Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0610, written 8 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2025 |
|---|---|
| Reference | 2025-0610 |
| Deceased | Oliver Mulangala |
| Coroner | Jonathan Stevens |
| Coroner area | Surrey |
| Category | State Custody related deaths · Alcohol, drug and medication related deaths |
| Organisation named | West London NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Justice, Ministry of Justice, 102 Petty France, Westminster, London, SW1H 9AJ 2. The Minister of State for Prisons, Parole and Probation, 102 Petty France, Westminster, London, SW1H 9AJ 3. The Governor, HMP High Down, High Down Lane, Sutton, SM2 5PJ 1 CORONER I am Jonathan Stevens, Assistant Coroner, for the coroner area of SURREY 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 25th July 2024 Susan Ridge, Assistant Coroner, commenced an investigation into the death of OLIVER MULANGALA (aged 40). The investigation concluded at the end of an 8-day inquest before a jury on 26th November 2025. The conclusion of the inquest was: Drug related death The jury found, inter alia, that: “There was a prevalence of illegal Contributed to by the lack of resources including equipment and staff” within High Down Prison. Medical cause of death was found to be: 1 (a) Respiratory failure (b) Epileptic tonic-clonic seizure (c) ) toxicity 2 Tongue laceration associated blood loss; epilepsy 4 CIRCUMSTANCES OF THE DEATH Oliver Mulangala was taken into custody at HMP Wormwood Scrubs on 7th December 2022, and was transferred to HMP High Down on 5th June 2024. He had a history of substance misuse in the community and in prison. Mr Mulangala suffered from epilepsy and between May 2023 and November 2023 Mr Mulangala had a series of life-threatening seizures, requiring emergency hospital admission by ambulance and into ITU on a number of occasions, with him being in a Coma (on one admission). Based on the history of having taken prior to the onset of these serious seizures, he was diagnosed with drug ( the possible exception of the last admission. induced seizures, with A court appointed expert consultant neurologist told the court that triggering and seizure inducing’ and that taking makes death more likely. whilst suffering from epilepsy is ‘highly Mr Mulangala admitted to taking sleep. He accepted that his drug taking had induced seizures. Mr Mulangala was clearly concerned as to the severity of these life-threatening drug induced seizures and resolved to stop taking , and indeed there was no evidence that he had taken any illicit drugs in prison from 4th November 2023 until the morning of 13th July 2024 when he was found dead in his cell. to try and help him Mr Mulangala had died from a induced seizure. 5 CORONER’S CONCERNS HM Chief Inspector of Prisons produced a report in October 2023 following the unannounced inspection of HMP High Down from 13th July to 17th August 2023. In that report he reported as one of his priority concerns: “The availability and use of illicit drugs posed a threat to the stability of the prison, contributing to debt, bullying and fear. The positive drug testing rate at HMP High Down was among the highest in adult male prisons” HM Chief Inspector of Prisons produced a report in June 2024 following an inspection of HMP High Down from 3rd to 5th May 2024. In that report he reported: “The availability of illicit substances continued to be a serious concern that undermined safety and stability. The rate of positive drug tests remained as high as at our full inspection in 2023” During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- During the inquest the court heard evidence of the extent which ) are easily available to prisoners at HMP High Down. Prisoner A ( ) provided evidence that: “It’s probably easier to get some prisoners may get coerced and groomed into taking it and running up debts” or a mobile phone in here than it is to get sugar. I think Prison Officer B ( ) told the court: is a daily occurrence, it’s too much to handle…some batches are bad and they “ can then be violent” Prison Officer C ( ) told the court: “(They) can get it ( nearly every day when someone is found under the influence of NPS (New psychoactive substances). came into the prison there’s incidents ) so easily…since Prison Officer C told the court that he thought the problem of remained the same as it was in 2024. He also explained that prisoners were able to get possession of smart phones (even though they are not allowed to have them), and that having access to smart phones enabled prisoners to arrange for contraband to be delivered into prison, threaten and coerce, communicate across different prisons, and take and share video footage within the prison. within the prison He said: “If they have access to a phone it makes it easier for them to obtain drugs” He explained that when a new batch of another prisoner, effectively as a ‘guinea pig’, to see what the effect of the new batch is. He said that is in every prison but was a particular issue for HMP High Down. comes into prison, prisoners can pick on Prison Officer D ( had not changed since 2024. ) told the court that the problem with in the prison from the Forward Trust substance misuse service told the Witness E ( court from her experience in working within HM High Down from September 2023 to March 2025 that there are cases where a prisoner with no history of drug misuse in the community, has developed a drug habit whilst in prison. She told the court that there were cases where prisoners have been threatened or coerced into taking drugs in prison. She confirmed that she was aware of cases where prisoners are forced to be guinea pigs to test the potency of new batches of psychoactive substances. Witness F ( 2025 the mandatory drug testing showed a more positive