Sheldon Jeans

Parliamentary Under-Secretary of State for    
Women’s Health and Mental Health  

39 Victoria Street   
London SW1H 0EU   

HM Senior Coroner Rachael Clare Griffin  
Senior Coroner   
BCP Civic Centre  
Bourne Avenue  
Bournemouth   
BH2 6DY  

16th October 2025  

Dear Ms Griffin,   

Thank you for the Regulation 28 report of 25 July 2025 sent to the Secretary of State for 
Health and Social Care about the death of Sheldon Lawrence Jeans. I am replying as the 
Minister with responsibility for mental health and offender health. Thank you for the additional 
time provided to the Department to provide a response to the concerns raised in your report.  

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Jean’s 
death, and I offer my sincere condolences to his family and loved ones. The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention.   

Your report raises concerns over the availability illicitly brewed alcohol and a lack of national 
and local policy at HMP Guys Marsh, around the governance of medication held in prisoners’ 
possession in the prison estate. The first of these is a matter for my Ministerial colleagues 
at the Ministry of Justice.  

I understand your concerns about medication held in prisoners’ possession. It is important 
that  robust  governance  processes  are  in  place  to  ensure  safe  and  effective  medicines 
management.    In  preparing  this  response,  my  officials  have  made  enquiries  with  NHS 
England to ensure we adequately address your concerns.  

National NHS policies relating to the overarching use, governance and supply of medicines 
for prisoners are the same as those used for people in the community. As in the community, 
prescribed medicines are the patient’s property and taking them is an act of daily living which 
the patient is responsible for. Any unused medicines should be returned to the pharmacy or 
healthcare team for safe disposal.  

NHS  England  commissions  healthcare  services  for  prisoners  that  are  underpinned  by 
specific  service,  regulatory  and  professional  standards  and  national  guidance.  The  main 
underpinning standards and guidance for health, wellbeing and use of medicines in prisons 
are:  

    
  
  
  
  
  
  
  
  
   
   
  
   
  
  
 •  HM  Inspectorate  of  Prisons  Expectations.  These  describe  the  living  environment 
expectations which include safe storage facilities (lockable cupboards) for prisoners 
to  store  their  personal  possessions  including  medicines.  They  also  set  out  the 
importance  of  rehabilitation  and  the  need  for  prisoners  to  take  responsibility  for 
meeting  their  own  needs.  This  underpins  the  policy  to  provide  medicines  in-
possession so that prisoners continue to manage their health and wellbeing whilst in 
prison,  enabling  them  to  continue  to  do  so  on  release.  Specific  measures  for  in-
possession  medicines  are  also  included  making  it  clear  that,  subject  to  a  regularly 
reviewed in-possession risk assessment, patients can store their medicines securely 
and self-administer them.   

•  The  Royal  Pharmaceutical  Society’s  professional  standards  for  the  optimisation  of 
medicines  in  secure  environments.    These  set  out  standards  for  medicines 
management for prisoners on admission, during their stay and on release.   

I recognise that that there is a difficult balance to be had between allowing prisoners to look 
after their own prescription medicines (as they would in the community) and mitigating the 
risk of the illicit diversion of these medicines within a prison environment for all the reasons 
you set out in your report.  

Procedures  and  governance  around  the  management  of  prescription  medicines  will  vary 
between  different  prison  categories  and  local  risks  and  incidents.  Various  processes  are 
used  to  inform  medicines  use  and  safety  in  each  prison  including  security  and  clinical 
incident  management  and  review;  in-cell  searches  and  clinical  therapeutic  or  substance 
misuse testing. National guidance could further complicate what is already a complex issue 
for both prisoners and prison staff.  

Instead, NHS service commissioners use contractual monitoring, outcomes from regulatory 
inspections and regional governance to provide assurance that the standards and guidance 
are being delivered.  

