Themes | Prison & Custody Safety | The Accountability Index

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 9 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 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.

9 sources
Prevention of Future Deaths reports(62)— showing 50 strongest matches
Adrian Johnson
20 Dec 2013 · London (Inner South)
Concerns: The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in case management, with no handover from case manager to case manager.
Response (HM Prison and Probation Service): NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject …
Overdue
Wayne Broad
17 Jan 2014 · London (North)
Concerns: There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees also need alignment with best practice.
Response: The Secretary of State states that specialist substance misuse nurses may not be the most effective use of resources in all hospitals and that a specialist substance misuse nurse would …
Overdue
Edward Devlin
22 Jul 2014 · County Durham & Darlington
Concerns: Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Response (Care UK): Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat …
Overdue
Yohannes Kidane
03 Sep 2014 · Birmingham & Solihull
Concerns: Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.
Response (HM Prison and Probation Service): NOMS reviewed the night staffing level for HMP Birmingham and found it acceptable, noting G4S's deployment of a Prison Custody Officer. They state that the Night Orderly Officer arranges cover …
Response (Birmingham Solihull NHS): The Trust has liaised with Birmingham Community Healthcare Trust and G4S to address staffing concerns and is considering options for staff breaks, including administrative duty sharing. They are engaging the …
Responded
William Anderson
17 Oct 2014 · West Yorkshire (East)
Concerns: Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.
Overdue
Sharon Butcher
31 Mar 2015 · County Durham & Darlington
Concerns: There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack of clarity in response to medical emergencies at HMP Frankland and HMP Durham.
Response (HM Prison and Probation Service): HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where …
Overdue
Liam Smith
18 Sep 2015 · Worcestershire
Concerns: Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.
Response (HM Prison and Probation Service): HM Prison and Probation Service has reiterated the professional obligation of clinical staff to review relevant parts of prisoner's notes and has changed practices relating to high risk drug users …
Overdue
Kevin Forster
28 Oct 2015 · County Durham and Darlington
Concerns: HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.
Response: Healthcare staff have been reminded of the importance of full and contemporaneous notes, and training has been provided on substance misuse; clinical guidelines are being developed for substance misuse issues, …
Response: All staff have signed to confirm their understanding of the Emergency Code Protocol, and managers have verified their awareness. Pocket-sized cards explaining the protocol have been issued, and the protocol …
Responded
Dean Boland
25 Nov 2015 · Birmingham and Solihull
Concerns: Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, lack of overnight monitoring, and poor external security measures allow widespread drug use and concealment.
Response (HM Prison and Probation Service): Detox unit staff completed training on supervising opiate substitution medication, and awareness training is scheduled for completion in January 2016. Monthly strategy meetings are held to discuss drug misuse, and …
Overdue
Imran Douglas
29 Dec 2015 · London Inner (South)
Concerns: A more flexible, person-based system may be safer than the current rule-based system regarding the transition of duties from YOT/YJB to PMU at age 18. Also, there appeared to be a disconnection between Looked After Child pathway planning and Transition Planning.
Response (Leeds City Council): • Leeds City Council has been working to design a scheme which provides safe pedestrian assisted facilities across the Ring Road at this location and the neighbouring Coal Road junction. …
Overdue
Matthew Russell
27 Nov 2016 · Surrey
Concerns: Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.
Response (Central and North West London NHS Foundation Trust): The Trust has introduced Complex Case Review Meetings at HMP Highdown, to commence in February 2017, to include GPs, Primary Care, Mental Health, Substance Misuse; Social Care, Safer Custody and …
Overdue
James Spencer
20 Mar 2017 · Exeter and Greater Devon
Concerns: Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.
Response (James Spencer): Drug awareness training is now mandatory for all new operational colleagues working on the BASS contract and has been rolled out as refresher training for existing colleagues.
