Peter Campbell

Coroner ME Hassell 
Senior Coroner for Inner North 
London 
St Pancras Coroner’s Court 
Camley Street 
London 
N1C 4PP 

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

11 May 2026

Dear Ms Hassell, 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR PETER CAMPBELL 

Thank you for your Regulation 28 report of 11 March 2026 following the inquest into the 
death of Peter Campbell at HMP Pentonville on 8 October 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 Campbell’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 taken to prohibit the conveyance of drugs 
into prisons. 

HMPPS is committed to tackling the ingress of drugs and other contraband into prisons, 
which I recognise can cause serious harm, fuel violence, create instability, and 
undermine rehabilitation in prisons.  As prison security threats constantly evolve, we 
continuously shift and adapt our security measures to ensure we keep pace with 
changing threats. 

We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into 
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, dedicated 
search teams are in place to find and remove illicit items. They are equipped with specialist 

 
 
 
 
 
 
 
 
 
 
 
 
 
 tools to detect and retrieve mobile phones, which we know are used to facilitate drug 
conveyance and dealing within the estate.   

HMPPS recognises that the vast majority of prison staff are hardworking and dedicated, but 
unfortunately a very small minority engage in corrupt activity, including the conveyance of 
drugs into prisons. To prevent and deter staff from engaging in this, we have a dedicated 
counter corruption unit, which provides training, support and guidance to staff, as well as 
pursuing those who engage in this kind of criminality. Outcomes for staff found guilty of 
corruption can range from dismissal through to criminal prosecution. To support this work, 54 
priority establishments have airport-style enhanced gate security, including archway metal 
detectors, handheld wands, and X-ray baggage scanners, to screen staff and visitors.  

Another identified route of entry is through the use of drones. HMPPS works hard to 
deter, detect and disrupt the illegal use of drones that target our establishments. Whilst 
we cannot share specific details on our counter-drone measures as doing so would aid 
serious and organised criminals, I can confirm that our approach to this multi-faceted. We 
have invested over £40m in physical security measures across 34 prisons, including 
£10m on counter-drone measures, such as window replacements, external window grilles 
and specialist netting. 

HMPPS works closely with law enforcement agencies to tackle the issue of drones, which 
has already resulted in over 200 arrests linked to their use and has disrupted the activity 
of serious and organised crime networks. All closed prisons and young offender 
institutions have a 400-metre restricted fly zone in place which make all unauthorised 
drone incursions a crime. Additionally, we have developed comprehensive guidance and 
are upskilling staff to improve the response to drone activity at our prisons. HMPPS also 
conducts vulnerability assessments across the estate to understand the risk and to 
develop and implement plans to mitigate the threat. 

The holistic work between HMPPS and law enforcement agencies also applies to tackling 
the threat of serious and organised crime. Our area intelligence units play a critical role in 
gathering and analysing intelligence on serious and organised crime within prisons and 
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. 

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

Ms ME Hassell 

Senior Coroner 

Inner North London 

St Pancras Coroner’s Court 

Camley Street 

London 

N1C 4PP 

1st May 2026 

Dear Senior Coroner Hassell, 

Prevention  of  future  deaths  report  following  the  inquest  into  the  death  of  Peter 
Campbell (died 8 October 2024) 

I refer to the Regulation 28, Prevention of Future Deaths report (“PFD report”) report, dated 
11  March  2026,  sent  by  you  following  the  inquest  into  the  death  of  Mr  Campbell  at  HMP 
Pentonville.  The  PFD  report  was  sent  to  the  Chief  Executive,  HM  Prison  and  Probation 
Service (HMPPS) Ministry of Justice, Governing Governor at HM Prison Pentonville, the Chief 
Executive at Practice Plus Group (PPG) and myself, Chief Executive at Phoenix Futures. 

In the first instance, we would again like to offer our sincere condolences to Mr Campbell’s 
family. Every death in custody is a tragedy, and we remain committed to supporting people 
accessing services in ways that help prevent circumstances such as those that led to Mr 
Campbell’s passing. 