In the light of any serious incidents or fatalities attributed to medicines use and safety, NHS 
England  has  assured  me  that  it  proactively  shares  and  uses  the  learning  from  these  to 
remind  stakeholders  of  the  standards  and  expectation  for  safe practice  and  to  inform  the 
review of local policies.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.    

Yours sincerely,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
WOMEN’S HEALTH AND MENTAL HEALTH

Governor
HMP Guys Marsh
Shaftesbury
Dorset
SP7 0AH

HMP Guys Marsh 

Senior Coroner Rachael Clare Griffin 
Dorset Coroners’ Service 
Civic Centre 
Bourne Avenue 
Bournemouth 
BH2 6DY 

                             REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

                                                    MR SHELDON JEANS  

Dear Ms Griffin. 

Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death  
of Mr Sheldon Jeans at HMP Guys Marsh, which was sent to the Secretary of State for Health  
and Social Care, Chief Executive at Oxleas NHS Foundation Trust, Minister of State for  
Prisons, Probation and Reducing Reoffending and myself, 
HMP Guys Marsh. 

, Governing Governor at 

In the first instance, I would like to express my condolences the family of Sheldon Jeans for their 
loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.  

I am responding directly, to provide assurances that local actions and commitments agreed have 
been formally introduced where applicable.  

The management of illicitly brewed alcohol (IBA): 

The Drug and Alcohol Group (DAG) in HMPPS has developed and disseminated a range of 
materials specifically focused on IBA. Notably, the Drugs in Prison and Probation (DiPP) guide  
provides comprehensive information for staff at all levels — from frontline officers to heads of 
function. 

The material is designed to enhance understanding of substances, support structured discussions, 
raise awareness, and assist with induction processes for new staff.  

Harm reduction support for alcohol use is growing, with mutual aid groups like Alcoholics 
Anonymous playing a key role. 

In addition, we have further developed our Incentivised Substance Free Living (ISFL) unit here at 
HMP Guys Marsh. This specialised unit offers a supportive environment for individuals to address 
both alcohol and drug-related issues.  

As part of wider awareness efforts, we are aware that the National Prison Radio initiative is being 
recommissioned to feature speakers with lived experience of alcohol-related harm, helping to 
highlight the impact of illicit substance use and promote the support available.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In response to seasonal increases in IBA reported usage, the DAG issued a targeted briefing note 
outlining specific risks, indicators of IBA production, and guidance on effective operational 
responses. These materials have been shared with the Drug Strategy Lead here at HMP Guys 
Marsh to support local awareness-raising, harm reduction initiatives, and inform our decision-
making.  

We have also implemented a series of targeted local measures to mitigate the risks of IBA. 

A comprehensive Local Operating Procedure (LOP) has been introduced, to guide staff in 
managing incidents involving prisoners found under the influence, including those affected by IBA.  

Searching operations continue with a specific focus on identifying and safely removing IBA, which 
is subsequently reported and destroyed by the Security Department when discovered.  

To strengthen these efforts, the regional Dedicated Searching Team (DST) is regularly deployed to 
support intelligence-led searches where IBA is a priority concern.  

In addition, preventative steps have been taken to limit the availability of ingredients commonly 
used in brewing IBA. Yeast-based items have been removed from the canteen list, and fruit and 
natural sugar-based products have been restricted. These measures aim to reduce the opportunity 
for prisoners to produce IBA.  

Medication – In possession: 

The handling of medication held in possession (IP) by prisoners and prescribing practices in 
prisons are the responsibility of NHS England. Here at HMP Guys Marsh, our commissioned 
partner is Oxleas NHS Foundation Trust. 

The safe management of medication is governed by clinical guidance and national service 
specifications, which set out standards for prescribing, dispensing, and monitoring medication.  

In addition, in cell medication safes are available and we have renewed our focus on ensuring 
these are available and fit-for-purpose where utilised. 

Oxleas operate Medicines Management Committees, and I (Or delegated authority in my absence) 
attends these meetings to ensure collaborative oversight.  