Responded
Jonathan Palmer
31 May 2017 · London Inner (West)
Concerns: There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
Response (HM Prison Probation Service): A Safer Custody Learning Bulletin has been issued regarding receiving emergency calls and sharing risk information from families, Samaritans, and others. HMP Wandsworth conducts searches of all visitors and prisoners …
Overdue
John O’Meara
10 Jan 2018 · London (West)
Concerns: Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.
Response (HM Prison and Probation Service): Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff; notices have been …
Responded
Timothy Shaw
15 Feb 2018 · Essex
Concerns: Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.
Response (Care UK): Care UK acknowledges receipt of the report but states they ceased providing healthcare at HMP Chelmsford on 26 May 2017 and therefore will not be filing a substantive response.
Overdue
Andrew Craig
25 Jun 2018 · Dorset
Concerns: Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.
Response (HM Prison Probabtion Service): The plan to upgrade the cell windows has now been approved and is provisionally on Ministry of Justice programme for delivery in 2019/20. Additionally, a number of measures to reduce …
Response (Care UK): Care UK provides healthcare services at HMP Guys Marsh. In response to concerns about drug use, they have provided first aid training by prison staff and sourced posters highlighting the …
Overdue
Daniel Stokes
05 Nov 2018 · South Yorkshire (East)
Concerns: Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.
Overdue
Jerome Jones
01 Aug 2018 · Shropshire, Telford & Wrekin
Concerns: Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited access to medical records, posed significant dangers.
Response (Shropshire Community Health NHS Trust): The trust describes current practices for observing prisoners using illegal substances and referring them to support services. It notes that Forward Trust's access to medical records is under discussion with …
Response (HM Prison Probation Service): An updated drug strategy has been launched at the establishment, and staff were reminded of communication protocols for prisoners at risk from repeated use of psychoactive substances. By April 2019, …
Overdue
Tyrone Givans
23 Jan 2019 · London Inner (North)
Concerns: Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to significant safety concerns within the prison.
Response (Care UK): Care UK provides healthcare services at HMP Pentonville, and they are committed to working with partner agencies in tackling illicit substance supply and trading. A new Health and Wellbeing model …
Response (HM Prison and Probation Service): HMPPS published a national Prison Drugs Strategy in April and is revising and republishing its local drug strategy. A new equality policy framework with guidance on reasonable adjustments will be …
Overdue
Natasha Chin
10 Jan 2019 · Surrey
Concerns: Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.
Response (HM Inspector of Prisons): HM Inspectorate of Prisons acknowledges the report and will place a copy in their intelligence file to inform future inspections of HMP Bronzefield. They are unable to direct the prison …
Overdue
Ricardo Holgate
11 Jan 2019 · Birmingham and Solihull
Concerns: Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.
Response (GS4): G4S states that HMP Birmingham is currently being managed by HMPPS and decisions regarding actions/equipment are not within their remit, but they agree with the need for CCTV and airport-style …
Overdue
Andrew Carr
31 Jan 2019 · Birmingham and Solihull
Concerns: Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.
Overdue
Stephen Harte
01 Feb 2019 · Birmingham and Solihull
Concerns: Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not being searched upon entry.
Response (Birmingham and Solihull Mental Health NHS Trust): The trust is developing a drug strategy to address illicit substance use in the medium secure unit including risk assessments, educational sessions, opiate replacement consideration and potentially making Naloxone available …
Response (CQC): The CQC clarifies its role in inspections, stating they did not ask the trust to relax rules on takeaways, but did ask for review of blanket restrictions and active risk …
Responded
Martin Haines
16 Aug 2019 · East Sussex
Concerns: Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented responsibility across multiple agencies with poor communication and separate IT systems.