Phoenix Futures is a charity dedicated to supporting people with a wide range of challenges. 
This commitment underpins all aspects of our work. Phoenix Futures operates in partnership 
with other agencies, both within prison settings and in the community. 

A supplementary statement from the Service Manager was submitted during the inquest that 
captured  many  of  the  issues  raised  in  the  report.  As  a  learning  organisation,  we  remain 
committed to reflecting further on the concerns identified in the PFD report. 

The PFD highlighted the following points (summarised): 

Concern  one:  Failure  to  review  SystmOne  records  in  advance  of  providing  harm 
minimisation advice 

SystmOne is the healthcare record system used by both PPG and Phoenix Futures at HMP 
Pentonville. Recovery Workers joining Phoenix Futures receive SystmOne training from their 
line manager during their first week, supported further through shadowing with experienced 
colleagues. Additional guidance is also provided in the Recovery Worker Handbook. 

 
 
 
 
 
 
 Working alongside experienced colleagues provides new colleagues with practical support 
in  navigating  systems  such  as  SystmOne.  Phoenix  Futures  staff  also  have  access  to  an  IT 
support line if needed. 

Our process was, and remains, that wherever possible staff check SystmOne records before 
supporting people accessing services. There are occasions where records cannot be viewed 
by way of example where prison officers ask a Recovery Worker to review another person 
or if they require urgent support.  In other words, there are circumstances where, because 
of the urgency of a request, it is not possible to consult the records. 

As soon as the above concern was raised by the Learned Coroner, we immediately reminded 
all Recovery Workers to check SystmOne before visiting people accessing services to ensure 
they  are  aware  of  any  recent  incidents  or  changes  in  care  needs.  This  reminder  will  be 
reinforced during upcoming team meetings and will continue to be communicated every six 
months and, supported through supervision as per our protocol.  

As outlined above, there will, however, be occasions when a Recovery Worker cannot review 
SystmOne beforehand. 

Concern two: Conducting the consultation through the cell door, in the presence of a 
cellmate. 

Concern three: Having meaningful conversation regarding substance misuse, including 
attempts at persuasion. 

Phoenix Futures is committed to continuous learning and to developing best practice that 
safeguards the wellbeing of both people who access services and our colleagues. Whether a 
cell door is opened is not a decision that Phoenix Futures make, Phoenix Futures are not 
permitted to carry cell keys. Additionally, within the prison environment it is commonplace 
for  a  variety  of  disciplines;  Chaplin,  Iman,  Education  and  civilians,  to speak  to  prisoners 
through their door.  

Before offering any guidance or support to a person accessing services, an assessment of 
risk  must  be  carried  out.  If  that  person  appears  to  be  under  the  influence,  the  prison 
guidelines dictate that the cell door will not be opened furthermore Recovery Workers are 
not expected to place themselves in situations that could compromise their safety. We also 
recognise  that  many  of  our  colleagues  are  female,  and  this  must  be  factored  into  any 
assessment of risk. 

Substance  use  within  a  prison  environment  is  complex,  and  every  person  presents 
differently. As such, Phoenix Futures relies on Recovery Workers to complete a dynamic, 
multifactorial risk assessment that considers both the needs of the service user and their 
own personal safety.  

In response to the Coroner’s concern and within the regime of the prison, the importance 
of these points will be reinforced in team meetings.  

There  will  be  occasions  when,  for  the  safety  of  staff,  consultations  must  be  conducted 
through the cell door. This may occur when the prison regime does not permit cell doors to 
be opened or when staff determine, following a risk assessment, that it would not be safe 
to conduct the intervention otherwise 

 
 
 
 
 Mr  Campbell  was  seen  during  an  unscheduled  care  visit,  where  the  Recovery  Worker  is 
temporarily removed from their usual key-working duties to focus on supporting individuals 
who require more urgent harm-reduction advice. 

