The worrying increase of drug-related deaths in custody January 28, 2019 By Elizabeth Moody, Deputy Ombudsman (PPO’s Head of Fatal Incidents Investigations) The Prisons and Probation Ombudsman has become increasingly concerned by the number of deaths we are investigating in prisons, probation approved premises and immigration removal centres in which drugs have played a key part. Since January 2018, these have included: deaths from accidental or intentional overdoses; unexplained deaths of relatively young men from heart attacks and seizures; some apparent electrocutions; suicides apparently caused by the mood-altering effects of drugs; suicides related to drug debts and bullying; and homicides related to control of the drugs trade or triggered by PS-induced psychosis In most of these cases the drugs involved were psychoactive substances (PS), such as ‘spice’. However, a significant minority involved illicitly traded prescription drugs (tranquilisers, anti-depressants and strong analgesics, which can be dangerous in combination, and particularly when combined with opiates such as methadone or Subutex which are prescribed as heroin substitutes). Of course, what we see in our investigations is only the tip of the iceberg. For every death, there are many, many more incidents of non-fatal overdose, self-harm, mental health crises and violence. The damage that drugs are causing in prisons at present can hardly be over-stated. Four main themes emerge from our investigations into deaths… drugs are very readily available in most prisons outside the high security estate, and are increasingly available in immigration removal centres; while PS is the main problem in most prisons, there is also a problem in some prisons with illicitly traded prescription drugs; in many cases staff tell us that they were unaware that a prisoner was using drugs or being bullied over drug-related debts; even prisons with sound local drug policies are telling us that they are struggling to stem the supply and demand for drugs or to intervene effectively. Prescription drugs As far as the misuse of prescription drugs is concerned, I am surprised as a lay person how many prisoners appear to be prescribed strong analgesics, such as gabapentin and pregabalin. These drugs are used to treat epilepsy, anxiety and acute nerve pain, although in prison they frequently seem to be prescribed for chronic non-neuropathic pain. They are generally counter-indicated for people who have had addiction problems in the past or who are prescribed heroin substitutes such as methadone or Subutex. They can produce feelings of relaxation, calmness and euphoria and are also used illicitly to enhance the euphoric effects of other drugs, like opiates. They are likely to increase the risks of other drugs when taken in this way. Staff in the PPO are not clinically trained and we rely on clinical advisers appointed by NHS England and Healthcare Inspectorate Wales for advice on prescribing practices. However, given our increasing concerns about the involvement of prescription drugs in prison deaths, we shall be discussing this topic further with NHS England. Lack of staff engagement and/or capability We are seeing too many cases where, although our investigation reveals that the prisoner was regularly misusing drugs and/or being bullied over drug-related debts, staff tell us that they were completely unaware of this. If staff were genuinely unaware, it suggests a worrying lack of engagement with prisoners. In some cases this is borne out by a complete absence of any record of staff interactions with the prisoner. In other cases we suspect that staff do know what is going on but are failing to challenge or report prisoners who are known to be using drugs regularly. This may be because there are not enough staff or because staff lack the confidence or the experience to challenge prisoners. In some cases we suspect that staff at all grades have come to see drug use (particularly PS use) as the ‘new normal’, and have effectively given up trying to deal with the problem. I hope that the new key worker scheme announced by the Minister will help to overcome some of these problems. The need for national guidance and support Even when prisons have sound local drug strategies in place and appear to be doing their absolute best to limit the supply and demand for drugs, most of the Governors and staff we speak to tell us that they are struggling to deal with the problem. I am concerned that prisons are being left to develop and implement these local strategies themselves in a piecemeal fashion. Governors and their senior staff routinely tell us that they are not receiving sufficient guidance and support from the centre. To give one basic example, individual prisons are sourcing and buying equipment to test prisoners’ correspondence for drugs and employing a variety of strategies to test correspondence. They tell us that they need national advice on what equipment to buy to avoid expensive mistakes, and guidance on what strategies for testing correspondence are both cost-effective and lawful. Governors are also expressing concern to us that prisons’ capacity to identify PS is lagging behind developments in the drugs market – apparently new strains cannot be picked up by drug dogs and they see a need for more effective drug testing. Prisons are also taking different responses to those who are found in possession or to have used drugs, with some taking a punitive approach and putting prisoners on Basic, while others see this as counter-productive (in that it leads to prisoners spending more time in their cells with no TV and nothing to do but take drugs). Governors tell us that they want evidence-based advice on what works. Governors also tell us that they need more external health and counselling input that is bespoke to PS and has the expertise to reach out to determined PS users. They also see a need for a national lead to get other agencies (especially the police and healthcare providers) much more engaged with the problem as they are finding they lack the leverage to do this locally. Hard-pressed on the front lines We have discussed these issues with HMPPS officials. They acknowledge the scale of the problem and I know that there are discussions taking place on the importance of security measures, of effective inter-agency liaison, and of meaningful intervention and support. I also welcome the appointment of Ian Blakeman as Executive Director with responsibility for the newly established Drugs Task Force, and the development of Holme House as a drug recovery prison. However, at the moment hard-pressed colleagues on the front line are telling the PPO that they are not getting the clear advice and support they feel they need. As I have said, the PPO is only seeing the tip of the iceberg through our deaths investigations. We are not, therefore, in a position to offer solutions. I would, however, offer two personal thoughts, although I do not pretend that either is novel or revolutionary. First, trafficking drugs into prisons is big business and the police must have a bigger role to play. Secondly, the amount of time many prisoners are spending locked behind cell doors, without meaningful activity or any real interaction with staff, creates fertile ground for this astonishingly corrosive and damaging behaviour which brutalises the prison system and undermines those who seek to improve it.