Decisions about which medications are issued to prisoners, including those held in possession, are 
made by healthcare professionals following a comprehensive risk assessment of both the 
medication and the individual.  

Locally, at HMP Guys Marsh, non-tradeable medications may be issued as IP on a case-by-case 
basis, subject to a formal risk assessment conducted by healthcare staff. The provision of IP 
medication is designed to support independent living and prepare prisoners for reintegration into 
the community.  

Prisoners receiving IP medication must sign a compact agreeing to the safe storage and use of 
their medication, including the use of in-cell lockers. Breaches of this compact will result in the 
removal of IP medication.  

Oxleas NHS Foundation Trust, has committed to introducing regular assurance checks for all 
prisoners in receipt of IP medication, as agreed at the Local Quality Delivery Board in August 2025.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Thank you again for bringing your concerns to our attention.  

I trust that this response provides assurance that action is being taken to address the matters 
identified.  
Yours sincerely, 

Governor  
14/10/2025

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

Senior Coroner Rachael Clare Griffin   
Dorset Coroners’ Service 
Civic Centre  
Bourne Avenue  
Bournemouth 
BH2 6DY 

 22 August 2025  

Dear Ms Griffin 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR SHELDON JEANS 

Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death 
of Sheldon Jeans at HMP Guys Marsh, which was sent to the Secretary of State for Health 
and Social Care, Chief Executive at Oxleas NHS Foundation Trust, Minister of State for 
Prisons, Probation and Reducing Reoffending and the Governing Governor at HMP Guys 
Marsh. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as 
Director General of Operations. 

I know that you will share a copy of this response with Mr Jeans’ family, and I would firstly 
like to express my condolences for their loss. Every death in custody is a tragedy and the 
safety of those in our care is my absolute priority. 

Following evidence heard at the inquest, you have raised concerns regarding the national 
policy and local guidance at HMP Guys Marsh of the management of illicitly brewed alcohol 
and the handling of medication held in possession by prisoners.  

Regarding the management of illicitly brewed alcohol, the Drug and Alcohol Group (DAG) in 
HMPPS has developed and disseminated a range of materials specifically focused on illicitly 
brewed alcohol (IBA). Notably, the Drugs in Prison and Probation (DiPP) guide provides 
comprehensive information for staff at all levels—from frontline officers to heads of function. It 
is designed to enhance understanding of substances, support structured discussions, raise 
awareness, and assist with induction processes for new staff.  
Harm reduction support for alcohol use is growing across the prison estate, with mutual aid 
groups like Alcoholics Anonymous playing a key role. In addition, Incentivised Substance 
Free Living (ISFL) units are now available in 85 prisons, including at HMP Guys Marsh, 

 
 
 
 
 
 
 
 
 
 
 
 offering a supportive environment for individuals to address both alcohol and drug-related 
issues. As part of wider awareness efforts, Prison Radio is being recommissioned to feature 
speakers with lived experience of alcohol-related harm, helping to highlight the impact of 
substance use and promote the support available.  

In response to seasonal increases in IBA reported usage, the DAG issued a targeted briefing 
note outlining specific risks, indicators of IBA production, and guidance on effective 
operational responses. These materials have been shared with Drug Strategy Leads across 
the prison estate to support local awareness-raising, harm reduction initiatives, and inform 
decision-making.  

Operational colleagues are encouraged to remain vigilant regarding the ingredients and 
equipment commonly used in the production of IBA. Volumetric control is promoted as a key 
preventative measure during cell searches and wider area inspections, ensuring that 
ingredients and implements commonly used in the production of IBA are restricted to 
approved quantities.  

In addition to DAG’s workstreams, the Risk and Capabilities Unit (RaCU) provides 
operational guidance on managing IBA-related risks. This includes reviewing canteen items 
accessible to prisoners, identifying vulnerable areas, and reinforcing the importance of 
volumetric control.  