A new Recovery Worker does not join the unscheduled care rota until they have been signed 
off as competent to work independently. The timeframe for this can vary depending on the 
individual’s capability and previous experience but typically occurs within a few months. 

Unscheduled care is a vital part of Phoenix Futures’ service. It forms part of the immediate 
response when a person has taken a substance or following a code blue incident. It refers 
to immediate, unplanned intervention following suspected drug use or overdose. Its purpose 
is  to  provide  rapid  response  and  harm-reduction  advice,  often  bridging  gaps  between 
scheduled  treatment.  These  visits  may  be  undertaken  by  a  Recovery  worker  who  is  not 
previously known to the service user. 

The main focus during unscheduled care should be on providing essential harm-minimisation 
is  best  delivered  during  scheduled 
guidance,  while  more  comprehensive  advice 
appointments. Harm minimisation under pins all interactions and evidence shows that the 
brief harm minimisation interventions that explain the risk of drug use and how to minimise 
risks are persuasive in reducing harm. At certain points such as unscheduled care it should 
be a key focus, whilst during planned care, due to the structured nature, a broader range 
of interventions can also be employed. 

The above is provided by way of context, and to highlight the manner in which Unscheduled 
Care is provided by Phoenix Futures. 

Summary 

Phoenix Futures remains deeply saddened by the circumstances surrounding Mr Campbell’s 
passing. We have reflected, and continue to reflect, on the events leading up to his death.  

As outlined in the supplementary statement submitted during the inquest, Phoenix Futures 
not only promptly identified the necessary learning points and implemented changes where 
required. We hope these improvements provide strong assurance that the actions taken will 
be not only be implemented but will be sustained in the long term. 

We hope the above sets out the complex nature of assessments our colleagues undertake on 
a daily basis, and crucially that every individual person who accesses services is unique in 
their presentation. 

We  hope  that  this  response  gives  the  Coroner  assurance  that  these  matters  are  taken 
extremely  seriously  by  Phoenix  Futures  and  demonstrates  our  commitment  to  learn  and 
provide the best services possible.  

Yours Sincerely 

Chief Executive- Phoenix Futures

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 
REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 
2013 

Please do not include any living persons’ names in this document, in 
accordance with the Chief Coroner’s PFD Publication Policy (2026). 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, ME Hassell for the Coroner Area INNER NORTH LONDON in 
response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following 
an inquest into the death of Peter Campbell that concluded on 10 March 2026. 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, Practice Plus Group (PPG) provides this response within 
56 days (plus any extension granted) of the date of the Report to Prevent 
Future Deaths. 

2.  DATE OF RESPONSE 

6 MAY 2026 

3.  CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified in the report are as follows: 

For HMPPS and Pentonville 

In the narrative conclusion, the jury recorded a failure to prevent drugs from 
entering the prison. 

Every witness at inquest who expressed a view gave evidence that drugs are 
rife within Pentonville, as they are across the prison estate. They enter 
attached to drones and in throw overs; via prison officers, visitors and 
prisoners; and, to a lesser extent these days, in the post. Spice, a drug many 
times more potent and dangerous than cannabis, is impregnated onto pieces 
of paper so that it can be smoked. It has infiltrated the prison population with 
enormous reach and with potentially devastating consequences for the 
prisoners themselves and for others - there is a risk of prisoners leaving prison 
in a worse state than when they went in, a state that may of course be 

 
 
 
 
 reflected in violent reoffending. 

Initially, I was not going to include that failure within my prevention of future 
deaths report, because the availability of drugs in prison seems such a huge 
and intractable problem. However, on reflection it seems to me that it would be 
complacent to view the size of the problem as prohibitive. Perhaps the size of 
the problem dictates only the size of the solution required.  

At inquest, I heard about other aspects of the prison regime that were sub 
optimal, but it appeared that since Mr Campbell’s death, the staff at Pentonville 
had taken steps to address these. 

However, the mass availability of drugs apparently persists without abatement. 
This is not in any way peculiar to Pentonville, but Pentonville is an exemplar. 

