Unsecured medication in prisoners' possession
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.
The story, report by report
Spacing grows with the time between reports.
“(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
- 1 year laterClosely 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.”
- All reports to Oxleas NHS Foundation Trust
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.
2024 → 2025Sheldon Jeans1 year after Benjamin Harrison · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with how medication kept in prisoners' possession is managed, noting insufficient guidance or policy. The earlier report stresses lack of staff briefing, while the later report points to missing national and local policies governing possession and access.
Benjamin Harrison · 19 Jul 2024
“(2) Prison staff did not receive a briefing about prisoners with medication in possession in accordance with PS24/2011”
Original on judiciary.uk ↗ Sheldon Jeans · 25 Jul 2025
“(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 ↗ Stated action in the response to the earlier report
“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 action · timescale: end of the year
“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 action · timescale: Autumn 2024
“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 action
“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.”
- 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 Oxleas NHS Foundation Trust 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 |
|---|---|---|---|---|
| 2024 → 2025 | 0.76 | 0.27 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Oxleas NHS Foundation Trust
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.