Response (Department of Health and Social Care): The Department of Health and Social Care states that providers of healthcare services are responsible for the quality and safety of the care they provide and expects the healthcare providers …
Response (NHS England): NHS England reports that it has reviewed its commissioning contract performance and quality assurance systems following the death. Improvements include a revised governance structure with a Quality Board and Serious …
Response (HM Prison and Probation Service): HMPPS published the Prisons Drug Strategy in April 2019 and each prison has responsibility for reviewing their own local substance misuse strategy. A notice is now displayed in the control …
Responded
Leroy Medford
09 Jul 2019 · Berkside
Concerns: The coroner expresses concern that officers were unaware of a requirement in the Drugs SOP for an officer to be within the cell with a detained person, and recommends a national review of how training is delivered and monitored within the police service.
Response (Thames Valley Police): Thames Valley Police have initiated a quarterly Drug Concealment Working Group and are refreshing guidance for superintendents on managing drugs concealment cases (target Nov 2019). They are developing healthcare pathways …
Response (National Police Chiefs' Council): The NPCC is closely involved in the College of Policing’s work on a national strategy for police learning, which may address concerns around training. The NPCC has shared the coroner's …
Overdue
Mark Jarvis
19 Sep 2019 · Suffolk
Concerns: The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.
Overdue
Imran Mahmood
04 Sep 2019 · Staffordshire South
Concerns: E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related to both illicit drug use and potential fires.
Response (HM Prison and Probation Services): HMPPS is considering alternative vape devices, including one using vapourless valve technology, to mitigate risks associated with e-cigarettes in prisons, but is constrained by cost and commercial availability.
Responded
Neville McNair
05 Nov 2019 · East Sussex
Concerns: Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no clear local protocol existed for its use.
Response (NHS England): The Forward Trust provides substance misuse services at HMP Lewes and has a protocol for opioid overdose, with staff trained in naloxone administration. NHS England has developed a quality assurance …
Response (HM Prisons and Probation Service): HMPPS is preparing a pilot project to train prison staff in a number of prisons in the north of England to administer naloxone, and is considering the use of alternatives …
Overdue
Luke Jones
03 Dec 2019 · North Wales (East and Central)
Concerns: Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.
Response (HM Prison and Probation Service): HMP Berwyn has implemented various measures to tackle psychoactive substances, including improved gate searching, changes in the supervision of domestic visits, safe detoxification on reception, and extended mandatory drug testing. …
Overdue
Daniel Coleman
25 Aug 2020 · Inner North London
Concerns: Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.
Response (Camden Council): Camden Council is revising its Drug and Alcohol Policy, consulting with Hampton Knight and Trade Unions, with a planned testing regime rollout in the new year, dependent on the ongoing …
Responded
Anthony Clacher
22 Oct 2021 · Dorset
Concerns: A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.
Response (NHS England): NHS England highlights that the Digital Person Escort Record (DPER) has been live across the prison estate since November 2020, and all reception healthcare staff should have access to the …
Response (NHS England): NHS Digital is considering the coroner's concerns about SystmOne in prisons when developing the capabilities for the HJIS re-procurement in 2022/23 and will consider adopting GP IT related products such …
Response (Department of Health Social Care): The Department of Health and Social Care acknowledges the concerns raised, highlights the National Partnership Agreement for Prison Healthcare, and notes actions NHS England is taking regarding substance misuse in …
Response (HM Prison and Probation Service): HMPPS is considering a national rollout of local initiatives (including those from HMP Guys Marsh) to improve welfare checks on prisoners under the influence of psychoactive substances, and is developing …
Responded
Kyle Nel
22 Dec 2021 · Dorset
Concerns: The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.
Response (HM Prison and Probation Service): HMPPS replaced the Custodial Violence Management Model with the Challenge, Support and Intervention Plan (CSIP), a violence reduction case management model, and HMP Guys Marsh has a dedicated drug strategy …
Responded
Ian Miller
05 Jan 2022 · Gwent
Concerns: A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Response (HM Prison and Probation Service): The prison updated its prisoner induction process in January 2022 to include information on in-possession medication, the dangers of misusing prescription drugs, and instructions to report concerns. Guidance was issued …
Overdue
Thomas Smith
16 Jul 2022 · Bedfordshire and Luton
Concerns: Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks or patient care plans, compromising safety.