 For Phoenix and PPG 

Mr Campbell collapsed in prison on 18 September 2024 as he had done 
before following the use of spice, and the prison and healthcare staff 
responded to this as an emergency code blue. The ambulance service was 
called and he was immediately conveyed to hospital where he was 
resuscitated. 

The jury found a failure by the prison drug service to provide a meaningful 
interaction with Mr Campbell between the collapse on 18 September 2024 and 
the fatal collapse on 3 October 2024. This was partly because a visit was not 
arranged promptly, a systemic issue that since seems to have been 
addressed. 

However, I also heard evidence that, when the Phoenix recovery worker did go 
to see Mr Campbell on 1 October 2024 in an attempt to promote harm 
minimisation: 

•  She did not read any part of his medical records before she saw him, 
and she did not know whether she was meant so to do. She was. 

•  She spoke to him through the hatch in the cell door, with his cellmate 

present. This was her normal practice, but she was not able to say why. 
It should not have been. 

•  She did not have any meaningful discussion with him about his drug 

use, either the use that led to his collapse on 18 September 2024 or his 
use generally. She should have. 

•  She gave him various pieces of harm minimisation guidance in keeping 
with her training, including the advice to avoid using drugs whilst alone. 
This advice was later confirmed as within policy by the Phoenix head of 
service. However, it does not seem to take account of the fact that 

 
 smoking a drug in a small cell with a cellmate puts the cellmate at risk. 

•  Mr Campbell told her that he was not under the influence at the time. 
The recovery worker was not wholly convinced, but she did not return 
later that day or the following day to see if better engagement was 
possible. She should have. 

•  She did not know whether her interaction with Mr Campbell was in 
accordance with her training. I was told that it was not. She had not 
received further training or changed her practice since his death. 

•  The drug recovery worker was the last healthcare worker to see Mr 

Campbell before his fatal collapse from drugs and did so just two days 
before that occurred. However, the gaps in her care of Mr Campbell 
were not identified by the investigation following his death by Phoenix 
and PPG (or by the Prisons and Probation Ombudsman). 

•  She had not changed her practice since Mr Campbell’s death, but any 
gaps in her care of other prisoners had also not been identified in the 
following year and a half, either by routine supervision or by audit. I 
heard that audits are undertaken of the medical records only. 

Therefore, the first time that Phoenix and PPG recognised a drug recovery 
worker’s failures to follow their procedures over at least a year and a half, was 
at the inquest 

3. 

DETAILS OF ACTION TAKEN, how has the concern been addressed. 
[If no action is proposed please explain why here]. 

Please note that any links to webpages included in the response will not be 
checked for sensitive information prior to publication, as the information is 
already online. 

We do not propose to respond to the points raised above in respect of HMPPS 
and HMP Pentonville as these matters are for separate organisations. 

Likewise, the points raised under the heading for Phoenix and PPG mainly 
relate to Phoenix Futures and the steps taken by one of their employees. 
Whilst we work closely with Phoenix as one of our subcontractors at 
Pentonville and work together to improve services and continue our strong 
working partnership, we do not propose to comment on their service or 
individual employees. We understand that Phoenix will be responding to the 
points raised separately. 

The latter 2 bullet points raised however, do touch upon PPG and our internal 
processes for post incident reviews. It is important to note, as identified by the 
learned Coroner, that the PPO investigation also did not identify the issues 
raised. Our internal process for learning reports are thorough and of great 
importance to us as an organisation. We carry out multiple reports into all 
deaths in custody in order to identify issues and areas of good practice, and to 
learn lessons and implement change where required.  

 
 As noted, we conduct a number of responses to any event where learning 
points may arise and this is always completed for any death in custody across 
all PPG establishments. Learning responses can include: 

•  Swarm Huddles – this is a rapid, informal team-based meeting held 
shortly after an incident to build a shared understanding of what 
happened, capture early learning and identify any immediate safety 
actions. 

