Lack of naloxone availability and training in prisons
NHS England received 2 coroners' reports about this hazard between 5 Nov 2019 and 2 Jan 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 5 years 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them.”
Original on judiciary.uk ↗ Repeated from the earlier report:naloxoneavailable
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2025Joseph Forbes Black5 years 2 months after Neville McNair · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient access to naloxone as a factor that could lead to preventable overdose deaths. The earlier report focuses on prison staff lacking training and naloxone availability, while the later report concerns broader community providers not being allowed to supply naloxone kits to at‑risk drug users.
Neville McNair · 5 Nov 2019
“all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone.”
Original on judiciary.uk ↗ Joseph Forbes Black · 2 Jan 2025
“I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2025 | 0.68 | 0.22 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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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.