Locally, HMP Guys Marsh has implemented a series of targeted local measures to mitigate 
the risks of IBA. A comprehensive Local Operating Procedure (LOP) has been introduced to 
guide staff in managing incidents involving prisoners found under the influence, including 
those affected by IBA. Searching operations continue with a specific focus on identifying and 
safely removing IBA, which must be reported and destroyed by the Security Department. To 
strengthen these efforts, the Dedicated Searching Team is deployed to support intelligence-
led searches where IBA is a priority concern.  

In addition, preventative steps have been taken to limit the availability of ingredients 
commonly used in brewing IBA. Yeast-based items have been removed from the canteen list, 
and fruit and natural sugar-based products have been restricted. These measures aim to 
reduce the opportunity for prisoners to produce IBA.  

The handling of medication held in possession (IP) by prisoners and prescribing practices in 
prisons are the responsibility of NHS England. The safe management of medication is 
governed by clinical guidance and national service specifications, which set out standards for 
prescribing, dispensing, and monitoring medication.  

In addition, in cell medication safes are available on the National Prison Industries Product 
List and every prison is able to order them. 

 
 
 
 
 
 
 
 
 Healthcare providers are required to operate Medicines Management Committees, and 
prison governors are invited to attend these meetings to ensure collaborative oversight. 
Decisions about which medications are issued to prisoners, including those held in 
possession, are made by healthcare professionals following a comprehensive risk 
assessment of both the medication and the individual. 

Locally, at HMP Guys Marsh, non-tradeable medications may be issued as IP on a case-by-
case basis, subject to a formal risk assessment conducted by healthcare staff. The provision 
of IP medication is designed to support independent living and prepare prisoners for 
reintegration into the community. Prisoners receiving IP medication must sign a compact 
agreeing to the safe storage and use of their medication, including the use of in-cell lockers. 
Breaches of this compact will result in the removal of IP medication.  

The healthcare provider at HMP Guys Marsh, Oxleas NHS Foundation Trust, has committed 
to introducing regular assurance checks for all prisoners in receipt of IP medication, as 
agreed at the Local Quality Delivery Board in August 2025.  

Additionally, in-cell lockers will be replaced if damaged and their condition will be monitored 
through daily Accommodation Fabric Checks across all residential units. 

Thank you again for bringing your concerns to my attention. I trust that this response 
provides assurance that action is being taken to address the matters identified. 

Yours sincerely, 

Director General of Operations

Oxleas NHS Foundation Trust 

Pinewood House  
Pinewood Place 
Dartford 
DA2 7WG  

oxleas.nhs.uk 

21 August 2025 

Ms. Rachael C. Griffin  
Coroner for the County of Dorset 
Civic Centre 
Bourne Avenue 
Bournemouth 
BH2 6DY 

Dear Ms. Griffin, 

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS  

Please find our response to the Regulation 28 Report to Prevent Future Deaths following the 
inquest touching the death of Mr. Sheldon Lawrence Jeans, who died on 13 November 2022 
at HMP Guys Marsh. The matters of concern are outlined and responded to.  

The matters of concern are as follows: 

(1)  There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform 
staff working in prisons of the dangers of illicitly brewed alcohol, also known as 
hooch. There is also a lack of policy and guidance to assist those working within the 
prisoner estate with the management and governance of the access to, and use of, 
illicitly brewed alcohol. Illicitly brewed alcohol is a common substance across the 
prisoner estate.  

(2)   Prisoners can have access to certain medication to hold in their possession which 

could be accessed by other prisoners and there is a lack of national policy, and local 
policy at HMP Guys Marsh, from a healthcare and prison perspective, around the 
governance of medication held in possession in the prison estate.  

There are many ways in which alcohol can be illicitly brewed in the prison setting. It is 
known that certain prescribed medications could be used to assist in the fermenting process 
and, where possible, we have already removed these from the prescribing formulary or 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 ensure that they are only provided on a supervised (not-in-possession) basis and are 
consumed at the medication hatch to minimise the risk of diversion.  There is no national 
NHS policy to assist those working within the prisoner estate with the management and 
governance of the access to, and use of, illicitly brewed alcohol.  Change, Grow, Live (CGL) 
our psychosocial substance misuse provider, deliver the following in relation to the use of 
alcohol with our prison population:  

•  Alcohol workshops and associated workbooks 
•  Harm reduction sessions, information and resources – including hooch specific 

information. 