•  Hot debrief – this takes place immediately after a clinical event to 
identify early learning points but also to support staff involved. 

•  Post-Incident Initial Review (PIIR) – this is a structured discussion 

conducted within 72 hours of an incident. It seeks to understand what 
happened and why, explore outcomes and promote learning. This 
involves staff directly. 

•  Clinical Case Review (CCR) – this is a structured multi-disciplinary 

discussion after an event to learn from both successes and failures. It 
explores the care provided, identifies any contributing factors, 
examines systems and gains a broader insight into any specific safety 
themes, pathways and/or processes. This investigation process aims to 
foster a culture of continuous improvement and sustainability of good 
practices. 

•  Patient Safety Incident Investigation (PSII) – this is a formal systems 
based investigation triggered by incidents that pose significant safety 
risks or have potential for further learning. This follows on from a PIIR 
and CCR where further review may be considered beneficial or 
necessary. 

•  Thematic Reviews – used to analyse a group of related incidents. 

•  Other investigations include; complaint reviews, HR matters and 

professional regulation reviews. 

For all deaths in custody a PIIR and CCR is completed, and a PSII is 
completed on occasion where deemed necessary by the patient safety team. 
There may be some exceptions where a CCR is not completed but this would 
only be where the death was expected and no issues arise from the PIIR, or 
post-release deaths, again where no issues arise out of the PIIR. These 
reports are thorough and include a multi-disciplinary approach. As will have 
been seen in the CCR for Peter Campbell this includes stakeholders from 
Phoenix Futures, BEH and HMPPS, as well as PPG managers and medical 
leads. A chronology of the care is reviewed and it identifies areas that went 
well and what could have been done better. Subcontractors and organisations 
which we work closely with are included to promote wider learning and obtain 
different perspectives which is vital to build a culture of good communication 
and collaboration within the establishments we operate. 

As part of the processes staff involved in the patient’s care are spoken to, 
interviewed or asked for statements so that their perspectives are taken into 
consideration. We will continue to seek the views of staff who had significant 
interactions with patients involved in a DIC or other incident, as well as those 
who may have been the last or latter interactions. 

We continue to work closely with Phoenix Futures, specifically at HMP 
Pentonville, and have a strong working relationship with them. They continue 
to provide a vital resource to patients at HMP Pentonville and we are provided 
with assurances regarding their services, staff and management. The review of 

 subcontractors such as Phoenix Futures is managed via Practice Plus Groups 
‘Standard Operating Procedure for management of Sub-Contracted Services’. 
This formalises a local, regional and national process that is adhered to by 
HMP Pentonville. Additional regional scrutiny will be implemented at HMP 
Pentonville for the following 6 months to ensure that the SOP is being 
implemented correctly and any issues arising from either organisation can be 
addressed quickly and effectively.  

In respect of investigations undertaken by PPG generally, the organisation has 
strengthened its governance arrangements to support more consistent and 
balanced decision-making regarding the appropriate level of investigation. A 
weekly national decision-making forum has been introduced to review medium 
to high-risk patient safety incidents and determine appropriate level of learning 
response i.e. whether a Patient Safety Incident Investigation (PSII) or other 
structured review methodology is required. 

In addition, senior clinical leaders now provide quality assurance and sign-off 
for all patient safety incident investigations to ensure appropriate clinical 
scrutiny, learning and response to incidents. 

4.  DETAILS OF FURTHER ACTION PROPOSED 

Please note that any links to webpages included in the response will not be 
checked for sensitive information prior to publication, as the information is 
already online. 

