Kevin Forster

“It was clear from evidence that there is a serious drug problem in HMP Durham. This has led to a degree of complacency and acceptance by staff of that situation.”

“Healthcare staff were unaware of what, if any, drugs policy was in lace at the time. A policy known as a "Drugs Overdose Policy" which had, in various guises been in operation since 2008 included a definition of overdose as the "purposeful or accidental act of ingesting an amount of a drug or substance that may cause harm to health”

“Upon obtaining the contract for healthcare at HMP Durham, G4S have instituted have implemented a new policy, but evidence was given that staff had not been given any formal training on it, though the document (running to 12 pages) had been emailed”

“The evidence indicated that there was a lack of guidance as to how staff should react when faced with a person who had overdosed; no local procedures as envisaged by the policy were disclosed, what should be done when there is no indicator as to what substance had been ingested and what would be the appropriate level of observations recognising that (Policy paragraph 8.1) symptoms may develop later”

“Given the apparent scale of the drug problem in HMP Durham, it would seem to be prudent for there to be a clear and workable policy and one which staff that healthcare staff is able to implement with discipline staff knowing sufficient to be able to identify in what circumstances healthcare staff need to become involved”

“There was a lack of an on-going treatment plan prepared for the deceased by nursing staff who attended on him and there was inadequate recording that they had done and what they had to do”