Response (Responses from NHS England): ELFT has refreshed staff training on risks associated with spice and reiterated the need for robust pre-leave risk assessments, communicated and agreed by the nurse in charge, prior to a …
Overdue
Christopher Ryan
22 Jul 2022 · West London
Concerns: The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.
Response (South West London and St Georges Mental Health): The Trust details the policy regarding smoking, highlighting that it isn't permitted in buildings, carparks, grounds and gardens. The Trust has committed to undertaking a formal and comprehensive review of …
Responded
Stephen Weatherley
20 Jul 2023 · Inner South London
Concerns: Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Response (HM Inspectorate of Prisons): HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform …
Response (HM Inspectorate of Prisons): HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform …
Response (Serco 1): Serco (HMP Thameside) details actions taken, including the introduction of MS Teams folders for data retention, enhanced security strategies with trained analysts, and the implementation of a bodyscanner, with learnings …
Response (HM Prison and Probation Service): HM Prison and Probation Service acknowledges the concerns regarding record keeping and data retention at HMP Thameside, confirms receipt of the prison director's response, and outlines the contract delivery indicators …
Responded
Kristopher Tilbury
08 Sep 2023 · Hertfordshire
Concerns: HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.
Overdue
Steven Sanders
29 Sep 2023 · Birmingham and Solihull
Concerns: An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses significant risk to vulnerable patients with mental illness and compromised judgment.
Response (CQC): CQC requested the Chief Coroner's Office to disseminate messaging to all coroners regarding notifications of inquests and Regulation 28 reports, including specific email addresses for submissions. The Chief Coroner's Office …
Overdue
John Pace
13 Nov 2023 · Essex
Concerns: A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk to future prisoners' safety.
Response (the Forward Trust): The Forward Trust has drafted and implemented a new protocol on the 'Management of Non-engaging Service Users Protocol'. A dissemination and training programme has been facilitated, and the protocol has …
Overdue
Kane Boyce
17 Jan 2024 · Nottingham and Nottinghamshire
Concerns: Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Response (Sodexo): Sodexo states that the MOJ have confirmed that all managers, including the Senior Leadership Team, are to undergo the national ACCT training as a matter of urgency, this will include …
Response (HM Prison and Probation Service): HMPPS issued guidance and a standard template for Early Learning Reviews (ELRs) in 2021, held a workshop with Group Safety Leads (GSLs) in July 2022, and another in April 2024 …
Responded
Liam Turner
05 Feb 2024 · Manchester City
Concerns: It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.
Response (HM Prison and Probation Service): HMPPS re-issued the First Aid Policy Framework in August 2023, highlighting training requirements and the need for risk assessments to determine adequate numbers of trained staff. HMP Manchester issued guidance …
Responded
John Singleton
16 Nov 2023 · Cheshire
Concerns: The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround is inefficient and poses significant risks.
Response (NHS England): NHS England will explore the functionality of the Health and Justice Information Service (HJIS) to flag medication non-compliance and work to facilitate roll out across the estate. In the interim, …
Responded
Amanda Richardson
09 Sep 2024 · West Yorkshire (East)
Concerns: Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a mental health hospital allowed illicit drugs to be present.
Response (InMind): Inmind Healthcare states that they completed a Serious Incident Report and implemented an action plan of recommendations, with details of steps and actions implemented and embedded by Inmind following this …
Overdue
Jonathon Lawlor
25 Nov 2024 · Mid Kent and Medway
Concerns: Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
Response (HM Prison and Probation Service): HMP Elmley has been compiling a Key Work Delivery Strategy to address and improve the issue of key work, with the goal of ensuring that all prisoners are allocated a …
Responded
Anthony Binfield
17 Dec 2025 · Nottingham City and Nottinghamshire
Concerns: A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.
Response (HM Prison and Probation Service): HMPPS has reinforced the importance of clear observation panels at HMP Lowdham Grange through staff briefings, Governor's orders, and video messages to prisoners. Prisoners blocking panels may face sanctions and …
Responded
Isaiah Olugosi
24 Feb 2025 · West London
Concerns: A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
Response (HM Prison and Probation Service): HMPPS expresses condolences and notes the concerns raised. The prison has addressed phone line issues ensuring the prison can be called at any time and that this is regularly tested. …
Responded
Gavin Wheale
10 Jul 2025 · Birmingham and Solihull
Concerns: The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with concealed items.
Response (HM Prison and Probabtion Service): HMP Birmingham will update its Secreted Items Policy to include guidance for staff on actions to take when a prisoner has ingested an item. They will also issue guidance to …
Responded
Sheldon Jeans
25 Jul 2025 · Dorset
Concerns: The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.
Response (HM Prison Probation Service): HMP Guys Marsh has developed its Incentivised Substance Free Living (ISFL) unit, provides comprehensive staff information on illicitly brewed alcohol, and ensures in-cell medication safes are available and fit for …
Response (Oxleas NHS Foundation Trust): Oxleas NHS Foundation Trust will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh focusing on safe storage and proper disposal of medication. …
Response (HM Prison and Probation Services): HMPPS has developed and disseminated materials focused on illicitly brewed alcohol (IBA), including the Drugs in Prison and Probation (DiPP) guide. The healthcare provider at HMP Guys Marsh, Oxleas NHS …
Response (Department for Health and Social Care): The Department acknowledges concerns about medication held in prisoners' possession, but states that national NHS policies for prisoners are the same as those used in the community. They believe existing …
Responded
Lewis Petryszyn
31 Jul 2025 · South Wales Central
Concerns: Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed care and intervention from the Dyfodol service.
Response (G4s Care): G4S states that timeframes are already contained within policies and procedures as required nationally and pursuant to the service level agreement with CTMUHB, and those timeframes are complied with, therefore …
Overdue
Martin Collins
17 Sep 2025 · Suffolk
Concerns: The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Response (HM Prison Probation Service): HMPPS has initiated discussions with BT to explore the feasibility of monitoring call volumes as a potential indicator of heightened suicide/self-harm risk as part of an ongoing development project. They …
Responded
Select committee recommendations(34)
#198 — Ensure uniform security standards throughout the prison estate to mitigate all potential ingress risks.
Justice Committee
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. …
Gov response: We appreciate the Committee’s focus on security within our prisons and wish to emphasise the significant steps taken to strengthen our defence against the supply of drugs, often fuelled by Serious and Organised Crime (SOC). …
Accepted
#197 — Advanced drug detection technology is an essential prerequisite for preventing drug ingress
Justice Committee
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 …
Gov response: We appreciate the Committee’s focus on security within our prisons and wish to emphasise the significant steps taken to strengthen our defence against the supply of drugs, often fuelled by Serious and Organised Crime (SOC). …
Accepted
#196 — Effective collaboration requires consistent intelligence sharing to disrupt OCG drone operations
Justice Committee
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 …
Gov response: Partially accept We recognise the serious threat posed by Serious and Organised Crime (SOC) seeking to compromise prison security through drone incursions and illicit mobile phones and we agree that strong partnerships and intelligence-sharing are …
Partially Accepted
#195 — Manage key OCG operators under enhanced security, segregating them from general prison population
Justice Committee
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 …
Gov response: Reject We recognise how SOC operators can exploit vulnerable prisoners, creating debt and driving violence and self-harm, which undermines safety and stability across the prison estate. However, we do not accept the recommendation to segregate …
Not Accepted
#194 — Collaborate to develop systems tracking electronic transactions linked to OCG activity in prisons
Justice Committee
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)
Gov response: Partially accept Disrupting the illicit economy within prisons is critical to maintaining safety and security, and financial intelligence plays a key role in this effort. HMPPS already has a Financial Investigation Unit (FIU) with both …