picture than previously but accepted that drug testing indicated that in some months 25% of the prison population were testing positive for drugs, and it was difficult to measure the amount of drugs getting into the prison. She stated that the invisible drug” and it is lucrative for organised criminal gangs to supply drugs into prison. She explained that there were various ways drugs are understood to get into prison, including via drones, and gave the court a wish list of things she would like to have to help deal with the challenge of was “…so easy to convey into prison – it’s ) told the court that in in the prison. Witness G ( drugs are still readily available in HMP High Down, and that if the level of drugs remains at the same level it is only a matter of time before another prisoner dies at HMP High Down due access to illegal drugs. He accepted that the level of drugs in the prison increased the levels of violence and increased the level of risk to staff and prisoners. He accepted that the fact that prisoners were able to access smart phones assisted them in getting access to drugs. ) accepted that Witness H ( are used to deliver illegal items within prisons and, when used in conjunction with prisoners having access to mobile phones, are used with a high degree of accuracy. He explained that ) told the court that are used to carry increasingly large loads which means larger amounts of drugs can be brought into prisons together with mobile phones and weapons (potentially including firearms), thus presenting a significant risk to safety and prison security. He advised that if the prisoners are stopped from having and using mobile phones, that will reduce the risk created by someone far away from the prison, even from another country, although someone would still need to be local to the prison to load the afterwards. beforehand and retrieve the could be piloted by explained that the explained that . defence technology exists to detect, track and identify The Ministry of Justice (‘MOJ’) were asked on a number of occasions to provide the court with data on the number drug-related deaths in prisons in the UK in order for the court to understand the magnitude of the issue created by drugs in prisons in the UK. The MOJ advised that they did not have this data. The Office of National Statistics recorded, however, that between 2008 and 2019 there were 145 drug-related deaths in UK prisons, which equates to an average of 13.2 pa over that 11-year period. The 6th Report of the House of Commons Justice Committee states that between December 2022 and December 2024 there were 136 drug-related deaths in UK prisons, which equates to 68 death per year in that 2-year period, in other words about one every 5 days. In HMP High Down there have been 4 drug-related death in the last 4 years: (i) (ii) (iii) (iv) 9.11.22 – Prisoner W (Jason Kennedy) 8.8.23 – Prisoner X (Amer Fareed) 13.7.24 – Prisoner Y (Oliver Mulangala) 21.9.25 – Prisoner Z (Jean-Yves Daniel) It is of grave concern that: (1) New psychoactive substances, especially , are easily available in HM Prison High Down, as in many other prisons in England & Wales a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison (2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales (3) The use of in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security a. b. facilitate the delivery of drugs into prison to precise locations at specified times can be used to bring in other contraband including weapons and even firearms c. The increasing sophistication of (and their increasing payload) increases the risks and dangers to life (4) The Ministry of Justice advised the court that it does not hold statistics on drug- related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure. The concerns that I have found in this case mirror many of the concerns raised by the Chief Inspector of Prisons in his Annual Report published on 8th July 2025 in which he stated that “I cannot overstate my concern about the rapid and widespread ingress of illicit drugs” and reported that far too little was being done to keep drugs out of prisons, too many prisoners said it was easy to get hold of drugs, the rate of positive random tests was too high and raised concerns about the use of . The concerns that I have found in this case also mirror many of the concerns raised by the 6th report of the House of Commons Justice Committee (published on 31st October 2025) who reported that: (1) There has been a widespread and recent increase in the availability of drugs across the adult prison estate (paragraph 12) (2) A significant number of prisoners in England & Wales develop a drug habit whilst in prison (paragraph 13) (3) There has been a significant influx of psychoactive substances into prisons. In the 12 months to March 2025 the number of finds of psychoactive substances increased by 45%. In the year ending March 2024 psychoactive substance finds increased by 86% (paragraph 14) (4) The widespread and increasing availability of illicit substances has fostered a culture of acceptance that normalises drug use in prisons (paragraph 15) (5) Official statistics on drug use in prisons are likely an underestimate, primarily because the testing technology has not kept pace with the constant evolution of psychoactive substances (paragraph 18) (6) The effects of are highly unpredictable and can be extreme including violence, psychosis and death (paragraph 32) (7) Drug-related death and exploitation are fundamental drivers of violence, coercion and systemic instability across the prison estate. Those in debt are routinely exploited and forced to test new drugs (paragraph 54) (8) Between December 2022 and December 2024 the Prison & Probation Ombudsman investigated 136 drug-related deaths, deaths that are a direct consequence of a prison