Recurance · prevention of future deaths reports
Pre-inquest brief
Unrestricted access to novel psychoactive substances in prison
The earlier warning
Ricardo Holgate · 11 Jan 2019 · Louise Hunt, Birmingham and Solihull
“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.”
judiciary.uk/prevention-of-future-death-reports/ricardo-holgate
What was promised
Stated action 1 · response to Ricardo Holgate (11 Jan 2019) · stated 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 2 · response to Ricardo Holgate (11 Jan 2019) · stated timescale: none stated
“discussions between Mr [name redacted] and HMPPS are ongoing”
Stated action 3 · response to Luke Jones (3 Dec 2019) · stated timescale: none stated
“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.”
judiciary.uk/…/2019-0409-Response-from-HM-Prison-and-Probation-…
What recurred
- 3 Dec 2019 · Luke Jones · John Gittins
- 8 Sept 2023 · Kristopher Tilbury · Jonathan Stevens · Closely related · confidence 0.90 (high)
- 8 Dec 2025 · Oliver Mulangala · Jonathan Stevens · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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)”
Later · 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”
What happened next
No web check of the stated actions has been published for this chain.