
Response attribution not verified
#22 — 10-Year Drugs Strategy lacks detail on effectively tackling drug-related stigma.
Recommendation: The strategy states a commitment to breaking down stigma but provides little detail on how this commitment would be actioned. Stigma is a key issue for people with lived experience of using drugs and for their loved ones. Tackling stigma …
Response attribution not verified
#1 — Public health responses to drugs gain increasing support and alignment with conventions.
Recommendation: There is increasing support for public health responses as a tool to respond to drugs, and the adoption of such responses are within the spirit of the Drug Control Conventions.
Response attribution not verified
#8 — Commission national review of anabolic steroid use and launch safe use awareness campaign.
Recommendation: We recommend that the Department commissions a national review of the growing use of anabolic steroids in England as it relates to body image. We further recommend that the Department introduces a national awareness campaign around safe anabolic steroid use. …
Response attribution not verified
PPO death in custody recommendations(3)
The Governor
The Governor should continue to identify and address weaknesses in measures to prevent supply of drugs into Lewes and revise the substance misuse strategy in light of the findings.
The Governor
The Governor should ensure that the key drug issues at HMP Garth are identified, that the local drugs strategy is reviewed and revised, where appropriate, to address them and that staff are aware of its contents and their responsibilities.
The Director of HMP Lowdham Grange
The Director should request HMPPS Substance Misuse Group carry out a support visit to review the prison’s drug strategy and identify further measures they can take to reduce supply and demand.
NAO audit recommendations(7)
Reducing the harm from illegal drugs
The JCDU and departments should work with HM Treasury to provide greater certainty on future funding for the strategy. This includes: - exploring the potential for indicative commitments over the life of the strategy; and - DHSC identifying and resolving …
Partially accepted
Reducing the harm from illegal drugs
The JCDU and departments should develop and publish a long-term plan to deliver the 10-year strategy. As part of planning for the next Spending Review, the JCDU and departments should assess how the next phase of the programme builds on …
Accepted
Reducing the harm from illegal drugs
The JCDU and departments should maximise the impact of local partnerships by developing a deeper understanding of local variations, identifying innovative practice, areas that are lagging behind others and what is needed to strengthen responses. They should also consider how …
Accepted
Reducing the harm from illegal drugs
The JCDU and departments should strengthen their approach to evaluating impacts and understanding ?what works? by: - developing and publishing a long-term evaluation plan, supported by sufficient resources, to develop a deeper understanding of the impacts of strategy funding; and …
Accepted
Reducing the harm from illegal drugs
The JCDU and departments should work with HM Treasury to agree what is achievable before the next Spending Review. They should determine how to realistically demonstrate the impact of funding in the first three years, considering the lag time before …
Accepted
Reducing the harm from illegal drugs
The JCDU should work with departments to agree its role over the remainder of the 10-year strategy to ensure that roles and responsibilities are clear and its limited resources are directed in the most effective way.
Accepted
The effectiveness of government in tackling homelessness
As part of the next spending review, and to support a cross-cutting approach to tackling homelessness, we recommend that HM Treasury should consider ways to incentivise government departments to support homelessness prevention, to deliver better outcomes and improved value for …
Accepted
IMB individual recommendations(48)
Lewes (2024)
The Board asks for new measures to reduce the availability of illicit drugs and alcohol across the prison.
Governor / Director
Bedford (2024)
We are concerned that group and individual drug rehabilitation work is no longer carried out.
Governor / Director
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
Erlestoke (2020)
Drugs continue to represent a problem within the prison (see paragraph 4.15). What steps are proposed to assist the prison in intercepting drugs being brought into the prison?
HMPPS
In Progress
Rochester (2021)
The Board still retains the view that in order 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
Wayland (2022)
The Board considers that there might be thought given by the Minister to a consideration of post-release drug treatment perhaps through a new sentence licence requirement, given the links now, operationally, through the combined Prison and Probation Service.
Ministry of Justice
Sudbury (2023)
We have commented on the high proportion of positive mandatory drug testing (MDT) outcomes. What measures can be put in place to address this?
Governor / Director
Leicester (2023)
What plans does the governor have for working with the healthcare provider to ensure a full range of services are available for those who wish to reduce or cease their substance misuse?
Governor / Director
Dartmoor (2023)
What measures will be put in place to ensure that all incidents of prisoners being found under the influence of either drugs or alcohol are recorded effectively and the relevant departments are informed as soon as an incident is discovered?
Governor / Director
Springhill (2024)
The UK government continues to under-invest in the provision of the rehabilitation services needed to reduce recidivism. How will the Minister make the case for long-term investment in its open prisons, specifically in offender management and educational/vocational services?
Other
In Progress
Ranby (2024)
There continues to be a problem with the availability and use of illegal items in the prison. What further steps can the Governor take to address these problems?
Governor / Director
In Progress
Ranby (2024)
The level of illegal substances in the prison has remained high. What measures will the Prison Service take to tackle this situation?
HMPPS
In Progress
Leicester (2024)
Can the Governor work with healthcare commissioners and the provider to ensure that the healthcare unit provides a more holistic, therapeutic regime for prisoners who are seeking to reduce their substance misuse?
Governor / Director
Portland (2025)
The Minister should plan to support the Prison Service to reduce the prevalence of drugs and other illicit substances across the estate.
Ministry of Justice
In Progress
Erlestoke (2025)
What further actions are being considered to reduce the ingress of illicit substances? While the Board recognises enhanced security measures which have been put in place, drugs remain readily available throughout the prison.
Governor / Director
Wealstun (2020)
Ensure that funding is available to reinstate the Resolve offending behaviour programme, given the significant number of prisoners with a history of domestic violence. (see paragraph 7.3.5).
Governor / Director
In Progress
Portland (2020)
For a number of years, Portland has been unable to deliver a regime that meets the requirements of its prisoner population. Shutdowns are frequent, and last minute changes to the daily regime a regular occurrence. This is to the detriment of education and work opportunities for prisoners and the delivery of substance misuse and offending behaviour programmes. It has a …
Governor / Director
Lewes (2020)
The Board would also like to know when further resources will be put into improving safety for prisoners at the establishment, in particular to reduce the ingress and misuse of drugs.
HMPPS
In Progress
Whitemoor (2021)
Will HMPPS please give urgent attention to supporting prison governors in the battle to stop the importing and manufacture of illicit substances including hooch within the prison? These substances endanger the health and wellbeing of prisoners and the safety of officers and their wide-spread use should be a cause of national concern.
HMPPS
In Progress
Nottingham (2021)
We hope that lessons learned during the lockdown period, such as in relation to the reduced circulation of drugs, will be used to inform the organisation of the prison when the restrictions are lifted, so that the overall experience of prisoners is improved.
Governor / Director
Noted
Highpoint (2021)
In the interests of reducing reoffending and supporting prisoners’ progression, the Board asks for consideration of stable funding strategies for the provision of therapeutic initiatives (e.g. music/drama) across the prison estate.
Ministry of Justice
Bullingdon (2021)
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, including the greater use of sniffer dogs, the screening and copying of incoming mail, the installation of a body scanner for prisoners in reception, and the installation of …
HMPPS
In Progress
Buckley Hall (2021)
Provide sufficient additional funding for the new integrated drug recovery wing (6.5.1)
HMPPS
In Progress
Winchester (2022)
What measures can be taken to further reduce the supply of intoxicating substances, especially hooch, to prisoners?
Governor / Director
Noted
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 Governor take to address the availability and use of drugs in the prison?
Governor / Director
Sudbury (2023)
The Board’s observations are that the prison’s ongoing challenges of preventing the entry of illicit items seem to indicate a lack of human and technological resources to combat and discourage this behaviour. Will it be possible to address this in future resourcing allocation processes?
HMPPS
Bullingdon (2023)
The level of availability of illegal substances in the prison has remained high. Are there further measures which the Prison Service could take to reduce this level of availability?
HMPPS
Implemented
Wymott (2024)
The Board recognises the work that the prison is doing to tackle the influx of drugs into the prison (see section 4.5), however what more can be done to mitigate against this?
Governor / Director
Wormwood Scrubs (2024)
What plans are in place to address and reduce the availability of illicit substances in the prison?
Governor / Director
In Progress
Maidstone (2024)
Articulate a clear plan to reduce the prevalence of drugs within the prison estate, both from a demand and supply perspective, and provide guidance and resources for prisons to tackle this endemic problem.
HMPPS
In Progress
Gartree (2024)
Will the Governor continue to push for improvements to the security systems, to help prevent the influx of illicit items through the gate and/or via drones, etc? What additional steps is the Governor taking to reduce the importation of illicit items, including drugs and mobile phones?
Governor / Director
In Progress
Bedford (2024)
The insistence on providing additional maths and English places, at the expense of art and music, does not appear to recognise the elective nature of a prison where most inmates are on remand or the relationship between drug use and more attractive alternative activities. How will the Prison Service resolve this issue?
HMPPS
In Progress
Werrington (2025)
What further steps will be taken to prevent illicit items (particularly cannabis) entering the prison and being passed among young people?
Governor / Director
Wealstun (2025)
What will the Minister do to help tackle the increasing rates of illicit substances entering the prison and support the prison service in this work?
Other
In Progress
Bedford (2025)
What actions will be taken to make the strategy [drug and alcohol rehabilitation] more effective?
Governor / Director
Moorland (2020)
Can resources be provided to enable sufficient provision of programmes to allow prisoners to progress towards successful resettlement?
HMPPS
In Progress
Kirkham (2020)
There is an urgent need to find new office accommodation for the drug service and Custody to Work teams, who are currently housed in offices within the former oil rig buildings. These buildings are due for demolition in the very near future (see paragraph 6.5.2).
Governor / Director
Foston Hall (2020)
The cessation of the CARE (choices, actions, relationships, emotions) offending behaviour programme is a serious loss in provision for women prisoners (see paragraph 7.3.5).
HMPPS
Rejected
Birmingham (2020)
Strategies are in place inside the prison to manage bullying behaviour and address the seemingly endless cycle of debt and resulting violence. How will the minister communicate to other departments the need for corresponding measures in the community, to reduce the influence of urban street gangs and organised crime gangs?
Ministry of Justice
In Progress
Erlestoke (2021)
What steps are proposed to alleviate this national tragedy?
Ministry of Justice
In Progress
Bullingdon (2021)
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, including the greater use of sniffer dogs, the screening and copying of incoming mail, the installation of a body scanner for prisoners in reception, and the installation of …
Governor / Director
Gartree (2024)
What preventive measures are being taken to intercept and prevent frequent drone incursions, which deliver dangerous illicit items?
HMPPS
In Progress
Frankland (2024)
What is being done to reduce the availability of drugs in the prison?
Governor / Director
Five Wells (2024)
The Board remains concerned about the ingress of illicit items into the prison. Can more robust methods of detection be authorised?
HMPPS
In Progress
Lindholme (2025)
The Board asks that the Minister consider in what ways national resources could be deployed to provide additional support and resources to the prison in dealing with the serious ingress of illicit drugs, which is affecting its function as a training prison.
Ministry of Justice
In Progress
Leicester (2025)
What actions can HMPPS take to support the prison in effectively reducing the amount of drugs coming in? For example, inhibiting access by drones by replacement of opening windows with ones with vents?
HMPPS
In Progress
Erlestoke (2025)
Is access to nicotine replacement therapy being considered, given the high incidence of issues relating to vapes (especially debt)?
NHS / Healthcare Provider
In Progress
Brixton (2025)
This was to have been the reporting period in which Brixton changed from a category C resettlement prison to a category B primarily serving the courts. Preparations for this change have impeded work to reduce reoffending within the nine pathways: in particular mental health, substance misuse, education and vocational training. Will the Minister take note that this falls short of …
Other
In Progress
National patient safety alerts(1)
Health investigations(21)
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: Terry Ojuederie, Peterborough (2015) — Rec 100
The educational endeavour should include positive reasons not to use, such as progressing towards personal developmental goals.
east_of_england
Independent investigation: Terry Ojuederie, Peterborough (2015) — Rec 93
Prisoners who do not wish to stop using may benefit from motivational interviewing techniques to help them reflect on the part that substances are playing in their lives. Encouragement to explore the costs of using and the expected benefits of stopping might help the person incline towards a decision to …
east_of_england
Independent investigation: Kyle Maher, Tooting (2017) — Rec R5
EIS should consider using urine or saliva testing as part of care planning where it is known that the service user regularly takes drugs.
london
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.34
There should be further training for all Social Services staff especially those dealing with looked-after adolescents in risk assessment which should include child protection/vulnerability issues, deliberate self-harm and suicidality, violence assessment and substance misuse assessment and management.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.32
There should be further training for all CAMHS staff in risk assessment which should include child protection/vulnerability issues, deliberate self-harm and suicidality, violence assessment and substance misuse assessment and management.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.9a
It is recommended that the Deliberate Self Harm (DSH) assessment protocol is revised to give greater weight to issues of substance misuse and of potential risk to others and from others as well as the risk to self, ensuring that these points are documented.
north_west
Independent investigation: Gilbert McCallum, Dover (2001) — Rec 18.2
The protocols for inpatient detoxification should be reviewed in the light of the shortcomings identified.
south_east
Independent investigation into the care and treatment of patient M … — Rec 93
Prisoners who do not wish to stop using may benefit from motivational interviewing techniques to help them reflect on the part that substances are playing in their lives. Encouragement to explore the costs of using and the expected benefits of stopping might help the person incline towards a decision to …
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 100
The educational endeavour should include positive reasons not to use, such as progressing towards personal developmental goals.
east_of_england
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: Terry Ojuederie, Peterborough (2015) — 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 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 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: Eddie Thorpe, Dewsbury (2008) — Rec 5
The Trust has identified that progress has been made in the delivery of substance misuse services. It should now put in place a system, including an audit cycle, to assure itself and its commissioners that these developments are realising the intended and identified outcomes. The Trust has identified a number …
north_east_yorkshire
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: 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: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 32
Patients who present with dual diagnosis involving misuse of illicit substances and/or alcohol should be referred for specialist assessment to secure an appropriate clinical management plan, or at the very least be subjected to routine screening for such substances
london
Independent investigation: Cerys Yemm, Argoed (2014) — Rec 3
Welsh Government to review the provision and the availability of more structured interventions for individuals within the community that have both a personality disorder, mental health issues and substance misuse concerns.
wales
Independent investigation: Anthony Harrison, Andover (1998) — Rec 5
As alcohol misuse and drug misuse are becoming more common problems, local multi-agency strategies should be developed through the Drug Action Team and Drug Reference Groups, with appropriate links to local community safety strategies.
south_east
*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
Scottish Fatal Accident Inquiries(4)
Craig Alexander Corbett otherwise Duffy
It seems to me that a similar message, to the effect that one should not go to sea in any command (or even work) situation until one's body is clear of alcohol or at least no longer impaired by it, could and should be more strongly and more continuously disseminated amongst the sea-going community until the message really starts to …
Nov 2005
John MacDonald
It seems to me that a similar message, to the effect that one should not go to sea in any work situation until one's body is clear of alcohol - or at least no longer impaired by it, could and should be more strongly and more continuously disseminated amongst the sea-going community until the message really starts to drive home. …
Nov 2005
Stuart Graham Foster
If other tragedies are to be avoided society must change its attitude to the consumption of alcohol to excess. Education about the harmful effects of alcohol and the unacceptability of persons in a state of intoxication must be a continuing process. Consideration may need to be given to delivering the information contained in the Servewise course more frequently.
Jul 2007
Scott Andrew Ross
Feb 2024
Custody
Domestic Homicide Reviews(10)
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
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 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)
South Gloucestershire — recommendation 42
Practices to be encouraged to consider implementing a system of identifying and allocating known drug users to a specific GP who should co-ordinate their care, with flagging of records to indicate which GP they should be directed to.
South Gloucestershire Clinical Commissioning Group (ICB)
NHS Gloucestershire ICB
Milton Keynes — recommendation 10
It makes a recommendation around ‘date rape’ type drugs and the use of dating sites. Although Anthony’s death and this Review did not involve a dating site directly, there were suggestions that other, potentially dangerous events, were revealed in the course of the Review.
Milton Keynes Community Safety Partnership
Buckinghamshire — recommendation OHFT-2
Improve joint working with One Recovery Bucks.
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Buckinghamshire — recommendation ORB-6
Service users / patients should be reminded of the need to attend appointments and to fully participate in their recovery programme. Full compliance with the ORB ‘Did Not Attend ‘SOP.
One Recovery Bucks (Midlands Partnership NHS …
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
Durham — recommendation 3
SDP to ask all agencies to review how they share information in relation to excessive use of alcohol where cases indicate this is appropriate to prevent or reduce both violent crime and offences of Domestic Abuse happening in the future.
All agencies
Bedford — recommendation 3.49.
Probation Officers should ensure that information is shared with Children’s Social Care as soon as possible where children are in the household of an offender on IDAP and they are breached for non attendance or behaviour which increases risk to their partner or former partner, such as increased use of …
Probation
Probation Service