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Coroner’s reportPrevention of future deaths · 2015-0486

“There was a general lack of awareness and understanding of the drugs issues in the prison…”

Dated 25 Nov 2015, from the coroner for Birmingham and Solihull. Sent to 3 organisations or people.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

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  1. Report dated25 Nov 2015
  2. Deadline20 Jan 2016
  3. Published on judiciary.uk25 Nov 2015
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
National Offender Management ServiceResponse publishedPublished on judiciary.uk in November 2015.
Birmingham PrisonDeadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jan 2016. A reply may have been sent and not yet published.
Birmingham Community Healthcare NHS Foundation TrustNamed in the report as “Birmingham Community Healthcare NHS Trust”Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jan 2016. A reply may have been sent and not yet published.

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The coroner’s concerns

– 1. There was a general lack of awareness and understanding of the drugs issues in the prison by prison officers. Two prison officers who worked on B wing said they were unaware of any problems with prisoners using illicit drugs including general medications. Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners come by those drugs. 2. There is a lack of multi‐disciplinary approach to drug issues within the prison. The evidence heard at the inquest confirmed that prison officers, health workers and DART workers do not adequately discuss trends and general drugs issues to ensure all staff are up to date and aware of the problems. It is accepted that patient’s confidentiality needs to be maintained but it is essential to discuss trends and significant events in a multi‐disciplinary way. 3. General medicine administration does not involve a check of the mouth so prisoners can easily conceal tablets to sell later. 4. Cell searches only take place for a certain number of cells each month on a random basis as prescribed by NOMS, or for targeted cells when there is sufficient intelligence. Intelligence searches only take place when there is at least 2 pieces of intelligence. Given the extent of the drug problem on B wing this seems insufficient. 5. Prisoners on B wing are not viewed or monitored at all overnight unless they are on an ACCT. This gives them a considerable period of time to smoke and use drugs knowing there will be no supervision or observation from prison officers. 6. The prison deploy a security officer to B wing at night (172 prisoners).This person is unable to interact with prisoners and is only there to answer call bells. This seems inadequate given that this group of prisoners are at high risk of drug use particularly at night when there are no cell checks. 7. DART workers are currently unable to access compact drug results as workers are unable to log onto the computer. 8. Prison officers are unaware of positive drug test results and therefore unable to take any action in response. 9. There are several exercise areas at the prison. Only two have netting. Further consideration needs to be given to netting other areas given the number of packages being thrown over the wall and then secreted by prisoners on their person. The inquest heard that only a small proportion of packages are seized as they come over the wall. 10. The prison should investigate whether 3 prison officer on duty in the exercise area is sufficient for 172 prisoners given the number of packages that are thrown over the walls every week. 11. At present there is no ability to search or screen prisoners or visitors for drugs concealed on their person when they come into prison. Given that this is a major source of drugs coming into the prison further consideration need to be given, on a national level, as to how concealed drugs can be identified for example with the use of a full body scanner. The current scanner can only identify metal objects. 12. Birmingham prison has 2 drugs dogs who work on a shift pattern. This means not every area in the prison can be covered as only one dog is on duty at any one time. Given that these dogs are the only current mechanism for identifying certain drugs consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source
judiciary.uk, Prevention of Future Deaths reports, 2015-0486
Added to Minute Book
8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0

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