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recurance

Unsecured medication in prisoners' possession

Closely relatedConfidence 0.85 · high2 reports · 2024–2025 One-page brief (print or PDF)

Oxleas NHS Foundation Trust received 2 coroners' reports about this hazard between 19 Jul 2024 and 25 Jul 2025.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 3 specific actions.

2
reports
2
different coroners
2024–2025
years
0.85
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Benjamin Harrison↗

    19 Jul 2024 · Patricia Harding · Mid Kent & Medway

    “(2) Prison staff did not receive a briefing about prisoners with medication in possession in accordance with PS24/2011”
    Original on judiciary.uk ↗

    Oxleas NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

    “Following evidence heard at the inquest, you have raised concerns about the appropriate monitoring of prisoners suspected to be under the influence of illicit substances during the night state and that prison staff were not sufficiently briefed about prisoners keeping medication in their possession. You have also raised a concern in relation to healthcare staff sharing relevant medical information with prison staff. I note that you have also addressed your report to Oxleas NHS Foundation Trust”

    Stated timescale: end of the year

    “1. HMPPS colleagues have responsibility for reducing demand and supply of drugs in prisons, and there is a Governor responsible for Drug Strategy at the prison. The Drug Strategy meeting is attended by healthcare and issues including trends of use of drugs such as psychoactive substances 'spice' are explored. Change, Grow, Live (CGL) are subcontracted by Oxleas to provide psychosocial substance misuse and they have a large caseload at HMP Rochester who undertake group and 1:1 work to address”

    Stated timescale: Autumn 2024

  2. 1 year later

    Raised again · 1st time

    Sheldon Jeans↗

    25 Jul 2025 · Rachael Griffin · Dorset

    Closely relatedConfidence 0.85 · higha different coroner
    “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prison estate.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Prisonersmedicationpossessionprison

    Oxleas NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗

    “we will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh, but also within the wider Oxleas NHS Foundation Trust prison portfolio. These materials will focus on: - Safe storage of prescribed medication, including the use of personal lockable safes - responsibility of HMPPS. - Proper disposal of unused or discontinued medication.”
  3. All reports to Oxleas NHS Foundation Trust

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error