Oliver Mulangala: Prevention of future deaths report

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

I am Jonathan Stevens, Assistant Coroner, for the coroner area of SURREY

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. 

On 25^th 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 26^th November 2025. 

The conclusion of the inquest was: Drug related death

The jury found, inter alia, that:
“There was a prevalence of illegal [REDACTED] within High Down Prison.
Contributed to by the lack of resources including equipment and staff” 

Medical cause of death was found to be:
1 (a) Respiratory failure 
  (b) Epileptic tonic-clonic seizure 
 (c) [REDACTED] toxicity
2 Tongue laceration associated blood loss; epilepsy

Oliver Mulangala was taken into custody at HMP Wormwood Scrubs on 7^th December 2022, and was transferred to HMP High Down on 5^th 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 [REDACTED] prior to the onset of these serious seizures, he was diagnosed with drug (the possible exception of the last admission.

A court appointed expert consultant neurologist told the court that [REDACTED] is ‘highly  triggering and seizure inducing’ and that taking [REDACTED] whilst suffering from epilepsy makes death more likely.   
 
Mr Mulangala admitted to taking [REDACTED] sleep. He accepted that his
[REDACTED]  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 [REDACTED], and indeed there was no evidence that he had taken any  illicit drugs in prison from 4^th November 2023 until the morning of 13^th July 2024 when he was found dead in his cell.    

Mr Mulangala had died from a [REDACTED] induced seizure.

HM Chief Inspector of Prisons produced a report in October 2023 following the  unannounced inspection of HMP High Down from 13^th July to 17^th 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 3^rd to 5^th 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 [REDACTED]  are easily available to prisoners at HMP High Down. 

Prisoner A ([REDACTED]) provided evidence that:
“It’s probably easier to get [REDACTED] or a mobile phone in here than it is to get sugar.  I think some prisoners may get coerced and groomed into taking it and running up debts” 

Prison Officer B ([REDACTED]) told the court:
“[REDACTED]  is a daily occurrence, it’s too much to handle…some batches are bad and they can then be violent” 

Prison Officer C ([REDACTED]) told the court: nearly every day when someone is found under the influence of NPS (New psychoactive substances). 

Prison Officer C told the court that he thought the problem of [REDACTED] within the prison 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. 

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 [REDACTED] comes into prison, prisoners can pick on another prisoner, effectively as a ‘guinea pig’, to see what the effect of the new batch is. He said that [REDACTED] is in every prison but was a particular issue for HMP High Down. 

Prison Officer D ([REDACTED]) told the court that the problem with [REDACTED] in the prison had not changed since 2024. 

Witness E ([REDACTED]  from the Forward Trust substance misuse service told the 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 ([REDACTED]) told the court that in  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 [REDACTED] was “…so easy to convey into prison – it’s 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 [REDACTED] in the prison. 

Witness G ([REDACTED]) accepted that 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. 

Witness H ([REDACTED]) told the court that are used to  [REDACTED]
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  [REDACTED]  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 [REDACTED] explained that the [REDACTED] could be piloted 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  beforehand and retrieve the afterwards. 

[REDACTED] explained that [REDACTED] defence technology exists to detect, track [REDACTED] 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 6^th 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)         9.11.22 – Prisoner W (Jason Kennedy) 
(ii)        8.8.23 – Prisoner X (Amer Fareed) 
(iii)       13.7.24 – Prisoner Y (Oliver Mulangala) 
(iv)       21.9.25 – Prisoner Z (Jean-Yves Daniel)

It is of grave concern that:
(1)  New psychoactive substances, especially [REDACTED] , 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 [REDACTED] in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security 

[REDACTED]  facilitate the delivery of drugs into prison to precise locations at
specified times 
[REDACTED]  can be used to bring in other contraband including weapons and
even firearms 
c.   The increasing sophistication of [REDACTED] (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 8^th 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 [REDACTED].   

The concerns that I have found in this case also mirror many of the concerns raised by the 6^th report of the House of Commons Justice Committee (published on 31^st 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 [REDACTED] 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)  [REDACTED] have emerged as a growing and significant threat to prison security.  
The Report noted that the Chief Inspector of Prisons called for urgent action to Tackle [REDACTED] in January 2025, and in February 2025 told the Committee that “My biggest concern with drugs at the moment is the ingress of [REDACTED]…we are now seeing [REDACTED] able to deliver bespoke packages of drugs, mobile phones and other contraband directly to individual cells”. (paragraph 93) 
(10) Data on [REDACTED] incidents published in July 2025 recorded a 43% increase in the number of  [REDACTED]  incidents in prison in the 12 months to March 2025. There had been a 770% increase in drone sightings around prisons between 2019 and  2023 (paragraph 94) 
(11) [REDACTED]  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 [REDACTED]  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 8^th 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 [REDACTED] whilst an inmate at HM Prison The Mount in Hertfordshire. 

In that PFD I raised concerns about the high levels of [REDACTED] in the 
prison, a series of drug [REDACTED] related deaths that had occurred since Mr Tilbury’s death, and the significant risk of future deaths that existed because of the easy access to drugs in the prison. 

Notwithstanding that PFD issued on 8^th September 2023, prisoners have continued to  die in prisons in England & Wales due to easy access to illegal drugs, especially [REDACTED], 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. 

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.  

You are under a duty to respond to this report within 56 days of the date of this report, namely by 7^th 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. 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 
[REDACTED] (Mr Mulangala’s brother)
(ii)        The Prison & Probation Ombudsman 
(iii)        Central & North West London NHS Trust 
(iv)       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.