Prison drug policy enforcement
Failures in enforcing prison drug policies, including acting on positive drug tests for non-prescribed substances.
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.
62 PFD reports
34 committee recs
65 PPO recs
3 IOPC recs
217 IMB recs
134 IMB reports
1 Scottish FAI
4 Article 2 learning points
3 detention investigation recs
418 LGO/SPSO decisions
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(62)— showing 50 strongest matches
Adrian Johnson
Concerns: The coroner identified gaps in the assessment and management of tobacco withdrawal by healthcare professionals during initial prison screenings, which elevated the prisoner's vulnerability. Concerns also included insufficient healthcare input into ACCT reviews and inconsistent information sharing.
Response (HM Prison and Probation Service): • HM Prison and Probation Service (NOMS) and NHS England stated they would give further consideration to identifying tobacco withdrawal risks in screening processes and develop a care pathway, including … (AI summary)
Overdue
Wayne Broad
Concerns: The coroner identified a lack of dedicated substance misuse teams for detainees in police custody and for patients in hospitals. Concerns were also raised regarding the alignment of handcuffing policies for seriously ill detainees with ACPO guidance.
Response: • The responsibility for healthcare in police custody suites will transfer from individual police authorities to NHS England. • Healthcare for persons in custody will be commissioned to NHS standards … (AI summary)
Overdue
Edward Devlin
Concerns: The coroner identified a practice where nurses reportedly slide medication, including controlled drugs, under cell doors rather than directly handing it to patients. This raises concerns about whether patients receive their medication, the accuracy of drug records, and the potential for drug misuse or trading within the establishment.
Response (Care UK): • An investigation was commenced into the nurse's claim regarding medication administration practices. • Healthcare staff were interviewed, and a staff meeting was held to discuss the claim. • A … (AI summary)
Overdue
Yohannes Kidane
Concerns: Concerns were noted regarding inadequate night staffing on healthcare wards, which compromises the ability to conduct effective ACCT observations and affects staff welfare due to staff not taking breaks.
Response (HM Prison and Probation Service): • HM Prison and Probation Service reviewed night staffing levels at HMP Birmingham and concluded they were acceptable. • A Prison Custody Officer is deployed to patrol the healthcare centre … (AI summary)
Response (Birmingham Solihull NHS): • Birmingham Community Healthcare Trust reviewed its skill mix for Ward 1, which will result in the conversion of funding for unqualified staff into qualified nurses, with recruitment for an … (AI summary)
Responded
William Anderson
Concerns: The coroner noted insufficient staff vigilance regarding inmate social gatherings and a lack of training for staff in breathalyser use and emergency codes. Concerns were also raised about unrecorded inmate behaviour in observation books and delays in summoning paramedic assistance.
Overdue
Sharon Butcher
Concerns: The coroner noted a 10-minute delay in calling an ambulance after an emergency code, with the local protocol not followed. Similar issues with medical emergency responses, including incorrect codes and control room delays, have occurred at other prisons.
Response (HM Prison and Probation Service): • HMP Frankland revised local contingency plans and re-issued instructions to staff regarding calling an ambulance. • An additional learning bulletin was issued nationally by ERDG in April 2015. • … (AI summary)
Overdue
Liam Smith
Concerns: The coroner identified non-adherence to mandatory ACCT procedures for prisoners at risk of inadvertent self-harm, inadequate dissemination of medical information upon arrival, and gaps in healthcare staff's access to patient notes. There were also concerns about limited interaction with high-risk drug users.
Response (HM Prison and Probation Service): • A review of the Assessment, Care in Custody and Teamwork (ACCT) process is ongoing to inform changes to the current policy. • The prison and healthcare provider have reviewed … (AI summary)
Overdue
Kevin Forster
Concerns: The coroner identified a serious drug problem at HMP Durham and a lack of staff awareness and training regarding drug and overdose policies. There was insufficient guidance on managing overdoses, leading to delays in emergency response and a degree of complacency among staff.
Response: • The prison updated its Substance Misuse policy in April 2015 and subsequently initiated a joint project with Spectrum Community Health and NHS England to develop new clinical guidelines for … (AI summary)
Response: • All current staff have signed to confirm their understanding of the Emergency Code Protocol. • Staff have been issued with pocket-sized cards explaining the protocol, and it has been … (AI summary)
Responded
Dean Boland
Concerns: The coroner identified insufficient staff awareness and multi-disciplinary coordination regarding drug issues within the prison. Additional concerns included inadequate medication administration checks, limited cell searches, lack of overnight prisoner monitoring, and insufficient measures to prevent drugs entering the facility.
Response (HM Prison and Probation Service): • Training on supervising opiate substitution medication was completed for detox unit staff, with awareness training scheduled for completion by January 2016. • Mandatory attendance for B Wing prison officers … (AI summary)
Overdue
Imran Douglas
Concerns: The coroner identified concerns regarding the rigid legal handover of placement duties at age 18, which may occur before a young person's Transition Plan is completed. Also noted were gaps in knowledge and interagency working between social care and the secure estate for transition planning.
Responded
Matthew Russell
Concerns: The coroner noted insufficient monitoring of repeat prescriptions, a lack of structured care plans, and ineffective follow-up for missed appointments. Concerns also included inadequate staff training in the ACCT procedure and unclear procedures for prison gatehouse staff regarding prisoner safety alerts.
Response (Central and North West London NHS Foundation Trust): • CNWL undertook audits of anti-depressant prescribing and care plans, and implemented a new daily process for following up missed appointments. • A mandatory e-learning module for suicide prevention, including … (AI summary)
Overdue
James Spencer
Concerns: The coroner noted inadequate training for support officers in recognising drug-related collapse, particularly regarding risks for recently released prisoners. Review of induction policies, staff training, and ongoing updates was recommended to improve officer awareness and resident safety.
Response (James Spencer): • The drug training delivered to colleagues working on the BASS contract has been fully reviewed. • Drug awareness training is now delivered to all new operational colleagues working on … (AI summary)
Responded
Jonathan Palmer
Concerns: The coroner noted no effective system exists for prisoners' families to input relevant health information and ensure its dissemination to prison teams and proper recording. Concerns were also raised about the ineffective measures to control contraband, such as illicit drugs like Spice, entering the prison.
Response (HM Prison Probation Service): • HMPPS issued a Safer Custody Learning Bulletin in October 2016, providing guidance on receiving emergency calls and sharing risk information from families. • HMP Wandsworth implemented a multi-pronged approach … (AI summary)
Overdue
John O’Meara
Concerns: The coroner identified two concerns: delays in emergency service calls due to prison officers not strictly following the Code Blue/Red system, and an insufficient number of passive dogs to control Novel Psychoactive Substances in prisons.
Response (HM Prison and Probation Service): • The member of staff referenced in the concern is no longer employed at the prison. • The Governor will keep the situation under review to identify further steps to … (AI summary)
Responded
Timothy Shaw
Concerns: The coroner noted a lack of clarity among healthcare staff regarding Intelligence Reports, requiring improved communication, criteria, and audit. Further improvements are needed in reducing access to illegal substances, psychosocial service referrals, and record keeping.
Overdue
Andrew Craig
Concerns: The coroner identified ongoing issues with the use of prescription and illicit drugs at HMP Guys Marsh, noting that the chaotic medication dispensing process at the healthcare hatch allows for drug transfer and redistribution among prisoners.
Response (HM Prison Probabtion Service): • A plan to upgrade cell windows to 'safer cell' standards has been approved and is provisionally scheduled for delivery in 2019/20. • A new local substance misuse policy has … (AI summary)
Response (Care UK): • Care UK confirmed it had implemented measures to reduce medication diversion, including reviewing prescribing practices and reducing the number of patients receiving supervised medication. • Care UK provided substance … (AI summary)
Overdue
Daniel Stokes
Concerns: The coroner noted the jury's view that proper systems were lacking for prison healthcare staff to be trained and authorised to administer diazepam when a prisoner is suffering from controlled drug abuse.
Overdue
Jerome Jones
Concerns: The coroner identified a lack of policy for additional checks on prisoners with repeat NPS use, especially when combined with existing medical conditions. There was also no method for drug workers to communicate these risk factors to healthcare or prison officers, and drug workers lacked access to medical records to inform their advice.
Response (Shropshire Community Health NHS Trust): • The Trust described its current practice for additional observations following prisoner substance use and referral to Forward Trust staff. • The Trust stated that the Forward Trust is in … (AI summary)
Response (HM Prison Probation Service): • An updated drug strategy was launched at the establishment, and staff were notified of it, including reminders about healthcare staff's responsibility for determining and communicating additional checks for prisoners … (AI summary)
Overdue
Tyrone Givans
Response (Care UK): • Care UK stated it would work with partner agencies to address illicit substance supply and trading. • Care UK shared learning from the inquest regarding medical record anomalies with … (AI summary)
Response (HM Prison and Probation Service): • A national Prison Drugs Strategy was published in April, and HMP Pentonville is revising its local drug strategy and has reinstated its Drug Strategy Committee. • HMP Pentonville implemented … (AI summary)
Overdue
Natasha Chin
Concerns: The coroner identified issues with medication information sharing between clinical and discipline staff, inadequate opiate and alcohol withdrawal protocols, and a lack of formal audits on medication administration. There were also concerns about the adequacy of staff training.
Response (HM Inspector of Prisons): • HM Inspector of Prisons stated it would place a copy of the Regulation 28 report in its intelligence file to inform future inspections of HMP Bronzefield. • HM Inspector … (AI summary)
Overdue
Ricardo Holgate
Concerns: Further steps are necessary to improve the management of illicit substance misuse within the prison, including the installation of CCTV on all wings and airport-style scanners. Extending the current Governor's appointment would allow more work to be undertaken to enhance inmate safety.
Response (GS4): • G4S stated that funding for CCTV installation at HMP Birmingham had been approved. • G4S reported that Governor Newton's appointment had been extended. • G4S noted that discussions regarding … (AI summary)
Overdue
Andrew Carr
Concerns: Birmingham Prison did not review or record vital information about a prisoner's history of psychoactive substance use upon transfer. The report also highlighted that no solution had been found for five years to prevent drugs being passed through the prison's plumbing system.
Overdue
Stephen Harte
Concerns: The coroner noted that drugs could easily enter the medium secure unit due to unsearched takeaway food deliveries, insufficient searching of residents returning from leave, and staff not being routinely searched or their food inspected upon entry.
Response (Birmingham and Solihull Mental Health NHS Trust): • The Trust has implemented a range of additional controls to detect drugs, including regular drug screens, random searches, fortnightly drug dog visits, and the purchase of an amnesty box. … (AI summary)
Response (CQC): • The Care Quality Commission (CQC) issued a requirement notice to the trust for breaching Regulation 13 regarding blanket restrictions on food ordering and patient searches. • The CQC required … (AI summary)
Responded
Martin Haines
Concerns: The coroner noted fragmented healthcare responsibility in the prison, with insufficient communication and separate IT systems between providers. This affected the monitoring of the deceased's medical conditions and the establishment of clear protocols for emergency response.
