Derrion Adams
18 Nov 2025 · Coroner Emma Brown · Birmingham and Solihull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. novel psychoactive substances entering prison
“novel psychoactive substances and other contraband items were able to enter the prison via [REDACTED] and this continues”
2. delayed response to medical emergency
“staffing on the wing was not sufficient to ensure the call bell for [the deceased]'s cell was answered within the target time resulting in a delay in identifying and responding to his cardiac arrest”
3. escalating operational pressures
“current staffing benchmarks may not reflect the escalating operational pressures caused by the security threat from [REDACTED] and intermittent surges in psychoactive substance incidents”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“At the time there was no policy in place regarding welfare checks to be undertaken upon somebody found under the influence of psychoactive substances and the prison staff would rely upon guidance provided by the healthcare staff.”
This report
“Additionally the policy provides for the gathering of information and intelligence about the individual prisoner and the situation in the prison overall.”