drug supply that is both widespread and unregulated (paragraph 56) (9) have emerged as a growing and significant threat to prison security. in January 2025, and in February 2025 told the Committee that The Report noted that the Chief Inspector of Prisons called for urgent action to tackle “My biggest concern with drugs at the moment is the ingress of now seeing and other contraband directly to individual cells”. (paragraph 93) able to deliver bespoke packages of drugs, mobile phones …we are (10) Data on incidents published in July 2025 recorded a 43% increase in the incidents in prison in the 12 months to March 2025. There had number of been a 770% increase in drone sightings around prisons between 2019 and 2023 (paragraph 94) (11) are becoming increasingly sophisticated, capable of carrying larger packages of illicit items, up to 60kg (paragraph 95) (12) Both the Chief Inspector of Prisons and the Prison Probation Ombudsman have raised concerns about drones being used to deliver weapons, including firearms, into prison (paragraph 98) (13) The capability of to deliver not only large quantities of drugs and mobile phones, but also to deliver weapons with the potential for future delivery of firearms and explosives, is an extremely serious threat to the safety and security of prisons (paragraph 102) (14) Organised criminal gangs are involved in the conveyance and distribution of drugs in prison. The prison drug market is very lucrative and often run by organised criminal gangs (paragraph 106) (15) The access to external communication using a mobile phone allows prisoners and external networks to co-ordinate drug deliveries, manage supply chains and conduct financial transactions often using the dark web or encrypted services. A smart phone in prison is easily purchased at inflationary prices (paragraph 108) (16) Given that the organised crime group market is based on reliable means of communication and that sophisticated smart phones are readily available within prisons, eliminating external communications is the single most critical intervention to disrupt drug supply chain management, debt co-ordination and criminal operations (paragraph 111) The House of Commons report concluded as follows: “The ability of HMPPS to maintain safety and control, and offer effective rehabilitation, is being critically undermined because the trade and use of illicit drugs in our prisons has reached endemic levels. Fuelled by inflated profits, the supply of drugs by organised criminal gangs into prisons is a constant pressure; this is compounded by failures to address and reduce the underlying demand. The introduction of highly potent new psychoactive substances is driving alarming increases in violence, debt, and fatal overdoses, with the current testing regime failing to keep pace. Without urgent reform that addresses both the profitable supply networks and the discrepancies in treatment provision, the prisoner estate will remain unstable, unsafe and incapable of gaining control over the drugs crisis” Given the extent of the problems and the fact that England & Wales has the largest prison population of any country in Europe (86,888 as at 3.11.25) further loss of life due to drugs in prisons in England & Wales is not just a significant risk, it is (based on the latest available evidence) an inevitable weekly event. On 8th September 2023, in my capacity as HM Assistant Coroner for Hertfordshire, I issued a Prevention of Future Deaths Report following the inquest into the death of Kristopher Tilbury who died in September 2019 as a consequence of taking an inmate at HM Prison The Mount in Hertfordshire. whilst In that PFD I raised concerns about the high levels of prison, a series of drug death, and the significant risk of future deaths that existed because of the easy access to drugs in the prison. in the related deaths that had occurred since Mr Tilbury’s Notwithstanding that PFD issued on 8th September 2023, prisoners have continued to die in prisons in England & Wales due to easy access to illegal drugs, especially at a rate of over one a week. , Deaths in prison due to drugs will continue on a weekly basis until adequate and appropriate steps are taken to prevent these deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7th February 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (i) (ii) (iii) (iv) (Mr Mulangala’s brother) The Prison & Probation Ombudsman Central & North West London NHS Trust Forward Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 8th December 2025 Jonathan Stevens
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Jonathan Stevens Assistant Coroner for Surrey HM Coroner’s Court Station Approach Woking GU22 7AP Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 5 February 2026 Dear Mr Stevens, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR OLIVER MULANGALA Thank you for your Regulation 28 report of 8 December 2025 following the inquest into the death of Oliver Mulangala at HMP High Down on 19 January 2024. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS). I know that you will share a copy of this response with Mr Mulangala’s family, and I would first 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. You have raised concerns regarding the measures implemented to reduce the availability of illicit substances and mobile phones in prisons, the use of drones to convey illicit substances, and the statistical reporting of drug-related deaths within prisons in England and Wales. HMPPS is aware of the available routes for contraband, such as drugs and mobile phones, to enter prisons and how they are influenced by factors such as security measures, geographical location and prisoner cohort. Due to this, our approach to conveyance is multi- faceted. In the 2025/2026 financial year, HMPPS is investing over £40m in physical security measures across 34 prisons, including £10m on anti-drone measures, such as window replacements, external window grilles and specialist netting in over 15 priority prisons. HMPPS utilises multiple countermeasures and initiatives to tackle the conveyance of drugs and mobile phones into our prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, 54 priority establishments have airport-style enhanced gate security to screen staff and visitors, including archway metal detectors, handheld wands, and X-ray baggage scanners. HMPPS takes the threat of serious and organised crime incredibly seriously and we are working with other government departments to tackle organised criminals operating within the prison estate. The Crime in Prisons Taskforce has been established to work closely with the police and the Crown Prosecution Service to improve the amount of quality referrals made to the police and to increase prosecutions from crimes committed in prisons. The most serious crimes, including those where a mobile phone has been used to coordinate criminal activity or has been identified as belonging to a prisoner who is a high-risk offender, are also referred to the police in line with the Crime in Prisons Referral Agreement. Additionally, HMPPS works closely with other law enforcement agencies, including the National Crime Agency, through established tasking arrangements and intelligence sharing protocols. Our headquarters teams provide targeted support to the most at-risk prisons, ensuring that local security strategies are informed by national intelligence and operational priorities. As you have identified, one of the routes of entry for contraband is through the use of drones. HMPPS is committed to deterring, detecting and disrupting the illegal use of drones targeting prisons in England and Wales. Whilst we cannot share specific details on our counter-drone measures, as doing so would aid serious and organised criminals, please be assured that our approach is multi-faceted. This includes introducing physical security countermeasures, exploring technological developments, exploiting intelligence, strengthening legislation and working across government and with international partners on this global issue. We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat. I have received assurance from the Governor of HMP High Down that they will continue working with both regional and national Drug Strategy and Security teams and that a meeting is being arranged for Spring 2026 to discuss existing policies and practices aimed at tackling the conveyance of drugs, mobile phones, and the use of drones to assess what further actions can be taken to mitigate the risks. With regard to the reporting of deaths in custody, we publish Official Safety in Custody Statistics quarterly, but do not have a specific category of ‘drug-related’ in those statistics. For administrative and statistical purposes our classification is by apparent cause of death. This has evolved specifically to help place reliable numbers of deaths in prison custody in the public domain without undue delay, and we do not use the category of ‘drug- related’ in published statistics because it is difficult to identify such cases accurately within the timescale required for our publications. However, we do monitor such deaths closely and ensure that lessons are learned from them. All drug-related deaths are examined through our early learning review process, in which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the national Safety Group and Drug and Alcohol Group. And we study the outcomes of Prisons and Probation Ombudsman’s reports and inquests in these cases very carefully and take action to address any recommendations and matters of concern that are reported. In the published statistics deaths known to be drug-related are included either in the "self- inflicted: overdose" category or in the “other/non-natural” category, according to the circumstances of the case. However, the "other/non-natural" category also includes accidental deaths and the small proportion of deaths in which, even after all investigations have been concluded, the cause remains unknown, so it is not possible to derive a total figure for drug-related deaths. In order to provide more specific data about drug-related deaths we worked with the Office for National Statistics (ONS) on a 2023 publication which was produced by matching our deaths data with data from Coroner’s reports: Drug-related deaths and suicide in prison custody in England and Wales - Office for National Statistics. This showed that the risk of male prisoners dying from drug-related causes was similar to the general male population between 2008 and 2015, but was higher than the general male population between 2016 and 2019. Opiates were the most common drug type mentioned on death certificates, with methadone being the most common form. The second most common drug type was new psychoactive substances, which showed a particular increase in mentions between 2015 and 2019. There is inevitably a considerable time lag before more definitive statistics of this type can be produced: the decision was taken for the 2023 publication to stop at 2019 because at the time the Coroner’s data for later years was far from complete, reducing the quality of the results. We hope to collaborate with ONS again to provide a further version of this publication in the future. We also keep the contents of our Official Statistics under continuous review, to ensure their compliance with the three pillars of the Code of Practice for Statistics; trustworthiness, quality and value. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter. Yours sincerely, Interim Director General of Operations
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