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recurance

Inadequate staffing and training on new psychoactive substances

Closely relatedConfidence 0.80 · moderate2 reports · 2016–2020No published response to an earlier report One-page brief (print or PDF)

Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 3 May 2016 and 28 Aug 2020.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

No published response from Nottinghamshire Healthcare NHS Foundation Trust was found for the earlier reports.

2
reports
2
different coroners
2016–2020
years
0.80
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Shalane Blackwood↗

    3 May 2016 · Stephanie Haskey · Nottinghamshire

    “That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr [name redacted] are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future.”
    Original on judiciary.uk ↗

    No published response from Nottinghamshire Healthcare NHS Foundation Trust was found for this report.

  2. 4 years 4 months later

    Raised again · 1st time

    Carlington Spencer↗

    28 Aug 2020 · Timothy Brennand · Lincolnshire

    Closely relatedConfidence 0.80 · moderatea different coroner
    “Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice"”
    Original on judiciary.uk ↗

    Repeated from the earlier report:staffpsychoactivesubstances

    The most recent report. A response may not be due or published yet.

  3. All reports to Nottinghamshire Healthcare NHS Foundation Trust

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error