For additional resource about our incident response and patient safety team, 
please find the attached: 

•  Patient Safety Incident Response Plan PPG HIJ services 2025-2026 

•  PPG HIJ Patient Safety Governance Position Statement – March 2026 

SIGNATURE 

Medical Director

Position Statement

Development of Patient Safety Governance within Practice Plus Group Health in Justice
Services – March 2026

Practice Plus Group’s (PPG) Health in Justice (HiJ) directorate began implementing the Patient Safety
Incident Response Framework (PSIRF) in 2023 as one of the early adopters ahead of the national
requirement for providers to transition. Since the introduction of PSIRF, we have undertaken a
programme of work to embed the framework across our prison, immigration removal and non-
custodial health care services. This has involved developing governance structures, investigation
methodologies and learning processes designed to support proportionate responses to patient
safety incidents while ensuring that meaningful learning is identified and translated into
improvements in care.

In August 2025, PPG HiJ directorate further strengthened its patient safety governance
arrangements through the centralisation of the Patient Safety Team. The purpose of this change was
to improve organisational oversight of patient safety incidents across services, enhance the
consistency and quality of incident management and investigation, and strengthen the
organisation’s ability to identify emerging safety themes across multiple sites.

As PSIRF was embedded in practice and the organisation’s approach matured, internal review
indicated that the application of proportionality in some cases had tended toward the least intensive
investigation approach when decisions were taken at an individual level. While this reflected the
intention of PSIRF to avoid unnecessarily burdensome investigations, it was recognised that this
approach could risk limiting opportunities for deeper system learning and may not always provide
the level of analysis helpful to external processes such as coronial review.

In response, the organisation has strengthened its governance arrangements to support more
consistent and balanced decision-making regarding the appropriate level of investigation. A weekly
national decision-making forum has been introduced to review medium to high-risk patient safety
incidents and determine appropriate level of learning response i.e., whether a Patient Safety
Incident Investigation (PSII) or other structured review methodology is required.

In addition, senior clinical leaders now provide quality assurance and sign-off for all patient safety
incident investigations to ensure appropriate clinical scrutiny, learning and response to incidents.

The organisation has also introduced a centralised process to cross-reference learning from external
review mechanisms, including Prisons and Probation Ombudsman investigations and independent
clinical reviewer reports, ensuring that learning identified through external processes is considered
alongside internal incident reviews.

The centralisation of the Patient Safety Team has enabled a more structured approach to reviewing
learning from individual patient safety incidents and identifying emerging themes across services.
Learning identified through incident reviews is now considered through strengthened national

 governance forums, including Patient Safety Incident Response Group and National Quality
Assurance governance structures.

In addition, we are prioritising improvements in the quality and consistency of patient safety
investigations and reporting. Training, guidance and support are being provided to staff involved in
investigations to strengthen capability in systems-based investigation methodologies and improve
the clarity and quality of investigation reports.

As part of strengthening governance arrangements, we also established a HiJ Triage Professional
Decisions Panel (PDP) in early 2025. The PDP provides multidisciplinary oversight and guidance
where concerns arise relating to professional practice or fitness to practise. The panel enables cases
to be reviewed holistically with senior clinical input and supports proportionate and consistent
decision-making regarding professional conduct concerns.

The PDP operates alongside the organisation’s patient safety governance arrangements and is
closely connected. Where concerns relating to professional practice arise during the review of
patient safety incidents, these may be escalated to the PDP for further consideration. Similarly,
matters considered within the PDP may highlight wider system risks or learning which are then
reviewed through the Patient Safety Team’s governance processes.

PPG recognises that PSIRF learning responses and coronial investigations serve different but
complementary purposes. PSIRF focuses on organisational learning and improvement through
systems-based review, while coronial processes seek to establish the circumstances surrounding an
individual death, including matters relating to causation.

In line with guidance issued by NHS England and the Chief Coroner in early 2026, PPG aims to ensure
that its patient safety investigation processes support organisational learning while also providing
clear factual information and context where required to assist coronial processes.

These developments form part of an ongoing programme of work to strengthen patient safety
governance within our HiJ services and to ensure that incident responses are consistent,
proportionate and focused on identifying meaningful system learning. The organisation will continue
to review and strengthen its patient safety processes to support safer care for patients across all HiJ
settings.

Deputy Director of Nursing and Quality

5th March 2026