Neville McNair

Director General Prisons 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London SW1H 9AJ 

6 February 2020 

Ms Fiona King 
HM Assistant Coroner for East Sussex 
East Sussex Coroner’s Office 
Unit 56, Innovation Centre 
Highfield Drive 
St Leonards-On-Sea 
East Sussex TN38 9UH 

Dear Ms King 

Thank you for your Regulation 28 Report of 5 November 2019, following the inquest into the 
death of Neville McNair at HMP Lewes on 16 June 2018. I am grateful to you for granting an 
extension to the statutory deadline for my response. 

I would first like to express my condolences to the family and friends of Mr McNair for their 
loss. The safety of those in our care is my absolute priority and every death in custody is a 
tragedy. 

You have raised a concern about the availability of naloxone in prison establishments, 
drawing attention to the ‘Orange Book’ guidelines on clinical management. 

I understand that Professor Powis has responded separately to confirm that NHS England 
and NHS Improvement (NHSE&I) are committed to ensuring that prison healthcare 
providers comply with the guidelines, and that the Governor of HMP Lewes has agreed to 
work with the local healthcare provider and commissioner to review the protocol at the 
prison. 

I am committed to working with NHSE&I to make naloxone more readily available across 
the prison estate. This is not straightforward, and there are risks to both staff and prisoners 
that need to be managed. For this reason, the current position is that it is being 
administered only by healthcare professionals. There are a number of issues that require 
further consideration before we can move forward to involve prison staff more widely. 
Identifying a potential opioid overdose and administering treatment for it has not previously 
been a part of the role of prison officers and other non-clinical staff in prisons, and we will 
need to consider precisely how this will work in practice, and what training we will need to 
provide to equip staff to take it on. We will also need to consult trade unions as we develop 
our approach. 

We are working to determine the best way of managing the risks. Consideration is being 
given to the use of alternatives to intramuscular naloxone, such as nyxoid, a nasal form of 
naloxone. We are also preparing a pilot project to train prison staff in a number of prisons in 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the north of England. I will make sure that we continue to work with our health partners to 
take this forward as quickly as we can, whilst continuing to manage the risks to staff and 
prisoners. 

You may be interested to know that, in line with the clinical guidelines set out in the ‘Orange 
Book’, we have made naloxone more available to individuals in approved premises, and are 
issuing it to prisoners who are believed to be at high risk of overdose on release (e.g. those 
who have recently completed detoxification programmes). However, you will appreciate that 
we need to take the necessary time to establish the best way to protect both staff and 
prisoners from the risks associated with the deployment of naloxone before making it more 
broadly available within the custodial environment. 

Thank you again for raising this matter of concern with me. I hope that my response 
provides assurance that we are taking this seriously and committed to finding the best way 
to improve access to naloxone in prisons. 

Yours sincerely 

Director General for Prisons

Fiona King 

East Sussex Coroner’s Office 
Unit 56, Innovation Centre 
Highfield Drive 
St Leonards-on-Sea 
East Sussex 
TN38 9UH 

 Dear Ms King,  

National Medical Director  
NHS England & NHS Improvement  
Skipton House 
80 London Road 
London 
SE1 6LH 

10th January 2020  

Re: Regulation 28 Report to Prevent Future Deaths – Neville Lewis McNair 
(Date of Death 16th June 2018)  

Thank you for your Regulation 28 Report dated 5th November 2019 concerning the 
death of Neville Lewis McNair on 16th June 2018. Firstly, I would like to express my 
deep condolences to Neville McNair’s family.  

The regulation 28 report concludes Neville McNair’s death was a result of heroin 
toxicity with aspiration. Following the inquest, you raised concerns in your Regulation 
28 Report to NHS England that the drug misuse and dependence:  UK guidelines on 
clinical management “Orange Book” section 5.4.9.1 states that ‘all staff including 
non-healthcare staff and operational/security staff should have training in recognising 
and responding to opiate overdose including using available Naloxone.  Naloxone 
should be available in resuscitation kits and risk assessed areas in the prison so that 
it can be accessed and administered by clinical and non-clinical staff as per the local 
protocol’.  

The Inquest was unable to establish that there was a local protocol and none of the 
prison staff were aware of the requirement.  You were concerned that there is no 
Naloxone stored on the wings other than the healthcare wing and no prison officers 
appeared to have been trained in its use or know of its existence.  You believed this 
may be a national issue and not limited to HMP Lewes and in these circumstances 
believed the report should be a concern for all prisons and NHS staff working in 
prisons nationally. 

In response to the matters raised I can confirm that the Forward Trust who are 
commissioned to provide substance misuse services in HMP Lewes have a protocol 
in place in line with national clinical guidelines for the handling of suspected opioid 
overdose and they have assured us that Healthcare staff have access to and are 
trained in the administration of naloxone in the prison. Naloxone is available for the 
first line treatment of suspected opioid overdose contained within the accessible 

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ‘grab bags’ used by staff at HMP Lewes in the event of the sudden deterioration or 
collapse of a prisoner.   

NHS England and NHS Improvement Regional Health and Justice commissioners 
continue to work with Forward Trust and Sussex Partnership NHS Trust to ensure 
that the healthcare services delivered in HMP Lewes follow the national guidance as 
part of their quality assurance which is overseen via the Local Delivery Quality 
Board, Contract Review and Partnership Boards. 

I can confirm that your concerns were discussed at the HMP Lewes Quality Board on 
27th November. The governor at HMP Lewes who is the chair for this meeting has 
agreed to review the protocol. 

This issue has also raised concerns for NHS England and Improvement at the 
National level. The National Quality & Lead Nurse and the National Pharmaceutical 
Adviser both for Health and Justice have developed a quality assurance framework 
which has been sent to all Regional Commissioning teams. This will be used to 
assure themselves that all the quality standards in the National Clinical Guidelines 
are being met in all secure estate establishments. Where these are not being met an 
action plan will be developed and monitored by the regional commissioners via 
contract management processes. The results will also be presented to the local 
governance structures in time to go to the May 2020 National Quality Assurance 
Group (NQAG) where any additional work will be planned, and completion 
monitored.  

Thank you for bringing these important patient safety issues to my attention and 
please do not hesitate to contact me should you need any further information. 

Yours sincerely,