•  Specific training for staff – recently delivered at HMP Guys Marsh 
•  Welfare checks/brief interventions for anyone suspected to have been under the 

influence of hooch/other alcohol 

•  Assessments, reviews and personalised recovery planning – including use of 

motivational interviewing techniques 

•  Access to recovery programmes and mutual aid 

We acknowledge the concerns raised regarding the governance and safety of in-possession 
medication at HMP Guys Marsh and more broadly across the prison estate. The wellbeing of 
individuals in custody remains our top priority, and we are committed to ensuring that 
medication management practices are both safe and supportive of rehabilitation. 

The practice of allowing prisoners to hold certain medications in-possession is designed to 
promote personal responsibility and mirror community standards. This approach supports 
individuals in preparing for release and reintegration with the community and aligns with 
the principle of equivalence of care. It is also in line with a variety of nationally applicable 
guidance. https://www.rpharms.com/recognition/setting-professional-
standards/optimising-medicines-in-secure-environments. 

Before any medication is issued in-possession, a comprehensive risk assessment is 
undertaken to evaluate both the medication(s) and the individual’s suitability. This risk 
assessment can be updated / changed at any time but particularly in the event of a change 
of an individual’s circumstances. 

As people arrive in prison, they are required to sign a Compact that clearly outlines their 
responsibilities regarding the safe storage, use, and return of prescribed medication. While 
patients are requested to return any unused or discontinued medication to healthcare, we 
recognise that mandating this process is operationally challenging and relies heavily on 
individual compliance and would require assistance of the Prison Service. 

It should be highlighted that in addition to prescribed medication, prisoners are entitled to 
purchase a limited number of low-risk medications through the prison canteen. However, 
healthcare remains the preferred route for people to access medication, as it is more cost-
effective and provides clinical oversight. 

Healthcare teams conduct intelligence-led and random in-possession checks to monitor 
compliance and safety. Nonetheless, the overall security of the prison environment, 

 
 
 
 
 
 
 
 
 including the safeguarding of medication, is the responsibility of His Majesty’s Prison and 
Probation Service (HMPPS). We work closely with HMPPS to ensure that security protocols 
are upheld and adapted as needed. This also includes the supervision of not-in-possession 
medication provided by Prison staff at the medication hatches. 

To further support safe medication practices, we will be developing and distributing new 
health promotion materials to the prison population at HMP Guys Marsh, but also within 
the wider Oxleas NHS Foundation Trust prison portfolio. These materials will focus on: 

•  Safe storage of prescribed medication, including the use of personal lockable safes – 

responsibility of HMPPS. 

•  Proper disposal of unused or discontinued medication. 

There is no national policy around the governance of medication held in possession in the 
prison estate.  Attached is our recently published local In-possession Medication 
Compliance procedure which outlines bi-monthly in-cell compliance checks for patients on 
in-possession medication. This process, which is led by pharmacy staff with HMPPS support, 
checks to ensure medication adherence, prevent diversion, and upholds the safety of 
medication.  Any discrepancies would trigger a review, disciplinary action, or changes to in-
possession status. Documentation is maintained via SystmOne.  If required, formal 
notification letters are sent to the patients. The procedure aligns with NICE and Royal 
Pharmaceutical Society guidelines. Oversight is shared between pharmacy, wider healthcare 
and HMPPS teams and ensures that there are robust assurance mechanisms in place.    

Our shared goal is to ensure that all individuals in custody are supported in managing their 
health safely and responsibly. 

Yours sincerely 

Chief Executive Officer 

Cc

 Service Director Forensic & Offender Healthcare Services