HM Prison and Probation Service

Action Planned (AI summary) • HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. • The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention measures to officers, including what constitutes an observation and how to perform one. • All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes modules on the ACCT process.

Action Planned (AI summary) HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments to ligature resistant cells, and are hopeful that further installations will be possible in 2026/27. They use the Assessment, Care in Custody, and Teamwork (ACCT) case management approach to support individuals at risk of self-harm or suicide.

Action Planned (AI summary) HMPPS is reviewing national prison officer training, developing interim upskilling sessions on recognising risks and triggers, and considering upgrading Victorian-style windows to anti-ligature designs. They are concluding a project to convert 50 cells across 13 locations to a fully ligature‑resistant standard. HCRG is retraining reception nurses, introducing an Early Days in Custody (EDiC) Nurse role, improving identification and escalation of urgent mental health referrals, and reviewing the Mental Health Operational Standard Operating Procedures and referral processes.

Action Planned (AI summary) HMPPS is undertaking a cell design review to explore different materials that meet fire safety and anti-ligature requirements for bedding, expected to conclude at the end of 2026. To improve first-on-scene care, HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff.

Action Planned (AI summary) HMP Birmingham will update its Secreted Items Policy to include guidance for staff on actions to take when a prisoner has ingested an item. They will also issue guidance to staff to ensure a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision.

Action Planned (AI summary) NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.

Action Planned (AI summary) NHS England highlights the 'We Are Prison Nurses' campaign and nursing preceptorship to address workforce demands and notes several platforms locally to enable effective sharing of information. Findings will be tabled at a future NHS England Health and Justice Delivery Oversight Group. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. Serco has committed to undertaking a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet Office, to identify aspects of the prison transition that went wrong and produce a Transitions Playbook for future use. Sodexo highlights its compliance with Early Days In Custody PSI, use of SASH forms, ACCT training, and CMS for information sharing. Post-inquests, Sodexo ringfenced key safety tasks and safer custody staff to address resourcing pressures. Nottinghamshire Healthcare NHS Foundation Trust has enhanced Executive led oversight and assurance reviews for Offender Health, mandated daily checks of electronic patient records, and requires attendance at ACCT case reviews. They have also improved handover processes and email communication. HMPPS took over management of HMP Lowdham Grange on 1 August 2024. Since then, HMPPS has increased safer custody staffing levels, established a senior management team with relevant experience, and reviewed the ACCT process. Additionally, HMPPS has disseminated existing guidance regarding document retention and will review its approach to making formal admissions at inquests.

Action Planned (AI summary) HMP Elmley has been compiling a Key Work Delivery Strategy to address and improve the issue of key work, with the goal of ensuring that all prisoners are allocated a key worker and that specific cohorts of prisoners at risk of harm or self-harm are identified and supported by trained staff members. For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum.