Unrestricted access to novel psychoactive substances in prison
Ministry of Justice received 4 coroners' reports about this hazard between 11 Jan 2019 and 8 Dec 2025.
They came from 3 different coroners in 4 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 2 of the 3 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners - one in reception for prisoners and one in the visitor area.”
Original on judiciary.uk ↗ Ministry of Justice responded, stating 2 specific actions.Response (PDF) ↗
“G4S does agree with Mr [name redacted] that HMP Birmingham would benefit from CCTV and airport style scanners. It is G4S's understanding that Mr [name redacted] submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.”
Stated timescale: in due course
“discussions between Mr [name redacted] and HMPPS are ongoing”
- 11 months later
“there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken at HMP Berwyn (namely in relation to the installation of a Rapiscan to test some of the incoming mail)”
Original on judiciary.uk ↗ Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“the Governor of Berwyn and the Regional Substance Misuse lead for HMPPS Wales have revised the prison's Drug Strategy. This primarily focuses on restricting the availability of illicit items, ensuring that there are appropriate consequences for those found in possession, and offering appropriate support for dependent users.”
- 3 years 9 months laterClosely relatedConfidence 0.90 · higha different coroner
“it was extremely troubling that Mr [name redacted] was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount”
Original on judiciary.uk ↗ No published response from Ministry of Justice was found for this report.
- 2 years 3 months laterIdentical hazardConfidence 0.90 · higha different coroner
“(1) New psychoactive substances, especially [REDACTED] , are easily available in HM Prison High Down, as in many other prisons in England & Wales”
Original on judiciary.uk ↗ Ministry of Justice responded.Response (PDF) ↗
- All reports to Ministry of Justice
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2023Kristopher Tilbury3 years 9 months after Luke Jones · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the ongoing accessibility of illicit/psychoactive substances within a prison setting despite some interventions. They differ in the specific prison (HMP Berwyn vs HMP The Mount) and the exact substances mentioned.
Luke Jones · 3 Dec 2019
“there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken at HMP Berwyn (namely in relation to the installation of a Rapiscan to test some of the incoming mail)”
Original on judiciary.uk ↗ Kristopher Tilbury · 8 Sept 2023
“it was extremely troubling that Mr [name redacted] was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount”
Original on judiciary.uk ↗ 2019 → 2023Kristopher Tilbury4 years 8 months after Ricardo Holgate · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the ongoing problem of illicit substance misuse within prisons, indicating that drugs remain readily accessible to inmates.
Ricardo Holgate · 11 Jan 2019
“The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners - one in reception for prisoners and one in the visitor area.”
Original on judiciary.uk ↗ Kristopher Tilbury · 8 Sept 2023
“The report concluded that it was extremely troubling that Mr [name redacted] was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“G4S does agree with Mr [name redacted] that HMP Birmingham would benefit from CCTV and airport style scanners. It is G4S's understanding that Mr [name redacted] submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.”
2019 → 2025Oliver Mulangala6 years after Luke Jones · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the easy availability of novel psychoactive substances in prisons as a ongoing risk. They describe the same hazard—unrestricted access to NPS leading to potential deaths.
Luke Jones · 3 Dec 2019
“The report of the Prisons and Probation Ombudsman highlighted that there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken”
Original on judiciary.uk ↗ Oliver Mulangala · 8 Dec 2025
“(1) New psychoactive substances, especially [REDACTED] , are easily available in HM Prison High Down, as in many other prisons in England & Wales”
Original on judiciary.uk ↗ 2019 → 2025Oliver Mulangala6 years 11 months after Ricardo Holgate · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the ongoing problem of illicit substance misuse within prisons and its impact on safety and stability.
Ricardo Holgate · 11 Jan 2019
“The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners - one in reception for prisoners and one in the visitor area.”
Original on judiciary.uk ↗ Oliver Mulangala · 8 Dec 2025
“The availability of illicit substances continued to be a serious concern that undermined safety and stability. The rate of positive drug tests remained as high as at our full inspection in 2023”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“G4S does agree with Mr [name redacted] that HMP Birmingham would benefit from CCTV and airport style scanners. It is G4S's understanding that Mr [name redacted] submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.”
Stated action · timescale: in due course
“G4S does agree with Mr [name redacted] that HMP Birmingham would benefit from CCTV and airport style scanners. It is G4S's understanding that Mr [name redacted] submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.”
Stated action
“discussions between Mr [name redacted] and HMPPS are ongoing”
Stated action
“the Governor of Berwyn and the Regional Substance Misuse lead for HMPPS Wales have revised the prison's Drug Strategy. This primarily focuses on restricting the availability of illicit items, ensuring that there are appropriate consequences for those found in possession, and offering appropriate support for dependent users.”
No published response from Ministry of Justice was found for this report.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Ministry of Justice at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2023 | 0.72 | 0.30 | Closely related · 0.90 | different |
| 2019 → 2023 | 0.66 | 0.30 | Closely related · 0.90 | different |
| 2019 → 2025 | 0.78 | 0.19 | Identical · 0.90 | different |
| 2019 → 2025 | 0.61 | 0.26 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.