Partially Accepted
#193 — Accelerate deployment of advanced contraband detection and signal disruption technology with trained personnel
Justice Committee
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 …
Gov response: Partially accept The threat posed by illicit mobile phones and other contraband within prisons is escalating, and so we have a wide-ranging programme in place to prevent these from entering prisons in order to detect …
Partially Accepted
#192 — Eliminating external communication is critical to disrupting prison drug supply chains
Justice Committee
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 …
Gov response: Partially accept The threat posed by illicit mobile phones and other contraband within prisons is escalating, and so we have a wide-ranging programme in place to prevent these from entering prisons in order to detect …
Partially Accepted
#191 — Develop and deploy comprehensive anti-drone strategy and technology across high-risk prisons
Justice Committee
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, …
Gov response: Partially accept We recognise the evolving threat posed by drone technology and agree that maintaining security measures ahead of criminal innovation is essential to protecting the prison estate and public safety. HMPPS works hard to …
Partially Accepted
#190 — Employ dedicated intelligence-sharing protocols and joint task forces against organised drone and phone gangs
Justice Committee
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 …
Gov response: Partially accept We recognise the serious threat posed by Serious and Organised Crime (SOC) seeking to compromise prison security through drone incursions and illicit mobile phones and we agree that strong partnerships and intelligence-sharing are …
Partially Accepted
#189 — Current detection technologies outpaced by sophisticated drones and illicit mobile phone use
Justice Committee
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 …
Gov response: We appreciate the Committee’s focus on security within our prisons and wish to emphasise the significant steps taken to strengthen our defence against the supply of drugs, often fuelled by Serious and Organised Crime (SOC). …
Accepted
#188 — Reliance on staff sightings underestimates serious threat of increasing drone incidents
Justice Committee
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 …
Gov response: It is vital we address the underlying demand that drives drug use. Incentivised Substance-Free Living (ISFL) units are central to this approach, providing structured environments that support recovery and reduce harm. We have funded ISFLs …
Partially Accepted
#181 — Allocate dedicated capital funding for advanced prison detection technology and software updates
Justice Committee
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 …
Gov response: We recognise how SOC operators can exploit vulnerable prisoners, creating debt and driving violence and self-harm, which undermines safety and stability across the prison estate. However, we do not accept the recommendation to segregate individuals …
Not Accepted
#180 — Inconsistent deployment of security measures undermines their effectiveness against criminal networks
Justice Committee
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 …
Gov response: Disrupting the illicit economy within prisons is critical to maintaining safety and security, and financial intelligence plays a key role in this effort. HMPPS already has a Financial Investigation Unit (FIU) with both investigation and …
Partially Accepted
#179 — Require balancing prisoner punishments with mandatory drug treatment referrals and resourcing consistent adjudications
Justice Committee
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 …
Gov response: The threat posed by illicit mobile phones and other contraband within prisons is escalating, and so we have a wide-ranging programme in place to prevent these from entering prisons in order to detect and disrupt …
Partially Accepted
#177 — Regard staff exposures to drugs as serious workplace safety violations requiring immediate investigation.
Justice Committee
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)
Gov response: We recognise the serious threat posed by Serious and Organised Crime (SOC) seeking to compromise prison security through drone incursions and illicit mobile phones and we agree that strong partnerships and intelligence-sharing are essential in …
Partially Accepted
#176 — High prevalence of drugs, particularly NPS, poses an unacceptable threat to prison staff safety.
Justice Committee
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 …
Gov response: Rigorous recruitment processes for frontline staff are crucial in maintaining security and safety within prisons. To ensure this, HMPPS operates a centralised recruitment model for prison officers, which is streamlined to accommodate the very high …
Partially Accepted
#173 — Drug-related medical emergencies strain prison staff and reduce purposeful activity, fueling drug demand.
Justice Committee
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 …
Gov response: We recognise the importance of maintaining robust security infrastructure across the prison estate and so in the 2025/26 planned capital maintenance programme, approximately £40 million has been invested in security- related projects, including approximately £15 …
Not Accepted
#172 — Drug-related debt and exploitation are fundamental drivers of prison violence and systemic instability.
Justice Committee
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 …
Gov response: We recognise the importance of safeguarding legal privilege while preventing its exploitation for criminal purposes. The Ministry of Justice has developed a digital service, ‘Send legal mail to prisons’ which enables recognised legal representatives to …
Accepted
#167 — Consistently update prison drug testing methods to detect evolving New Psychoactive Substances.
Justice Committee
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 …
Gov response: NHS Substance Misuse teams already provide patients with take home naloxone kits and training in the use of them at release for patients who are clinically appropriate, and who consent to take it. However, we …
Partially Accepted
#166 — Take urgent steps to address the evolving threat of New Psychoactive Substances in prisons.
Justice Committee
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 …
Gov response: We welcome the Committee’s focus on positive staff-prisoner relationships, which are vital to rehabilitation. To ensure prison officers can effectively support prisoners with a drug dependency, we must tackle stigma, and improve staff understanding of …
Accepted
#165 — Significant shift towards undetected New Psychoactive Substances (NPS) in prisons.
Justice Committee
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 …
Gov response: Purposeful activity plays an important role in the prevention of drug use and supporting recovery within prisons. The Government remains firmly committed, as set out in our manifesto, to improving this and ensuring prisons are …
Accepted
#164 — Revise drug testing policy for dual response: disciplinary action and treatment referral.
Justice Committee
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 …
Gov response: We acknowledge the significant risk posed by the diversion and misuse of prescription medication within prisons. To prevent this, guidance on supervising medicine queues is already included in Prison Officer Guides, and harm reduction advice …
Partially Accepted
#163 — Speed up plans to introduce wastewater-based drug surveillance across the entire prison estate.
Justice Committee
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 …
Gov response: We review our drug testing processes on an ongoing basis to ensure they effectively monitor the constantly changing chemical composition of psychoactive substances. As the Committee recognises in their report, the scale of the challenge …
Accepted
#162 — Increase Mandatory Drug Testing rates across prisons to at least pre-pandemic levels.
Justice Committee
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, …
Gov response: The existing adjudications policy already allows Governors the discretion to award a suspended punishment in guilty findings, on the condition that the prisoner undertakes a rehabilitative activity, such as engagement with drug and alcohol treatment …
Partially Accepted
#161 — Restore consistent, high-volume Mandatory Drug Testing across the entire prison estate.
Justice Committee
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 …
Gov response: We recognise that prison wastewater testing could offer insight into the overall health of a prison population, including potential to monitor drug consumption. We are not yet in a position to commit to wider or …
Partially Accepted
#160 — Widespread illicit substance availability normalises drug use and addiction within prisons.
Justice Committee
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 …
Gov response: We recognise the value of drug testing in achieving a range of outcomes, including supporting our understanding of the level and types of drug use in prisons, identifying individuals who may benefit from treatment referrals, …
Partially Accepted
#178 — Significant backlog in adjudication process undermines prison discipline and progression model
Justice Committee
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 …
Gov response: We recognise the evolving threat posed by drone technology and agree that maintaining security measures ahead of criminal innovation is essential to protecting the prison estate and public safety. HMPPS works hard to deter, detect …
Partially Accepted
#23 — Crowding and capacity pressures severely impact prisoner health and drug treatment in prisons
Public Accounts Committee
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 …
Gov response: 5.11 The government agrees with the Committee’s recommendation. Recommendation implemented: April 2025 5.12 Action is underway to improve delivery through the national regime model. This annual cycle mandates prisons to set out their planned delivery, …
Accepted
#4 —
Public Accounts Committee
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 …
Gov response: The government disagrees with the Committee’s recommendation The government holds robust information on spend for its two air quality programmes: the Air Quality and Industrial Emissions Programme (Defra) and the Joint Air Quality Unit (Defra/DfT). …
Not Accepted
#12 — Inconsistent outcome measures for prisoners with substance misuse needs hinder effective evaluation.
Public Accounts Committee
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 …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2024 2.2 The government is committed to engaging offenders in substance misuse treatment at all stages of the criminal justice system to reduce …
Accepted
#7 — HMPPS needs plans to reinvigorate measures controlling substance abuse and violence
Justice Committee
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 …
Gov response: As commissioners, NHS England and NHS Improvement provide support to parts of the system that may be experiencing difficulties. As part of contract performance monitoring, NHS England and NHS Improvement commissioners review a number of …
Under Consideration
#19 — Poor quality probation referrals severely hinder effectiveness of CRS resettlement support for prison leavers.
Public Accounts Committee
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’ …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 HMPPS is reviewing its approach to ensuring good quality outcomes for prison leavers and people on probation are both achieved and evidenced. 4.3 HMPPS …
Accepted
#9 — Increasing benzodiazepine use and its link to drug deaths causes concern.
Home Affairs Committee
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 …
Gov response: The Government will provide the Committee with an update on the outcome of the consultation on or before 18 December 2023, once the consultation responses have been analysed. The Government shares the Committee’s concerns on …
Under Consideration
#8 — Concerns about increased NPS potency and use among vulnerable populations persist.
Home Affairs Committee
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 …
Gov response: The Psychoactive Substances Act continues to apply to all substances which are capable of producing a psychoactive effect in a person, but which are not exempt nor controlled by the Misuse of Drugs Act. The …
Accepted
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)
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
Article 2 learning points(4)
Detention investigations(3)
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
LGO (Local Government & … Planning
25-005-195 — Derbyshire Dales District Council
LGO (Local Government & … Planning Upheld
25-021-003 — North Yorkshire Council
LGO (Local Government & … Planning
25-014-441 — Epping Forest District Council
LGO (Local Government & … Planning
25-004-542 — Kirklees Metropolitan Borough Council
LGO (Local Government & … Planning
25-003-951 — London Borough of Harrow
LGO (Local Government & … Planning
25-006-279 — Stoke-on-Trent City Council
LGO (Local Government & … Planning
25-003-976 — Thurrock Council
LGO (Local Government & … Planning
24-020-373 — Wealden District Council
LGO (Local Government & … Planning
25-013-544 — Thurrock Council
LGO (Local Government & … Planning
25-002-051 — Waverley Borough Council
LGO (Local Government & … Planning
24-020-496 — Calderdale Metropolitan Borough Council
LGO (Local Government & … Planning
25-016-717 — Harborough District Council
LGO (Local Government & … Planning
25-015-562 — Tendring District Council
LGO (Local Government & … Planning
25-013-317 — Buckinghamshire Council
LGO (Local Government & … Planning
24-020-062 — London Borough of Merton
LGO (Local Government & … Planning
24-013-443 — Northumberland County Council
LGO (Local Government & … Planning
25-004-301 — Blackpool Borough Council
LGO (Local Government & … Planning Upheld
25-004-040 — Epsom & Ewell Borough Council
LGO (Local Government & … Planning
25-000-949 — North Yorkshire Council
LGO (Local Government & … Planning
25-016-511 — West Lancashire Borough Council
LGO (Local Government & … Planning Upheld
25-015-561 — Leeds City Council
LGO (Local Government & … Planning
25-014-112 — Cherwell District Council
LGO (Local Government & … Planning
25-016-327 — Hartlepool Borough Council
LGO (Local Government & … Planning
25-012-455 — Buckinghamshire Council
LGO (Local Government & … Planning
25-000-657 — North West Leicestershire District Council
LGO (Local Government & … Planning Upheld
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
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