Response (NHS England): • Sussex Partnership NHS Foundation Trust implemented staff training on detecting and managing diabetes and hypertension in line with National Institute for Care Excellence (NICE) guidelines, which was completed by … (AI summary)
Response (Department of Health and Social Care): • DHSC officials brought the coroner's reports to the attention of the Care Quality Commission. • The National Partnership Agreement for Prison Healthcare in England 2018-21 was revised to include … (AI summary)
Response (HM Prison and Probation Service): • The Prisons Drug Strategy was published in April 2019, and HMP Lewes updated its local Substance Misuse Strategy in June 2019 to address illicitly brewed alcohol. • HMP Lewes … (AI summary)
Responded
Leroy Medford
Concerns: The coroner noted officers were unaware of a specific Drugs SOP requirement for in-cell observation. Broader concerns were raised regarding the effectiveness of police training dissemination and monitoring across the country.
Response (Thames Valley Police): • Thames Valley Police updated its drugs recovery Standard Operating Procedure in July 2019 to improve accessibility and clarity for operational officers. • The force introduced specific briefings for officers … (AI summary)
Response (National Police Chiefs' Council): • The National Police Chiefs' Council's national lead for training and development is involved in the College of Policing’s work on a national strategy for police learning. • The report … (AI summary)
Overdue
Mark Jarvis
Concerns: The SystmOne computer system used for medication prescription and review at HMP Warren Hill was described as unclear and difficult, hindering GPs from verifying current prescriptions, tracking medication adherence, and managing prisoner medications effectively.
Overdue
Imran Mahmood
Concerns: Concerns were identified regarding the potential for e-cigarette heating coils in prison to be misused for drug preparation and to start fires. The coroner questioned if e-cigarettes for prison use could be manufactured with sealed heating components.
Response (HM Prison and Probation Services): • HM Prison and Probation Service is considering alternative vape devices, including a new device that uses vapourless valve technology. • It stated it would make a suitable alternative device … (AI summary)
Responded
Neville McNair
Concerns: HMP Lewes lacked a local protocol for Naloxone use, and prison officers were neither trained in its administration nor aware of its availability, despite national guidelines for all staff. Naloxone was also not stored on prison wings.
Response (NHS England): • The Forward Trust confirmed a protocol for opioid overdose is in place, with healthcare staff trained in naloxone administration and naloxone available in 'grab bags' at HMP Lewes. • … (AI summary)
Response (HM Prisons and Probation Service): • The Governor of HMP Lewes agreed to review the local naloxone protocol with the healthcare provider and commissioner. • A pilot project is being prepared to train prison staff … (AI summary)
Overdue
Luke Jones
Concerns: The coroner noted continuing concerns regarding the accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn. Despite some measures taken, the significant health risks posed by NPS mean they are considered a probable cause of future deaths at the prison.
Response (HM Prison and Probation Service): • HMP Berwyn and the Regional Substance Misuse lead for HMPPS Wales revised the prison’s Drug Strategy. • A Rapiscan machine was introduced, and gate searching procedures were improved. • … (AI summary)
Overdue
Daniel Coleman
Concerns: The coroner noted that Mr. Coleman was living unnoticed on a demolition site by managers and security, alongside concerns about inconsistent security patrols and incomplete site records. The report also highlighted an insufficient drug and alcohol risk assessment for individuals managing sites.
Response (Camden Council): • The Council has developed a 'Site Security Scope of Service' specification for security contractors, which includes detailed processes, a clause prohibiting accommodation on site, and requirements for weekly electronic … (AI summary)
Responded
Anthony Clacher
Concerns: The coroner noted the absence of a national policy or local protocol at the time of death for welfare checks and monitoring prisoners found under the influence of psychoactive substances, despite the known risks of deterioration and self-harm.
Response (NHS England): • The Digital Person Escort Record (DPER) has been implemented across the prison estate, and healthcare staff have access to the integrated summary care record (SCR) at reception. • A … (AI summary)
Response (NHS England): • NHS Digital stated it would support the re-procurement of the Health and Justice Information Service (HJIS) in 2022/23. • It confirmed it would consider the coroner's concern regarding SystmOne … (AI summary)
Response (Department of Health Social Care): • NHSEI published a revised service specification for Integrated Substance Misuse Services in Prison, which covers psychoactive substances. • NHSEI has worked with HMPPS to review the Assessment, Care in … (AI summary)
Response (HM Prison and Probation Service): • The national Drug Strategy Team gathered information on local initiatives for welfare checks and monitoring prisoners under the influence of psychoactive substances. • The team is in discussions with … (AI summary)
Responded
Kyle Nel
Concerns: The coroner raises concerns about the lack of a structured approach for recording and responding to family concerns regarding a prisoner's welfare, and the need to review security fences preventing the transfer of prohibited items between prison units.
Response (HM Prison and Probation Service): • HMP Guys Marsh has established multiple channels for families to raise concerns, including direct contact with the Safer Custody team and an out-of-hours orderly officer. • All family concerns … (AI summary)
Responded
Ian Miller
Concerns: Concerns were raised about medication management at HMP Usk, where prisoners self-manage drugs that are not securely stored. This contributes to widespread trading of prescribed medication among prisoners, risking future deaths.
Response (HM Prison and Probation Service): • The prisoner induction process was updated in January 2022 to include information on in-possession medication, misuse dangers, and reporting concerns. • Guidance was issued to staff in January 2022 … (AI summary)
Overdue
Thomas Smith
Concerns: The coroner identified insufficient staff knowledge and training on synthetic cannabinoid dangers in mental health settings. Additionally, the system for assessing risks during s.17 leave was inadequate, as escorting staff lacked access to vital patient information.
Response (Responses from NHS England): • NHS England reported that East London NHS Foundation Trust (ELFT) delivered training to staff on "Spice" awareness and engaged local drug and alcohol service providers. • NHS England stated … (AI summary)
Overdue
Christopher Ryan
Concerns: The coroner identified a blurring of boundaries between the intended 1:1 therapeutic escorted leave for MHA patients and the practice of one staff member accompanying multiple patients to an unsecure car park for smoking breaks. This meant restricted leave was used for smoking, and consideration was not given to a dedicated safe smoking area.
Response (South West London and St Georges Mental Health): • The Trust will review its leave form and guidance to better capture stipulations for escort staffing. • The Trust will ensure leave is facilitated according to these stipulations and … (AI summary)
Responded
Stephen Weatherley
Concerns: The coroner identified concerns regarding data recording and retention practices at HMP Thameside, including lost documents and incomplete records, and the absence of a written policy for suspected drug swallow incidents.
Response (HM Inspectorate of Prisons): • HM Inspectorate of Prisons conducted a full inspection of HMP Thameside in November 2021 and published reports detailing concerns and recommendations. • The Inspectorate stated that the information provided … (AI summary)
Response (HM Inspectorate of Prisons): • HM Inspectorate of Prisons stated the information provided by the Coroner would feature significantly in its assessment of risk at HMP Thameside. (AI summary)
Response (Serco 1): • The prison has implemented a system for data retention using MS Teams folders and conducts daily Quality Assurance audits. • Independent audits of document retention and PNOMIS files have … (AI summary)
Response (HM Prison and Probation Service): • The contract for HMP Thameside includes specific delivery indicators for the management of records and data retention. • The prison's performance is reviewed monthly and during quarterly contract reviews, … (AI summary)
Responded
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
Steven Sanders
Concerns: The coroner noted an endemic problem of illicit substance use within SAH, raising concerns that this risk is not being adequately mitigated. This situation poses a significant risk to vulnerable patients in the secure hospital environment.
Response (CQC): • The CQC conducted an unannounced, comprehensive inspection in January 2024, which specifically considered the concerns about illicit drug supply. • The inspection found that the provider had taken actions … (AI summary)
Overdue
John Pace
Concerns: The coroner noted that a new drug detoxification discharge pathway for prisoners at HMP Chelmsford lacks formal documentation, including protocols and policies. This absence prevents consistent implementation and monitoring, raising concerns about future risks to prisoners.
Response (the Forward Trust): • The Forward Trust drafted and implemented a new protocol on the ‘Management of Non-engaging Service Users Protocol’. • The new protocol was published on the policy section of their … (AI summary)
Overdue
Kane Boyce
Concerns: The coroner identified a practice of staff deliberately ignoring cell bells and a lack of policy regarding isolating power to cells. There was also a failure to follow the 'Under the Influence Policy' and insufficient staff understanding of Prison Service Instruction 64/2011 concerning trigger dates.
Response (Sodexo): • Sodexo stated it requires all cell bells to be answered within 5 minutes and has produced a policy for when it resumes operational management. • The HMPPS Governor has … (AI summary)
Response (HM Prison and Probation Service): • HMPPS issued guidance and a standard template for Early Learning Reviews in 2021. • Workshops were held with Group Safety Leads in July 2022 and April 2024 to enhance … (AI summary)
Responded
Liam Turner
Concerns: It is not mandatory for prison officers to maintain in-date basic first aid training, including CPR. This results in a significant proportion of staff having expired certifications.
Response (HM Prison and Probation Service): • HM Prison and Probation Service re-issued its First Aid Policy Framework in August 2023, which outlines training requirements and mandates local risk assessments. • HMP Manchester issued guidance and … (AI summary)
Responded
John Singleton
Concerns: The SystmOne electronic patient system in prisons lacks an automated warning flag to identify when prisoners do not collect or dispense prescribed medication, hindering early identification of non-compliance and requiring an inefficient manual cross-check.
Response (NHS England): • Work is underway to investigate the reporting functions in HJIS to identify mechanisms for non-collections of in-possession medication. • The National Director of Health & Justice will write to … (AI summary)
Responded
Amanda Richardson
Concerns: The coroner identified a lack of effective hospital systems to prevent a patient from receiving double the maximum medication dose for six months. Concerns were also raised about inadequate searches and record-keeping after a patient's unescorted leave, along with the overall security arrangements.
Response (InMind): • Inmind Healthcare completed a Serious Incident Report and shared it with the CQC and Commissioners. • The Serious Incident Report included an action plan of recommendations. • Inmind Healthcare … (AI summary)
Overdue
Jonathon Lawlor
Concerns: The coroner noted that Mr. Lawlor had only two keywork sessions in four months at HMP Elmley due to staff shortages, and that insufficient key-working could impact risk reduction for other prisoners.
Response (HM Prison and Probation Service): • His Majesty’s Prison and Probation Service (HMPPS) introduced a new regime and business planning process in January 2024, establishing key work as an operational priority. • HMPPS established a … (AI summary)
Responded
Anthony Binfield
Concerns: The coroner raises concerns about prison staff failing to manage cell observation panels safely and in accordance with policy, noting a culture of delayed cell entry when panels are obscured. This practice, which risks lives, persists despite previous incidents and multiple staff notices.
Response (HM Prison and Probation Service): • The Incentives Policy Framework has been updated to include specific reference to blocking observation panels, enabling sanctions against prisoners. • Staff receive regular briefings, notices, and induction training on … (AI summary)
Responded
Isaiah Olugosi
Concerns: The coroner notes that the prison's buzzer/intercom system had not worked for several years, and despite a jury finding this to be a failure, the prison or Ministry of Justice still deems it unnecessary, potentially hindering vital communication.
Response (HM Prison and Probation Service): • The prison addressed phone line issues to ensure external contact. • The Governor ordered the removal of external intercom units. (AI summary)
Responded
Gavin Wheale
Concerns: The HMP Birmingham secreted item policy lacks clear guidance for situations where an item has been ingested without its packaging. There is also no equivalent level of monitoring for prisoners previously under constant supervision when transferred to the prison regime.
Response (HM Prison and Probabtion Service): • HMP Birmingham committed to updating its local secreted items policy to include guidance for staff on suspected ingestion. • The West Midlands Group Safety Lead will ensure consistent guidance … (AI summary)
Responded
Sheldon Jeans
Concerns: The coroner noted a lack of national and local policy regarding illicitly brewed alcohol (hooch) in prisons. Concerns were also raised about insufficient governance for medication held in possession by prisoners, which could be accessed by others.
Response (HM Prison Probation Service): • The Drug and Alcohol Group (DAG) developed and disseminated materials, including the Drugs in Prison and Probation (DiPP) guide, to enhance staff understanding and support regarding illicitly brewed alcohol. … (AI summary)
Response (Oxleas NHS Foundation Trust): • The Trust has removed certain medications from its prescribing formulary or provides them on a supervised basis to minimise diversion risk, and its substance misuse provider delivers alcohol workshops, … (AI summary)
Response (HM Prison and Probation Services): • HMPPS's Drug and Alcohol Group developed and disseminated materials, including a guide and briefing notes, to enhance staff understanding and operational responses to illicitly brewed alcohol. • HMP Guys … (AI summary)
Response (Department for Health and Social Care): • The Department stated that national NHS policies for medicines governance and supply for prisoners align with those for people in the community, supported by HM Inspectorate of Prisons Expectations … (AI summary)
Responded
Lewis Petryszyn
Concerns: The coroner identified an absence of prescribed timeframes in policies for substance misuse intervention and support for prisoners, which poses a risk of delayed assistance.
Response (G4s Care): • Initial care plans are completed for prisoners identified as having substance misuse within three days. • Prisoners assessed as requiring caseload allocation are assigned a Dyfodol caseworker within three … (AI summary)
Overdue
Martin Collins
Concerns: The prison telephone system lacks automated capability to recognise high or unusual volumes of prisoner calls, which may lead to missed opportunities for staff to identify risk triggers and prevent suicide. The data is available but requires manual monitoring.
Response (HM Prison Probation Service): • HM Prison and Probation Service (HMPPS) held initial discussions with its telephony contractor, BT, to explore technical options for monitoring call volumes. • This work will be included as … (AI summary)
Responded
Select committee recommendations(34)
#198 — Ensure uniform security standards throughout the prison estate to mitigate all potential ingress risks.
Recommendation: Security measures must acknowledge the principle of displacement; as one route is closed, efforts must then be made to proactively mitigate risks across the full range of other potential ingress methods by ensuring uniform security standards throughout the prison estate. …
Response attribution not verified
#197 — Advanced drug detection technology is an essential prerequisite for preventing drug ingress
Recommendation: A major obstacle to tackling drug supply is the disparity in security equipment provision between prisons. The prisons that utilise drug detection technology demonstrate its profound and immediate impact on security. This confirms that investments in advanced detection machinery are …
Response attribution not verified
#196 — Effective collaboration requires consistent intelligence sharing to disrupt OCG drone operations
Recommendation: Collaboration between HMPPS and law enforcement agencies, such as the National Crime Agency and local police, is critical in identifying and disrupting the OCGs behind drone operations. We are pleased to hear that HMPPS have developed good working relationships with …
Response attribution not verified
#195 — Manage key OCG operators under enhanced security, segregating them from general prison population
Recommendation: Individuals identified as key OCG operators must be managed under enhanced security protocols and, where possible, segregated from the general prison population to prevent them from exploiting vulnerable prisoners and staff to maintain their “clean profile”. The practice of merely …
Response attribution not verified
#194 — Collaborate to develop systems tracking electronic transactions linked to OCG activity in prisons
Recommendation: HMPPS must urgently collaborate with law enforcement and financial institutions to develop and deploy systems capable of tracking electronic transactions linked to known or suspected OCG activity in the prison context. (Recommendation, Paragraph 113)
Response attribution not verified
#193 — Accelerate deployment of advanced contraband detection and signal disruption technology with trained personnel
Recommendation: The MoJ must ring-fence funds to accelerate the deployment of advanced contraband detection and signal disruption technology across the prison estate. Crucially, this must be paired with specialised recruitment and ongoing training to ensure personnel are proficient in operating the …
Response attribution not verified
#192 — Eliminating external communication is critical to disrupting prison drug supply chains
Recommendation: Given that the Organised Crime Group market is based on reliable means of communication and that sophisticated smartphones are readily available within prisons, eliminating external communication is the single most critical intervention to disrupt drug supply chain management, debt coordination …
Response attribution not verified
#191 — Develop and deploy comprehensive anti-drone strategy and technology across high-risk prisons
Recommendation: A clear and sufficiently resourced strategy is needed to address the evolving nature of drone technology. This strategy should look beyond current capabilities and anticipate future threats, such as the potential for drone- facilitated escapes and the delivery of firearms, …
Response attribution not verified
#190 — Employ dedicated intelligence-sharing protocols and joint task forces against organised drone and phone gangs
Recommendation: While current partnerships with police and the National Crime Agency aimed at tackling drone incursions are positive, they are not sufficient. The MoJ and HMPPS must employ dedicated intelligence-sharing protocols and joint task forces to specifically target the organised criminal …
Response attribution not verified
#189 — Current detection technologies outpaced by sophisticated drones and illicit mobile phone use
Recommendation: While the recent £40 million investment in prison security is a welcome step, current drug detection technologies are being outpaced by the sophistication of drones and the criminal networks behind them. The ability of criminals to leverage illicitly acquired mobile …
Response attribution not verified
#188 — Reliance on staff sightings underestimates serious threat of increasing drone incidents
Recommendation: We are alarmed by the rapid increase in drone incidents over the last three years, as confirmed by HMPPS’s own data. The current reliance on staff sightings to detect drones, as noted in the HMPPS Annual Digest, is insufficient and …
Response attribution not verified
#181 — Allocate dedicated capital funding for advanced prison detection technology and software updates
Recommendation: The Government must allocate dedicated capital funding for the accelerated acquisition and maintenance of advanced trace detection technology and full-body scanners in all prisons. This investment must include a mandated requirement for rapid, regular software library updates for all drug …
Response attribution not verified
#180 — Inconsistent deployment of security measures undermines their effectiveness against criminal networks
Recommendation: Our observations confirmed that existing security measures, such as sniffer dogs, are often deployed in an inconsistent manner. For example, drug detection dogs being used for only a few instances in a day in some prisons, rather than as part …
Response attribution not verified
#179 — Require balancing prisoner punishments with mandatory drug treatment referrals and resourcing consistent adjudications
Recommendation: We recommend that punishments, such as the loss of privileges, are balanced with a mandatory referral to drug treatment services. This ensures that individuals are held accountable while also directed towards the support they need to break the cycle of …
Response attribution not verified
#177 — Regard staff exposures to drugs as serious workplace safety violations requiring immediate investigation.
Recommendation: HMPPS must regard staff exposures to drugs as serious workplace safety violations, not as a normal part of the job and must take immediate action to investigate and resolve the causes of such incidents. (Recommendation, Paragraph 67)
Response attribution not verified
#176 — High prevalence of drugs, particularly NPS, poses an unacceptable threat to prison staff safety.
Recommendation: The high prevalence of drugs in prisons, particularly NPS, poses an unacceptable and direct threat to the safety and well-being of prison staff. The current reality of staff becoming “desensitised” to daily suffering is a sign of a failed system …
Response attribution not verified
#173 — Drug-related medical emergencies strain prison staff and reduce purposeful activity, fueling drug demand.
Recommendation: Every drug-related medical emergency in prison, especially when fatal, is a needless tragedy. The significant number of ’code blues’ in some prisons adds to the significant strain already being experienced by staff. This leads to regime restrictions and increased time …
Response attribution not verified
#172 — Drug-related debt and exploitation are fundamental drivers of prison violence and systemic instability.
Recommendation: Drug-related debt and exploitation are fundamental drivers of violence, coercion and systemic instability within the prison estate. The prevalence of drugs creates a shadow economy where debts, which can accrue up to £10,000, are collected through intimidation and violence. The …
Response attribution not verified
#167 — Consistently update prison drug testing methods to detect evolving New Psychoactive Substances.
Recommendation: The MoJ and HMPPS must consistently update prison drug testing methods to enable the detection of the constantly changing chemical makeup of these NPS, including synthetic cannabinoids and synthetic opioids. Robust data collection should be expanded to include drug purity/potency …
Response attribution not verified
#166 — Take urgent steps to address the evolving threat of New Psychoactive Substances in prisons.
Recommendation: Given the extreme potency and low lethal dose of substances such as Nitazenes and Fentanyl, the circulation of these drugs in prisons leads to a high risk of drug-related deaths and overdoses, as tragically seen at HMP Parc. The MoJ …
Response attribution not verified
#165 — Significant shift towards undetected New Psychoactive Substances (NPS) in prisons.
Recommendation: We are deeply concerned by the significant shift towards the use of New Psychoactive Substances (NPS), most notably synthetic cannabinoids and synthetic opioids. Their popularity is due to their affordability, accessibility and their potency. In turning to these drugs, prisoners …
Response attribution not verified
#164 — Revise drug testing policy for dual response: disciplinary action and treatment referral.
Recommendation: The MoJ and HMPPS must revise the drug testing policy to ensure that positive test results consistently trigger a dual response: swift and certain disciplinary action (with a rehabilitative element) and an immediate, 60 mandatory referral for a clinical needs …
Response attribution not verified
#163 — Speed up plans to introduce wastewater-based drug surveillance across the entire prison estate.
Recommendation: The MoJ and HMPPS must speed up plans to introduce wastewater- based surveillance to identify new substances across the entire prison estate. If successful, this wastewater surveillance should be deployed in all prisons to monitor drug usage trends within two …
Response attribution not verified
#162 — Increase Mandatory Drug Testing rates across prisons to at least pre-pandemic levels.
Recommendation: The MoJ and HMPPS must increase MDT rates to at least pre-pandemic levels. An immediate and mandatory intervention from regional or national HMPPS command, including the deployment of specialist teams to ensure testing is reinstated immediately, should be triggered. (Recommendation, …
Response attribution not verified
#161 — Restore consistent, high-volume Mandatory Drug Testing across the entire prison estate.
Recommendation: Mandatory Drug Testing rates do not reliably measure drug prevalence. The MoJ’s own admission that resource constraints limit its capacity for MDT testing and therefore its ability to produce robust, publishable data demonstrates the failure of the current approach. The …
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
#178 — Significant backlog in adjudication process undermines prison discipline and progression model
Recommendation: The significant backlog in the adjudication process, acknowledged by the Prisons Minister, undermines discipline in prisons. While current policy allows governors to balance punishment with support, we received evidence which shows this is not happening consistently. Some prisoners face no …
Response attribution not verified
#23 — Crowding and capacity pressures severely impact prisoner health and drug treatment in prisons
Recommendation: Several stakeholders provided written evidence on how crowding and capacity pressures are impacting health and drug treatment in prisons.78 For example, HM Inspectorate of Prisons (HMIP) noted that the strain at some reception prisons are under means that prisoners do …
Response attribution not verified
#4 —
Recommendation: It is unacceptable that HMPPS still does not know if or how tagging reduces reoffending, and it has been too slow to improve data. Despite our previous recommendations, HMPPS still does not know the impact of tagging. The Ministry recognises …
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
#7 — HMPPS needs plans to reinvigorate measures controlling substance abuse and violence
Recommendation: As the covid-19 restrictions in prisons are released, HMPPS (including the Youth Custody Service), should have plans ready for how it will reinvigorate its measures to control unwelcome and unintended issues such as substance abuse and violence in prisons. (Paragraph …
Response attribution not verified
#19 — Poor quality probation referrals severely hinder effectiveness of CRS resettlement support for prison leavers.
Recommendation: HMPPS audited 28 of its highest-value CRS contracts between June and September 2022, which identified ineffective early performance against service standards and contractual requirements. HMPPS rated the quality of the Probation Service’s referrals to CRS providers as ‘amber/red’ or ‘red’ …
Response attribution not verified
#9 — Increasing benzodiazepine use and its link to drug deaths causes concern.
Recommendation: We are concerned about the increasing prevalence of benzodiazepine use, and its implication in drug misuse deaths, across the UK. We await the outcome of the Home Office’s consultation on the creation of a new offence to better enable law …
Response attribution not verified
#8 — Concerns about increased NPS potency and use among vulnerable populations persist.
Recommendation: We recognise that the Psychoactive Substances Act 2016 was enacted to deal with the surge in new psychoactive substances (NPS) and the related health harms. We note that it was successful in removing the open sale of NPS but are …
Response attribution not verified
PPO death in custody recommendations(65)— showing 50 strongest matches
The Director at Parc
The Director at Parc should ensure that prisoners with substance misuse issues are supported and that efforts to tackle the availability of illicit substances are prioritised.
The Governor
The Governor should ensure that staff report and record all instances of illicit drug misuse and refer prisoners promptly to appropriate prison support services.
The Governor
The Governor should ensure that the diversion and trading of prescribed medication is fully addressed in the prison’s local drug strategy; medication dispensing is supervised at all times, in line with the local policy; and guidance is issued on effective …
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 review the local drug strategy and ensure that where mail is intercepted and is positive for illicit substances, the intended recipient is referred to the prison’s Substance Misuse Services Team and record that the referral has been …
The Governor
The Governor should ensure that when staff suspect that a prisoner is under the influence of psychoactive substances, they contact healthcare staff and monitor the prisoner until healthcare staff arrive.
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 Head of Healthcare
The Head of Healthcare should ensure that healthcare staff follow a clear and robust process when they find prisoners with illicit prescription drugs, including that they record, communicate and address it appropriately.
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 Head of Healthcare
The Head of Healthcare should ensure that staff: • carry out a breathalyser test on prisoners who are withdrawing from alcohol when they arrive; and • put an appropriate monitoring plan in place for prisoners withdrawing from drugs or alcohol …
The Head of Healthcare
The Head of Healthcare should ensure that prison staff in the FNC have written guidance on what symptoms they should watch for in detoxing prisoners and when they should seek medical help.
The Governor
The Governor should consider detoxification awareness training for all officers who work in the First Night Centre, to ensure safe and supportive management of prisoners withdrawing from drugs.
The Prison Group Director for women’s prisons
The Prison Group Director for women’s prisons should write to the Ombudsman setting out what he has done to satisfy himself that there is sufficient healthcare presence in the first night centre; that prison staff working in the first night …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all prisoners arriving with or developing signs of drug or alcohol withdrawal are regularly monitored, including clinical observations overnight and during the day, until they are stable.
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.
Governors of prisons with MCBS units
Governors should ensure that: there is an effective security and searching strategy in place in MCBS units, which reflects the specific risks of the prisoners housed there; prisoners and cells are searched thoroughly and in line with the local policy; …
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 Peterborough
The Director should ensure that prison staff contact healthcare staff and monitor prisoners appropriately when they suspect that they have used illicit drugs.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure there is a systematic process to identify prisoners who need to receive methadone.
The Director of HMP Forest Bank
The Director should continue to identify and address weaknesses in measures to prevent the supply of drugs into Forest Bank and revise the substance misuse strategy in light of the findings.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that suspected drug use is recorded and reported in line with local guidelines, with appropriate testing and support provided to prisoners suspected of using illicit substances.
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.
The Director General of Prisons
The Director General of Prisons should urgently consider what additional support can be put in place to address staffing shortages at The Mount and consider, as a matter of urgency, how it can reasonably be expected to deliver an effective …
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that: • any information suggesting a prisoner has or is at risk of substance misuse is shared with the substance misuse service, and • the substance misuse service are invited to …
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 Drug Strategy and the Lead Pharmacist
The Head of Drug Strategy and the Lead Pharmacist should develop officer training on monitoring medication and the risks associated with prisoners using unprescribed medication and ensure it is delivered.
The AP manager
The AP manager should ensure that residents suspected of using illicit drugs in the premises are appropriately challenged, drug tests are carried out where there are suspicions and that staff search their rooms in line with current guidelines.
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 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.
The Governor of HMP Erlestoke
The Governor should ensure that the key drug issues at Erlestoke are identified and that their drugs strategy is kept under review to ensure that these key issues are addressed.
The Governor
The Governor should ensure that staff adhere to the requirements in Governor’s Notice 107-17 when prisoners are suspected of using PS.
The Probation Service
The Probation Service should ensure that AP staff conduct daily alcohol tests for residents awaiting alcohol tags to be fitted.
The Director of HMP Peterborough
The Director should consider whether a full diagnostic review of the prison’s drug strategy, including any potential areas of weakness in the prison’s efforts to reduce supply, would be helpful.
HMP Peterborough
Peterborough should continue to prioritise and develop their drug strategy.
The Approved Premises Manager
The Approved Premises Manager should develop a local substance misuse policy, in line with the requirements of the Approved Premises Manual. The policy should set out procedures for requesting substance misuse tests and room searches.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review the Swallowed and Secreted Items Policy to include prisoners who have had illicit items taken from them and ensure any information about secreted illicit items is communicated and considered appropriately.
The Governor and Head of Healthcare of HMP Bedford
The Governor and Head of Healthcare should introduce a robust audit process to ensure that when a prisoner is suspected to be under the influence staff understand and follow the protocol.
The Governor and Head of Healthcare of HMP Bedford
The Governor and Head of Healthcare should review whether the current medication administration process is sufficiently robust and identify any weaknesses to minimise the risk of diversion.
The Director of HMP Parc
The Director should ensure that officers supervise medication queues appropriately to limit opportunities for diversion of medication.
The Head of the Birmingham Probation Delivery Unit
The Head of the Birmingham Probation Delivery Unit should ensure that probation practitioners are aware of the drug testing arrangements for AP residents and arrange more frequent drug testing, if appropriate.
The Manager of Carpenter House AP
The Manager of Carpenter House AP should ensure that when staff suspect that a resident has used drugs, they: • make a record on nDelius so that the probation practitioner is aware; • carry out a drug test as soon …
The Governor and the Head of Healthcare
prompt and thorough investigations are made when a prisoner is thought to have taken an illicit substance, committed an act of self-harm or commenced a dirty protest.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review the presence of healthcare and substance misuse staff in the First Night Centre.
The Governor of HMP Risley
The Governor of HMP Risley should ensure that staff always make a referral to drug treatment services when a prisoner is found to be under the influence of PS.
The Governor of HMP Risley
The Governor of HMP Risley should ensure that staff are aware of their responsibilities in operating the Tackling Anti-Social Behaviour and Incentives and Earned Privileges strategies in relation to illicit drug use and that measures taken are proportionate to the …
The National Approved Premises Team
The National Approved Premises Team should ensure that residents suspected of using illicit drugs in the premises are appropriately challenged and that staff search their room in line with current guidelines.
The National Approved Premises Team
The National Approved Premises Team should ensure that all new residents are told about their reduced drug tolerance and increased overdose on arrival at the AP, in line with the expectations of the Approved Premises’ Manual.
The Head of Healthcare
The Head of Healthcare should ensure that when a prisoner reports an overdose of prescribed medication, healthcare staff follow a recognised process to urgently establish what medications, and how much, might have been taken.
The Governor of HMP Lewes
The Governor will wish to assure himself that robust actions are being taken to prevent medication being illicitly traded and that prisoners receive appropriate substance misuse support following intelligence that this is occurring.
The National Probation Service
The National Probation Service should review the quality and reliability of the drug testing kits available in Glogan House and provide them with effective means to test for a wide range of substances including some prescription drugs and psychoactive substances.
IOPC learning recommendations(3)
Recommendation - Lancashire Constabulary, August 2022
The IOPC recommends that Lancashire Constabulary should update their custody policies and procedures to ensure that metal detectors are used as part of all searches when booking detainees into custody (provided it is safe to do so). Consideration should also …
National recommendation - National Police Chiefs' Council, August 2022
The IOPC recommends that the National Police Chiefs' Council (NPCC) shares the learning from IOPC cases with force custody leads, asking them to review their custody policies, procedures and training to ensure that metal detectors are used as part of …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should take steps to ensure that all searches in custody are completed to a high standard and that force policies and Authorised Professional Practice (APP) are followed. This follows an incident where a man …
IMB annual reports(134)— showing 50 strongest matches
Coldingley (2022)
HMP Coldingley, a men's Category C resettlement and training prison, has largely recovered from pandemic restrictions, with prisoners now enjoying increased time out of cell and positive staff-prisoner relations. While refurbishment plans are underway and healthcare is well-regarded, significant concerns persist regarding the high volume of illicit items, the continued absence of in-cell sanitation in older wings, and the inadequacy of educational provision. The Board also highlights issues with prisoner property management, disproportionate use of force against Muslim prisoners, and a lack of control for the Governor over infrastructure projects and education contracts.
PRISON
Key concerns
The Mount (2023)
HMP The Mount faced a challenging year ending February 2023, marked by a severe drug crisis involving Fentanyl-laced Spice, resulting in nine deaths, five of which were drug-related. Persistent staffing shortages led to a restrictive regime, limiting prisoners' access to education, work, and purposeful activity. Key concerns included overcrowding from cell doubling, significant healthcare waiting times exacerbated by escort shortages, and a failure to deliver adequate resettlement and offending behaviour programmes, contributing to an increase in prisoner complaints.
PRISON
Key concerns
Wealstun (2023)
HMP Wealstun, a Category C prison, has an operational capacity of 856 and a CNA of 809. The IMB reports improvements in reception processes and generally good collaboration between prison and healthcare teams. However, significant concerns persist regarding unacceptable time out of cell, pervasive part-time work, and critically low key worker session delivery. Overcrowding, the poor condition of older wings, and challenges in managing illicit items also remain key issues.
PRISON
Key concerns
Wymott (2023)
HMP Wymott faces significant challenges including a rise in violence and self-harm, severe staff shortages impacting safety and regime, and inhumane conditions on A and B wings where refurbishment is repeatedly delayed. Overcrowding forces prisoners to double up in unsuitable cells, while healthcare struggles with inadequate facilities and high agency staff reliance. The Board commends efforts in education and resettlement, and the positive feedback on the new J wing.
PRISON
Key concerns
Wetherby (2023)
HMYOI Wetherby experienced a challenging reporting year ending August 2023, marked by periods of severe instability, high violent behaviour, and increasing contraband finds. While the Board commended improvements in the estate, healthcare provision, and some excellent resettlement initiatives, significant concerns persist regarding the unpredictable regime, insufficient time out of cell, and the inadequate conditions on B wing. Staffing issues, including high turnover and an imbalance in officer demographics, continue to impact regime delivery, alongside national policy impacts such as Operation Safeguard and the high number of young people on remand with limited support.
PRISON
Key concerns
Swaleside (2020)
HMP Swaleside reported a year of significant progress in safety and a generally improved environment, despite the challenges of COVID-19. However, the Board highlighted persistent concerns including unacceptably high violence, poor performance of maintenance provider GFSL, and severely limited opportunities for purposeful activity and vocational training for residents. Issues with hygiene, contraband, and cancelled healthcare appointments also remain key areas for development.
PRISON
Key concerns
Rochester (2020)
HMP/YOI Rochester remains a Category C resettlement prison providing a safe and decent environment, with commendations for its Key Worker system and effective response to Covid-19. Despite challenges such as drug availability and deteriorating buildings, the prison offers a humane regime with good work activity engagement and mental healthcare. Key concerns include persistent staffing shortages, issues with prisoner property transfers, and a critical lack of suitable accommodation for prisoners upon release.
PRISON
Key concerns
Berwyn (2020)
HMP Berwyn is a Category C resettlement and training prison with an operational capacity of 2,106. The Board reports a prison in continuous evolution, marked by improved leadership and several positive initiatives in healthcare and education. However, significant concerns persist, including the availability of illicit substances, unaddressed deficiencies in meeting room facilities, and challenges arising from the double-cell design. High rates of self-harm, assaults, and non-attendance at purposeful activities also highlight ongoing issues within the establishment.
PRISON
Key concerns
Coldingley (2021)
HMP Coldingley, a Category C training prison, faced significant challenges due to the Covid-19 pandemic, impacting regime, education, and work. The Board commends staff for maintaining a humane regime, containing Covid-19 outbreaks, and facilitating out-of-cell time. Key concerns include illicit items leading to violence, the lack of in-cell sanitation in older wings, and the poor state of the estate. The report highlights progress in areas like new accommodation pods and education initiatives but calls for addressing long-standing issues such as IPP prisoners and resettlement challenges.
PRISON
Key concerns
Whitemoor (2021)
HMP Whitemoor operated under severe COVID-19 restrictions, leading to prisoners spending over 21 hours locked in cells daily, significantly impacting mental health and purposeful activity. Despite this, the prison maintained order and controlled infection effectively. Key challenges include increased substance misuse, persistently high segregation unit occupancy, and the urgent need for in-cell telephones and improved estate maintenance. The IMB commends the prison's efforts in managing the pandemic and establishing a rehabilitative culture, while highlighting critical areas for development.
PRISON
Key concerns
Parc (2021)
The reporting period at HMP Parc (March 2020 – February 2021) was profoundly shaped by the Covid-19 pandemic, leading to a highly restrictive regime with prisoners confined to cells for up to 23 hours daily and no physical IMB visits. Despite these challenging conditions, the Board praised staff's exceptional efforts in maintaining safety, preventing Covid-19 deaths, and achieving reductions in assaults and use of force incidents. Key concerns highlighted included the continued entry of illicit drugs, excessive waiting times for dental and specialist healthcare, and the withdrawal of secondary mental health services.
PRISON
Key concerns
Bullingdon (2022)
HMP Bullingdon faced chronic overcrowding and significant staff shortages, which impacted safety, regime delivery, and staff-prisoner relationships throughout the reporting year. While healthcare provision was generally good and improvements were seen in some areas like equality data analysis and IT systems, challenges such as high violence, drug availability, and prisoner churn hindering progression persisted. The Board highlighted a continuing high number of self-harm incidents, though a recent decline was noted.
PRISON
Key concerns
Leyhill (2023)
HMP Leyhill, a Category D open prison, faces a complex transition with reduced capacity due to construction and a changing demographic towards a younger population. While safety, healthcare uptake, and education attendance are positive, significant concerns persist regarding resettlement delays for IPP prisoners due to a lack of approved premises and inefficiencies in external probation. Alarm systems, staffing levels, and the increasing presence of illicit items also require urgent attention, alongside challenges in food budgeting and healthcare screening for new arrivals.
PRISON
Key concerns
Five Wells (2023)
HMP Five Wells, a Category C prison, opened in February 2022 and housed 1200 prisoners by March 2023, below its operational capacity of 1680. The IMB noted successes such as positive visitor feedback and streamlined safeguarding, but raised significant concerns including widespread illicit items, severe staffing shortages, and numerous design flaws in the new build. Key areas needing development involve consistent regime application, improved food and canteen services, and the re-establishment of resettlement-focused programmes like ROTL.
PRISON
Key concerns
Parc (2022)
This report for HMP Parc covers a period dominated by the Covid-19 pandemic, leading to significant regime restrictions and staff shortages. Despite these challenges, the Board found that staff maintained a safe environment for prisoners, with reductions in some violent incidents. However, healthcare, mental health support, and purposeful activity were severely impacted by limited resources and external agency support, and concerns persisted regarding drug entry and food quality.
PRISON
Key concerns
Forest Bank (2023)
HMP Forest Bank, a Category B reception and resettlement prison, reported a 13% increase in self-harm but a 5% reduction in violence and 14% reduction in use of force. The Board raised concerns about illicit items, the use of segregation for mental health cases, and low out-of-cell time. Healthcare services saw a new provider and improved access via kiosks, while purposeful activity hours remained low. Six deaths in custody were reported during the period.
PRISON
Key concerns
Guys Marsh (2023)
The Independent Monitoring Board at HMP Guys Marsh noted positive developments including sufficient organisational support for safety, the appointment of a neurodiversity support manager, and a seamless transition to a new healthcare provider. However, significant concerns remain regarding persistent drug and alcohol use driving violence, ineffective risk management plans, and unacceptably high prisoner-on-prisoner assaults. The Board also highlighted issues with accommodation standards, a long dental waiting list, and underutilised education and work provisions.
PRISON
Key concerns
Isis (2023)
HMP/YOI Isis, a YOI and Category C training prison, experienced a marked increase in violence and self-harm during 2023, attributed partly to a younger demographic and increased prisoner mixing. Staffing shortages and a high number of 'ineffective' staff consistently impacted regime delivery, education, and healthcare access. The Board highlighted persistent concerns with property management, cell cleanliness, and the limited range of rehabilitation programmes.
PRISON
Key concerns
Hindley (2023)
HMP/YOI Hindley, a Category C training and resettlement prison for adult males and young adults, operated near its 600 operational capacity during the reporting period. The Board noted positive developments in leadership presence, communication, and some healthcare provision, which was rated good by HMIP. However, significant concerns persist, particularly regarding escalating violence, high self-harm rates (up 87%), and widespread drug availability. Persistent staff shortages lead to redeployment, impacting purposeful activity, key worker sessions, and overall regime delivery. The Board also highlights issues with outdated accommodation, delays in adjudications, and the need for improved support for complex mental health needs and disabled prisoners.
PRISON
Key concerns
Highpoint (2023)
HMP Highpoint, a large Category C training and resettlement prison, reported around 1,300 prisoners during a year marked by significant increases in self-harm, violence, and assaults on staff. Key concerns included persistent issues with prisoner property management, inadequate maintenance services, and the ongoing challenge of contraband entry. Despite these, the report highlighted positive areas such as effective induction, a strong segregation unit, and robust neurodiversity support, alongside commendations for healthcare provision.
PRISON
Key concerns
Huntercombe (2023)
HMP Huntercombe, a Category C prison for foreign national men, largely maintained a full regime during 2023, with positive staff-prisoner relationships and a reduction in ACCTs. However, the Board remains significantly concerned about the influx of illicit items, persistent issues with heating, hot water, and cell window repairs, and an unsuitable healthcare building. Delays in transferring mentally unwell prisoners and ongoing property problems for those being deported are also highlighted, alongside staffing pressures in the Offender Management Unit.
PRISON
Key concerns
High Down (2023)
HMP High Down, a Category C training and resettlement prison, experienced significant increases in assaults and illicit item finds during 2023, raising serious safety concerns. Staffing shortages in key work and the Offender Management Unit severely impacted regime delivery and prisoner progression. While improvements were noted in mental health transfer times and family contact, persistent issues with property loss, poor shower conditions, and limited purposeful activity for prisoners, particularly vulnerable ones, remained key challenges.
PRISON
Key concerns
Lowdham Grange (2024)
HMP Lowdham Grange was deemed not safe enough during the reporting period, with significant increases in violence, self-harm incidents, and drug availability. The operational transition and subsequent HMPPS 'step-in' contributed to an unstable and restrictive regime, compounded by staff shortages and insufficient oversight of use of force. Key concerns include inadequate healthcare provision, poor living conditions, and a lack of purposeful activity and effective resettlement support.
PRISON
Key concerns
The Mount (2024)
HMP The Mount has demonstrated significant progress over the last year, particularly in staffing, regime improvement, and the management of safety for vulnerable prisoners. However, profound systemic issues persist, notably the inhumane and unsupported detention of IPP prisoners, and chronic overcrowding due to cell doubling. The prison continues to struggle with pervasive drug availability and inadequate external support for resettlement, leading to high rates of homelessness upon release.
PRISON
Key concerns
Onley (2024)
HMP Onley is a Category C training and resettlement prison that faced challenges during the reporting year ending February 2024. While staffing levels for officers improved, this did not translate into increased key work activity or a consistently full regime. Key concerns include increased illicit substance availability and drone activity, a rise in prisoner-on-prisoner violence, and persistent issues with property transfers and poor cell/yard conditions. Healthcare saw some improvements in GP/dental wait times, but mental health and drug rehabilitation were affected by staff shortages.
PRISON
Key concerns
Five Wells (2024)
HMP Five Wells, a privately run Category C prison, increased its population to 1,700 by March 2024, leading to the doubling up of some cells. While the Board noted significant operational improvements under new leadership and generally good accommodation, it raised serious concerns about the prevalence of illicit substances, self-harm, and the management of use of force incidents. Challenges persist in staff recruitment, education provision, and the under-resourcing of the IMB itself.
PRISON
Key concerns
Stoke Heath (2024)
HMP/YOI Stoke Heath saw positive developments in education and purposeful activity, leading to increased prisoner satisfaction and a significant drop in unemployment. The key worker scheme improved contact, and healthcare benefited from paramedics and a successful hepatitis C elimination. However, the Board noted a concerning rise in self-harm, assaults, well as issues with cramped living conditions, an aging estate, and limited mental health therapy. Persistent problems with property transfers and an under-resourced offender management unit also remained key concerns.
PRISON
Key concerns
Bedford (2024)
HMP Bedford, a Category B YOI, continues to face significant challenges including persistent overcrowding and an inconsistent induction process, despite some improvements in wing cleanliness and key worker implementation. The report highlights serious concerns regarding healthcare, characterized by poor communication and a decline in drug rehabilitation services. Security remains an issue with illicit items readily entering the prison, and high levels of assaults on staff, although recent improvements are noted. The Board also raises concerns about the unaddressed needs of its large remand population, the lack of digital infrastructure, and disproportionate adjudications.
PRISON
Key concerns
Kirkham (2023)
HMP Kirkham faced unprecedented challenges in 2023, primarily due to the Temporary Presumptive Recategorisation Scheme (TPRS) which led to a significant influx of prisoners and placed immense pressure on staff, resources, and the prison's resettlement-focused regime. While the Board noted staff's resilience and improvements in some areas like healthcare waiting times and new facilities, key concerns included increased assaults, persistent illicit substance issues, and significant disruption to purposeful activities and resettlement services. Staffing shortages exacerbated these problems, leading to curtailment of activities and impacting crucial offender management processes.
PRISON
Key concerns
Aylesbury (2024)
HMP Aylesbury, a Category C prison, completed its transformation from a YOI this year, adapting to an older population with improved but still sub-standard regime delivery. Significant efforts were made to enhance safety, reduce gang violence, and manage illicit items, though their incursion remains a serious problem. While staffing levels improved, staff inexperience and a lack of purposeful activity remain key challenges impacting prisoner wellbeing, progression, and resettlement, as evidenced by long waiting times for healthcare and inadequate release preparation.
PRISON
Key concerns
Wormwood Scrubs (2024)
HMP Wormwood Scrubs faced significant challenges during the reporting year, including an increased population running near operational capacity and a sustained upward trend in violence and self-harm incidents towards the end of the period. While some progress was made in healthcare and education, these gains were frequently undermined by critical staffing shortages leading to cancelled activities and appointments. Outdated infrastructure and the ongoing availability of illicit substances remained persistent issues, severely impacting safety, conditions, and the humane treatment of prisoners.
PRISON
Key concerns
Maidstone (2024)
HMP Maidstone generally operates as a safe and humane Category C foreign national prison, with improvements noted in reception processes, ACCT care, and analysis of violent incidents. The Board commended staff care in healthcare and overall good relationships, but raised significant concerns regarding the prevalence of illicit substances, the limited purposeful activity and lack of ROTL, and delays in mental health transfers due to national bed shortages. Improvements are needed in staffing for UoF oversight, translation services, and collaboration with immigration authorities.
PRISON
Key concerns
Wayland (2024)
The IMB's latest survey at HMP Wayland shows a generally positive shift across many areas, including improved induction experiences, property handling, and healthcare complaint responses. However, significant challenges persist, particularly concerning staff's ability to provide effective support for personal issues and loneliness, which has worsened. Concerns also remain regarding cell decency, the pervasive availability of drugs, inadequate resettlement preparation, and the perceived unfairness of the complaints system, indicating much work is still needed.
PRISON
Key concerns
Lowdham Grange (2025)
HMP Lowdham Grange has seen some safety improvements since HMPPS took over, but faces critical challenges including six deaths in custody, widespread drug availability with high positive test rates, and a significant increase in use of force. Healthcare provision remains a major concern due to chronic staffing shortages, lack of night cover, and long mental health transfer delays. Persistent under-resourcing in probation and psychology departments impacts prisoner progression and resettlement, while the regime continues to be hampered by staffing issues and reduced social visits.
PRISON
Key concerns
Hindley (2024)
HMP/YOI Hindley, a Category C prison, operated at or near its 600 operational capacity throughout 2024, housing adult and young adult males. The Board noted some positives like improved healthcare provision and staff-prisoner relationships, particularly in wellbeing areas. However, significant concerns remain, primarily regarding rising violence, high drug availability, and self-harm incidents. Unacceptable staff absence led to extended lockdowns and a severe lack of purposeful activity, while the physical estate continues to be unfit for purpose with no plans for refurbishment.
PRISON
Key concerns
Lindholme (2025)
HMP Lindholme, a Category C male training prison, faced significant challenges in the reporting year ending January 2025, largely due to a substantial ingress of illicit drugs, which led to increased violence and self-harm incidents. The prison's population of 946 was held in an establishment designed for 924, including 160 doubled-up cells. Key concerns include prisoner safety, the misuse of segregation as a sanctuary, and inadequate education and work provisions, impacting preparation for release.
PRISON
Key concerns
Garth (2024)
HMP Garth, a Category B training prison, experienced a challenging year ending November 2024, marked by a 45% increase in violence and significant staffing shortages. These issues led to frequent regime changes, excessive prisoner time in cells, and difficulties in delivering purposeful activity. Key concerns include easy access to illicit drugs, the prolonged detention of mentally unwell prisoners in segregation, and the ongoing injustice faced by IPP prisoners, all compounded by critical issues in staff recruitment and retention and the deteriorating prison estate.
PRISON
Key concerns
Thorn Cross (2025)
HMP/YOI Thorn Cross maintains a safe and rehabilitative environment with positive staff-prisoner relationships and strong support for education and community employment. Despite these strengths, significant concerns include an inadequate kitchen, persistent issues with illicit items, and challenges in mental health engagement. Delays in infrastructure projects and restricted gym access during non-working hours also require urgent attention.
PRISON
Key concerns
Onley (2025)
HMP Onley, a Category C prison, experienced a challenging year with significant increases in violence and self-harm incidents. Key concerns include high levels of illicit substances, poor living conditions, and unacceptable waiting times for healthcare. Despite some positive developments in key worker delivery and resettlement initiatives, staffing shortages and backlogs in offender management continue to hinder progression.
PRISON
Key concerns
Erlestoke (2025)
HMP Erlestoke is a Category C training and resettlement prison with an operational capacity of 512. The Board observed improvements in healthcare attendance and use of force scrutiny, alongside a decrease in staff turnover. However, significant concerns remain regarding the deteriorating healthcare building, the pervasive availability of illicit substances, and the inadequate provision for vulnerable prisoners, including the elderly and those requiring essential medication on transfer.
PRISON
Key concerns
The Mount (2025)
HMP The Mount's IMB report highlights a period of little significant change, despite staff's efforts to manage challenges like drugs and overcrowding. While staff-prisoner interactions and healthcare provision showed improvements, key concerns persist regarding the inadequate support for IPP prisoners, severe overcrowding impacting living conditions, and limited purposeful activity opportunities. The Board also noted issues with property management and the unsuitability of the reception area.
PRISON
Key concerns
Parc (2024)
HMP/YOI Parc, a Category B/C resettlement prison, faced significant challenges including 19 deaths in custody, with a notable cluster of drug-related fatalities, and high levels of self-harm and violence, though a downtrend was observed towards the end of the reporting period. Persistent concerns included poor food quality and quantity, insufficient keyworkers, and ongoing issues with property transfers. Healthcare provision was strained by excessive waiting times for GP and mental health services, and staff shortages, though some improvements were noted in healthcare access and anti-drug measures.
PRISON
Key concerns
Styal (2025)
HMP/YOI Styal, a local women's prison, grapples with a complex population, leading to concerns about high self-harm rates and an increased number of deaths in custody. The Board highlights persistent issues with estate maintenance, fire safety, and a lack of consistent staff supervision on houses, which impacts prisoner safety and regime delivery. Despite improvements in healthcare and education attendance, significant delays in mental health transfers and pressure on resettlement accommodation remain critical challenges.
PRISON
Key concerns
Wealstun (2025)
HMP Wealstun has experienced a substantial increase in prisoner receptions and churn, impacting stability, staff workload, and resettlement efforts. Key concerns include rising violence, persistent drug availability, and poor conditions in older wings, alongside insufficient time out of cell and challenges faced by IPP prisoners. The Board notes good healthcare provision and well-managed segregation, but highlights staff retention issues, inconsistent regime application, and delays in drug test results.
PRISON
Key concerns
Coldingley (2025)
HMP Coldingley, a Category C resettlement and training prison, faced significant challenges this year due to accelerated prisoner churn, impacting safety, healthcare, and purposeful activity. While improved staffing led to better regime and communication, issues like widespread drug availability, delayed cell refurbishment, and slow mental health transfers remain key concerns. The Board noted positive efforts in staff-prisoner relationships and education but highlighted the need for systemic improvements in property handling and monitoring of progress.
PRISON
Key concerns
Pentonville (2025)
HMP Pentonville, a category B local prison, faced significant challenges including severe overcrowding, crumbling infrastructure, and a rise in drug use. While some improvements were noted in safety management, the Board raised serious concerns about inhumane living conditions, inadequate key work provision, and delays in support for vulnerable prisoners. The report highlights the impact of capacity pressures on regime delivery and resettlement efforts, stressing the need for urgent investment in the prison's fabric and resources.
PRISON
Key concerns
Swaleside (2025)
HMP Swaleside has faced significant challenges, including a major influx of inexperienced staff leading to operational and relationship issues, and a pervasive problem with gang culture, illicit drug use, and high violence levels. Despite some positive developments in healthcare and equality initiatives, major concerns persist regarding prisoner mental health, an inadequate regime, overcrowding, and the effectiveness of security measures against contraband. The Board highlights the urgent need to address staff experience, regime provision, mental health support, and the management of illicit items and violence.
PRISON
Key concerns
Wormwood Scrubs (2025)
HMP Wormwood Scrubs continues to face significant challenges despite some positive developments in safety and healthcare. While incidents of violence and self-harm remain lower than comparator prisons, illicit drug use and inconsistent staff practices, particularly regarding body-worn cameras, are persistent concerns. The antiquated infrastructure, overcrowding, and an inconsistent regime that leaves many prisoners locked in cells for extended periods severely impact humane treatment and purposeful activity. Staffing issues contribute to the poor delivery of the key worker scheme and a rise in complaints about staff conduct, alongside noted disproportionalities in disciplinary measures against certain demographic groups.
PRISON
Key concerns
Brixton (2025)
HMP Brixton operated as an overcrowded Category C resettlement prison during the reporting year, with a population of 697 against a CNA of 530. The year was marked by preparations for a delayed re-role to Category B, which disrupted rehabilitation efforts. Positive developments included a reduction in self-harm, improved induction processes, and good staff-prisoner relations, alongside high-quality food provision. However, significant concerns persisted regarding drug availability, property loss, unlawful detentions, and the impact of the re-role on resettlement and purposeful activity.
PRISON
Key concerns
The Mount (2020)
The Independent Monitoring Board reports on HMP The Mount for 2019-2020, highlighting significant challenges stemming from chronic under-funding, which affects staffing, infrastructure, and rehabilitative opportunities. Despite these issues, the Board notes improvements in decency, security, and healthcare provision, commending staff efforts. Key concerns include the pervasive drug problem, insufficient Category D and IPP progression places, and the failure to embed new initiatives like the key worker scheme.
PRISON
Key concerns
IMB individual recommendations(217)— showing 50 strongest matches
Send (2020)
The prison is not preventing illegal drugs from entering the establishment. This is having a negative impact on stability and the safety of prisoners (4.3, 4.6).
Governor / Director
Implemented
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
Send (2021)
The Board is concerned that drugs have continued to enter the prison throughout the reporting year. This is having a negative impact on the safety of prisoners (4.6).
Governor / Director
Springhill (2021)
The open estate has not been allocated body scanners. Given the relatively large number of IRs/finds compared with neighbouring Grendon (see 4.5.3), where a scanner has been used, this would seem to be an opportunity to improve the detection of illicit items.
HMPPS
Rejected
Lowdham Grange (2021)
Continue to increase efforts to curb the import of drugs and illicit items into Lowdham Grange.
Governor / Director
Noted
Frankland (2022)
What further action can be taken to prevent illicit drugs/items getting into the estate?
Governor / Director
Frankland (2022)
How are illicit drugs getting into the estate?
HMPPS
Erlestoke (2023)
What additional long term strategies can be put in place to substantially reduce access to illicit substances?
Governor / Director
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
Isle of Wight (2024)
All positive drug test results are forwarded by security to the substance misuse treatment team so that support can be provided. Could a similar centralised approach be adopted so that the inclusion team is notified when a prisoner is under the influence or alcohol is found in their cell?
Governor / Director
Foston Hall (2024)
Whilst the increase in remand and recall prisoners has led to a rise in illicit items coming into Foston Hall, what increased measures to disrupt the supply and trading of illicit items will be taken by the prison?
Governor / Director
In Progress
Erlestoke (2024)
What steps will be taken to reduce the ingress and availability of illicit substances?
Governor / Director
Coldingley (2024)
Is the Governor concerned about the level of use of illicit substances on the ISFL wing? Does he consider the wing suitable for providing the specialised support for which it was designed? If not, what are his plans?
Governor / Director
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
Coldingley (2025)
The Governor should outline how the widespread availability of drugs and other illicit substances around the site is going to be curtailed and eliminated.
Governor / Director
Noted
The Mount (2020)
Tackling drug supply and demand needs to be central to much of the prison’s daily work.
Governor / Director
In Progress
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
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
Peterborough (Men) (2020)
The Board remains concerned at the level of illicit substance availability and use, and its consequences for prisoners’ safety (see paragraph 4.5), but is encouraged that further security measures have been put in place to mitigate this.
Governor / Director
Onley (2020)
The Board feels that providing meaningful employment and tackling the large amount of drugs available in the establishment are the priorities that need to be improved in the short term.
Governor / Director
Partially Accepted
Norwich (2020)
Is the Prison Service analysing the repercussions of the replacement of tobacco by vapes, and what are the conclusions?
HMPPS
Implemented
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
Highpoint (2020)
The Board hopes the provision of a dedicated wing for those prisoners wanting to engage fully with drug recovery programmes can go ahead in the near future.
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
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
Manchester (2021)
The Board notes the increase in the number of packages containing illegal substances being thrown over the perimeter wall into the prison. What measures have been implemented to reduce the risk of prisoners accessing packages whilst on exercise?
Governor / Director
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
Winchester (2022)
What measures can be taken to further reduce the supply of intoxicating substances, especially hooch, to prisoners?
Governor / Director
Noted
Full Sutton (2022)
Ensure that the focus on drug testing (random, suspicion, and reception) is maintained and takes place to the required levels (see also section 4.5.1).
Governor / Director
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
Peterborough (men) (2023)
What steps are being taken to control drugs entering the prison?
Governor / Director
Onley (2023)
When will there be a return to full mandatory drug testing (MDT)?
Governor / Director
Low Newton (2023)
Is there a need for reconsideration of drugs search policy and equipment in the women’s estate?
HMPPS
Noted
Gartree (2023)
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
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
Coldingley (2023)
In order to keep prisoners safe and the wings more orderly, what plans does the Governor have to deal with the alarmingly high increase in the use and manufacture of illegally brewed alcohol and psychoactive substances?
Governor / Director
Channings Wood (2023)
After a welcome and sustained downward trend in many safety indicators, the Board has noted an increase is serious assaults, the number of prisoners self-isolating and above average levels of self-harm. Given the belief that the main underlying cause is the availability of drugs, what further measures can be taken to intercept them? Are there further technological solutions which would …
Governor / Director
Bullingdon (2023)
There continues to be a problem with the availability and use of illegal substances in the prison. What further steps can the Governor take to address this problem?
Governor / Director
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
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
Onley (2024)
When will mandatory drug testing (MDT) be implemented on a routine and ongoing basis within the establishment? Will this be sufficient to fully understand the prevalence of drug taking within the population?
Governor / Director
Maidstone (2024)
How will the Minister support the Prison Service to reduce the prevalence of drugs and other illegal items across the estate?
Ministry of Justice
In Progress
Lewes (2024)
The Board asks for new measures to reduce the availability of illicit drugs and alcohol across the prison.
Governor / Director
Hindley (2024)
The Board continues to be very concerned about the level of the use of illicit substances throughout the prison and the apparent ease with which items enter. The Board acknowledge the work carried out by staff to attempt to minimise this, including the particularly difficult challenge of drone deliveries, but remain concerned about the lack of security checks at the …
Governor / Director
Partially Accepted
Foston Hall (2024)
Without a body scanner at reception, staff are hampered from detecting drugs concealed by prisoners on arrival. When will this equipment be provided, which will go towards creating a safer environment for prisoners?
HMPPS
In Progress
Forest Bank (2024)
Illicit items continue to be an operational and safety challenge. What investment and support will the operator be provided with to prevent illicit items entering the prison?
Governor / Director
In Progress
Bedford (2024)
It does not appear difficult for drugs and other illicit items to get into the prison: on average, there is at least one find every day.
Governor / Director
Aylesbury (2024)
Continue to disrupt the supply of illicit items by all means available.
Governor / Director
Health investigations(5)
Independent investigation into the care and treatment of patient M … — Rec 98
The prime time for conveying this information is at reception into the prison; partly for the prisoner’s safety but also to promote the culture that help with substance misuse issues is available. Specific vulnerabilities which may predispose to using in prison (such as past behaviours, or current mood disorder) can …
east_of_england
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: Darren Flynn, HMP Swaleside (2015) — Rec 2
The Governor should ensure that Swaleside has an effective security and searching strategy, which reflects the particular risks of prisoners in the Pathways Unit.
london
Independent investigation into the care and treatment of Patient R: … — Rec 9
The Trust should revise their drug detection policy to include procedures around the use of drug detection dogs, and specifically a process for making service users aware that drug detection dogs may visit acute inpatient areas.
5 Boroughs Partnership NHS Foundation Trust
north_west
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
Article 2 learning points(4)
— LP 1
HMP Featherstone and the health care providers in the prison should explore how to maximize information-sharing between Health Care and Security so that both of these components of care can work together to reduce the ingress and use of illicit substances in the prison. This includes the completion of agreed …
HMP Featherstone, Midlands Partnership NHS …
Accepted
— LP 2
The CARATS teams should record information about their interviews with prisoners in unit history sheets, and share assessments with staff who are managing prisoners, particularly when an ACCT (formerly F2052SH) process has been opened. These records should be available when required for any future investigations.
HMPPS
Implemented
— LP 1
It is noted that the Internal Investigation, 2002, recommended attendance by the Chaplaincy at F2052SH (now ACCT – Assessment, Care in Custody and Teamwork) reviews both locally and nationally, and this recommendation is supported. In cases where drug abuse is involved a CARATS representative should also attend, and Education staff …
HMPPS
Rejected
— LP 6
If it has not already done so, NOMS may wish to consider reviewing its policies and procedures relating to the seizure, recording, retention and continuity of seized items, particularly in respect of critical incidents or where items are likely to be used as evidence in subsequent criminal proceedings.
NOMS
Accepted
Detention investigations(3)
Review into the Welfare in Detention of Vulnerable Persons — Rec 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 Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R21
The SMT and staff must enforce the ban on smoking inside Brook House. (To be completed within 3 months)
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 49
The Home Office and NHS England should promote the self-‐administration of drugs where risk assessments support that approach.
Immigration Detention
LGO / SPSO decisions(418)
24-011-845 — Dartford Borough Council
Summary: We will not investigate Mrs X’s complaint about the Council’s handling of her reports of encroachment by her neighbour onto her property. This is because encroachment is a private civil matter between Mrs X and her neighbour and it is therefore unlikely we could achieve any worthwhile outcome for …
LGO (Local Government & …
Planning
Nov 2024
25-012-798 — South Derbyshire District Council
We will not investigate this complaint that the Council failed to follow its complaint process when considering the complainant’s concerns about the handling of the planning enforcement investigation into works on his land. It is not a good use of public resources to investigate complaints about complaint procedures, if we …
LGO (Local Government & …
Planning
Feb 2026
25-005-195 — Derbyshire Dales District Council
Summary: There was no fault in the Council’s decision not to take enforcement action against a breach of planning permission near the complainant’s home. However, the Council was at fault for refusing to accept his complaint about this. This did not cause the complainant an injustice, but the Council has, …
LGO (Local Government & …
Planning
Upheld
Feb 2026
25-021-003 — North Yorkshire Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Feb 2026
25-014-441 — Epping Forest District Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Feb 2026
25-004-542 — Kirklees Metropolitan Borough Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Feb 2026
25-003-951 — London Borough of Harrow
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Feb 2026
25-006-279 — Stoke-on-Trent City Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Feb 2026
25-003-976 — Thurrock Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Feb 2026
24-020-373 — Wealden District Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Feb 2026
25-013-544 — Thurrock Council
We will not investigate this complaint about a lack of enforcement action by the Council against an alleged breach of planning control. Mr X does not live near the site and investigation would be unlikely to find sufficient injustice to him caused by any fault to warrant our further involvement.
LGO (Local Government & …
Planning
Feb 2026
25-002-051 — Waverley Borough Council
Summary: We will not investigate this complaint about how the Council dealt with breaches of planning control. This is because we are unlikely to find fault.
LGO (Local Government & …
Planning
Jan 2026
24-020-496 — Calderdale Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint about the Council not maintaining a public right of way where he lives. This is because it is reasonable for him to pursue this matter at court. Also, we will not investigate his complaint that the Council is ignoring a breach of …
LGO (Local Government & …
Planning
Jan 2026
25-016-717 — Harborough District Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Planning
Jan 2026
25-015-562 — Tendring District Council
Summary: We will not investigate this complaint about how the Council dealt with a possible breach of planning control and a statutory nuisance. This is because we are unlikely to find fault.
LGO (Local Government & …
Planning
Jan 2026
25-013-317 — Buckinghamshire Council
Summary: We will not investigate this complaint about how the Council dealt with a breach of planning control. This is because we are unlikely to find fault.
LGO (Local Government & …
Planning
Jan 2026
24-020-062 — London Borough of Merton
Summary: We will not investigate this complaint about the way the Council dealt with a breach of planning control. Further investigation will not lead to a different outcome.
LGO (Local Government & …
Planning
Jan 2026
24-013-443 — Northumberland County Council
Summary: We will not investigate this complaint about the Council’s failure to take enforcement action against a breach of planning control. The Council has issued an Enforcement Notice. It will consider further action if the Notice is not complied with. Further investigation will not lead to a different outcome.
LGO (Local Government & …
Planning
Jan 2026
25-004-301 — Blackpool Borough Council
Summary: Mrs F complained about the Council’s handling of planning control concerns about a property she owns. She said it wrongly threatened with enforcement action which led to her having building costs and financial losses. We found fault by the Council for its flawed assumptions about the permitted use of …
LGO (Local Government & …
Planning
Upheld
Jan 2026
25-004-040 — Epsom & Ewell Borough Council
Summary: We will not investigate this complaint about the Council allowing a wedding venue to operate from a building in the complainant’s local area. There is insufficient evidence of fault in the way the Council reached its decision.
LGO (Local Government & …
Planning
Jan 2026
25-000-949 — North Yorkshire Council
Summary: We will not investigate Mr X’s complaint about the Council’s decision to grant planning permission for his neighbour’s fence. There is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Planning
Jan 2026
25-016-511 — West Lancashire Borough Council
Summary: Mr C complained the Council failed to comply with a recommendation we made after our previous investigation of a complaint he made to us. There was fault by the Council. It did not comply with our recommended action which it agreed to. Because of the fault, Mr C suffered …
LGO (Local Government & …
Planning
Upheld
Jan 2026
25-015-561 — Leeds City Council
Summary: We will not investigate Mr and Mrs X’s complaint about planning enforcement. They have appealed the planning decision, and it would have been reasonable for them to appeal the planning enforcement notice. This means we do not have the power to consider their complaint.
LGO (Local Government & …
Planning
Jan 2026
25-014-112 — Cherwell District Council
Summary: We will not investigate Ms X’s complaint about how the Council handled her concerns about a neighbour’s aerial. This is because there is insufficient evidence of fault.
LGO (Local Government & …
Planning
Jan 2026
25-016-327 — Hartlepool Borough Council
Summary: We will not investigate this complaint about how the Council dealt with a breach of planning control. This is because we are unlikely to find fault and the complainant has not suffered significant injustice.
LGO (Local Government & …
Planning
Jan 2026
25-012-455 — Buckinghamshire Council
Summary: We will not investigate Mr X’s complaint about planning enforcement at a neighbouring property. There is insufficient evidence of fault to justify investigation.
LGO (Local Government & …
Planning
Jan 2026
25-000-657 — North West Leicestershire District Council
Summary: Mr X complained about the Council’s handling of planning enforcement and other concerns for a development of homes. He said it had failed to hold the developer to account. We have not found fault in the process the Council followed to consider his concerns. While it has taken a …
LGO (Local Government & …
Planning
Upheld
Jan 2026
21-012-370 — Milton Keynes Council
Summary: We will not investigate this complaint about how a Council dealt with a planning application or enforcement matters. This is because Mr X is a member of a residents group that has exercised its right of appeal to the Planning Inspector.
LGO (Local Government & …
Planning
Jan 2022
21-005-239 — City of Bradford Metropolitan District Council
Summary: There was no fault by the Council in its handling of the complainant’s reports of breaches of planning control at a neighbouring property.
LGO (Local Government & …
Planning
Not Upheld
Jan 2022
20-012-381 — Nuneaton & Bedworth Borough Council
Summary: Mr X complained about the Council’s decisions relating to development on land next to his home. We ended our investigation as it is unlikely to result in a finding of fault or a remedy for Mr X.
LGO (Local Government & …
Planning
Not Upheld
Jan 2022
21-013-359 — Milton Keynes Council
Summary: We will not investigate this complaint about how a Council dealt with a planning application or enforcement matters. This is because Ms X has exercised her right of appeal to the Planning Inspector.
LGO (Local Government & …
Planning
Jan 2022
21-015-518 — Lancaster City Council
Summary: We will not investigate this complaint that the Council has taken no enforcement action against an outbuilding erected by the complainant’s neighbour. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. There is not enough evidence …
LGO (Local Government & …
Planning
Feb 2022
21-016-268 — St Helens Metropolitan Borough Council
Summary: We cannot investigate Mr X’s complaint about the Council’s planning enforcement actions. Mr X used his right of appeal to the planning inspector and more recently the case has been in court.
LGO (Local Government & …
Planning
Feb 2022
21-006-599 — Dacorum Borough Council
Summary: We will not investigate this complaint about matters surrounding a planning enforcement case. Mr X lives nearly 2 miles from the location of the alleged planning breach. We do not consider that any fault has caused Mr X an injustice that would justify our involvement.
LGO (Local Government & …
Planning
Upheld
Feb 2022
21-006-333 — New Forest District Council
Summary: Mr C complained about the Council’s response to alleged breaches of planning control by his neighbour. We did not find fault with the Council for the way it investigated the alleged breaches. We found some fault with the way the Council communicated with Mr C about his complaint. The …
LGO (Local Government & …
Planning
Upheld
Mar 2022
21-017-698 — Rother District Council
Summary: Mr X complains that the Council has not taken action to ensure a development near him is completed. We will not investigate this complaint because there is no evidence of fault by the Council causing injustice.
LGO (Local Government & …
Planning
Mar 2022
20-013-700 — Reading Borough Council
Summary: We will not investigate this complaint about the Council’s actions in relation to a development next to Dr X’s property. There is no evidence of fault in how the Council has reached decisions about planning matters. The Council has also apologised for delays in dealing with Dr X’s complaints …
LGO (Local Government & …
Planning
Mar 2022
21-010-212 — Bristol City Council
Summary: Ms X complained the Council failed to take enforcement action against her neighbours, when they built an extension to a greater height than permission allowed for. We have discontinued our investigation. The planning enforcement case is still active so it is not possible for us to determine the level …
LGO (Local Government & …
Planning
Not Upheld
Mar 2022
21-017-560 — London Borough of Hillingdon
Mr X complains about the Council’s failure to take enforcement action against a neighbour. We will not investigate this complaint because there is no evidence of fault by the Council.
LGO (Local Government & …
Planning
Apr 2022
21-018-114 — Guildford Borough Council
Summary: Ms X complains about the Council’s handling of matters relating to a business which operates below her flat. We will not investigate the complaint because it is a late complaint and so falls outside our jurisdiction.
LGO (Local Government & …
Planning
Apr 2022
21-012-632 — Herefordshire Council
Summary: We will not investigate this complaint about the Council’s handling of enforcement matters relating to a turning area to the front of the complainant’s home. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. Parts of …
LGO (Local Government & …
Planning
Apr 2022
22-000-352 — London Borough of Hounslow
Summary: We will not investigate this complaint about the Council’s failure to take enforce a planning condition which it imposed to protect the complainants amenity. This is because the events happened too long ago, and I see no reason why the matter could not have been raised sooner.
LGO (Local Government & …
Planning
May 2022
22-003-609 — Wiltshire Council
Summary: We cannot investigate this complaint about the Council’s handling of an enforcement investigation into a structure erected by the complainant. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. The complainant has already appealed to the …
LGO (Local Government & …
Planning
Jul 2022
22-000-602 — Bolton Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s handling of matters relating to an HMO conversion next to Ms X’s home. This is because there is insufficient evidence of fault by the Council to warrant an investigation.
LGO (Local Government & …
Planning
Jul 2022
22-004-758 — London Borough of Redbridge
Ms X complains that the Council has provided misleading information to the Planning Inspector. We will not investigate this complaint because she appealed to a Planning Inspector.
LGO (Local Government & …
Planning
Jul 2022
21-013-459 — Wokingham Borough Council
Summary: There is no fault in how the Council dealt with the planning matters at the house next to Mr B. It took the impact on him into account, and properly considered its response to breaches of planning control.
LGO (Local Government & …
Planning
Not Upheld
Jul 2022
21-015-232 — Royal Borough of Kensington & Chelsea
Summary: Mr B complained the Council failed to take planning enforcement action to ensure that a restaurant near to his home complied with the condition on the planning permission. He said the restaurant operates in a way that means he, and his neighbours, suffer disturbance from customers leaving the premises …
LGO (Local Government & …
Planning
Upheld
Jul 2022
21-013-797 — City of York Council
X complained the Council failed to take appropriate and timely enforcement action regarding a breach of planning control near his home. He says his outlook is now unsightly and he has spent a significant amount of time and effort progressing the matter with the Council.
LGO (Local Government & …
Planning
Upheld
Aug 2022
22-003-657 — Stockport Metropolitan Borough Council
Summary: Mr X complained about unreasonable delay in the Council investigating his planning enforcement allegation. There was delay and this is fault, but there is no evidence to show that the outcome of the Council’s planning enforcement decision would have been different.
LGO (Local Government & …
Planning
Upheld
Sep 2022
22-003-485 — Isle of Wight Council
Summary: We will not investigate Mrs X’s complaint about the Council’s handling of a planning enforcement matter. This is because there is not enough evidence of fault by the Council affecting its decision. We also could not say the Council’s actions caused Mrs X injustice and we cannot achieve the …
LGO (Local Government & …
Planning
Sep 2022