Poor prisoner suicide risk assessment
91 items
1 source
Inadequate assessment of self-harm/suicide risk for prisoners, particularly those without existing care plans.
Cross-Source Insight
Poor prisoner suicide risk assessment has been flagged across 1 independent accountability source:
91 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (91)
Mujahid Adam
Concerns: Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, allowed access to ligature material which was missed during daily checks.
Pending
Gareth Chumber-Kelly
Concerns: Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.
Pending
Sundeep Ghuman
Concerns: Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Response: HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with …
Overdue
Oliver Mulangala
Concerns: The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety concerns.
Response: HMPPS is investing over £40m in physical security measures across 34 prisons in 2025/2026, including anti-drone technology, and all adult male closed prisons are equipped with X-ray body scanners. They …
Overdue
Stuart Berry
Concerns: Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed to the death.
Response: HMPPS has developed interim upskilling sessions on self-harm and suicide risks for prison officers, and the Safety Support Skills training module is under national review. Four ligature-resistant cells were completed …
Response: HCRG is strengthening interfaces, retraining reception nurses, and has introduced a dedicated Early Days in Custody (EDiC) Nurse role to lead an action plan for improving care standards. They have …
Overdue
Derrion Adams
Concerns: Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing levels may be insufficient to manage these challenges.
Response: HM Prison and Probation Service has implemented Incentivised Substance Free Living Units in 85 prisons, embedded Drug Strategy Leads, and introduced the Adult Health, Care and Wellbeing Core Capabilities Framework. …
Responded
Steven Davidson
Concerns: Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.
Response: HCRG has amended its training provision to include mandatory structured SystmOne training for all new staff during induction and refresher training for existing staff. They are also embedding this training …
Responded
Stuart Fowkes
Concerns: Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being missed in subsequent actions.
Response: Devon and Cornwall Police have conducted a comprehensive review of their missing persons and vulnerable people policy, resulting in a new standard operating procedure and a dedicated point of contact …
Responded
Steven Hart
Concerns: Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out to standard, contributing to the death.
Overdue
Martin Collins
Concerns: The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Response: HM Prison and Probation Service confirms initial discussions are underway with BT to explore the technical feasibility of implementing automated monitoring of prisoner call volumes, with this work to be …
Overdue
Haydar Jefferies
Concerns: HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours clinical mental health support, leading to inadequate crisis management.
Overdue
Wayne Bayley
Concerns: National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Responded
Mark Beresford
Concerns: Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
Responded
George Kyriacos Petrou
Concerns: Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions may not receive necessary observation.
Overdue
John Hurst
Concerns: Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from the CJLD assessment.
Responded
Kieran Lavin
Concerns: Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal patient transport risk assessment remains inadequate, lacking specific questions for comprehensive evaluation.
Responded
Daniel Beckford
Concerns: Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
Overdue
Yuri Hatton
Concerns: Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
Overdue
Christopher MacGillivray
Concerns: Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals released at short notice.
Overdue
Marlin Burrows
Concerns: The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Responded
Scott Rider
Concerns: The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if not reviewed.
Responded
Kenneth Baylis
Concerns: The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Responded
Kane Boyce
Concerns: Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Responded
Wyndham Thomas
Concerns: The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.
Responded
Paul Perrott
Concerns: Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were unaware of the patient's critical suicide risk history.
Overdue
Samuel Jones
Concerns: Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial information was frequently overlooked.
Responded
Haik Nikolyan
Concerns: HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.
Responded
Matthew Harris
Concerns: Police officers failed to document the deceased's recent suicidal ideation on Person Escort Record and Self-Harm warning forms, risking future underestimation or complete disregard of suicide risk for persons in custody.
Responded
Vaughan Whalley
Concerns: Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate practitioner-detainee interaction, compromised effective risk management. A manager's review also lacked critical analysis or learning identification.
Responded
Jai Singh
Concerns: Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of a psychiatrist and ongoing risk assessment documentation.
Responded
Floyd Carruthers
Concerns: Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious activity.
Overdue
Carl Langdell
Concerns: A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells overnight, and a national proposal is underway to remove identified risks.
Overdue
Robert Evans
Concerns: HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.
Responded
Gary McDonald
Concerns: Prison healthcare failed to follow up on significant discrepancies between a prisoner's self-reported mental health and his GP records, particularly concerning past suicide attempts, leaving him vulnerable in early custody.
Responded
Khalid Abiaz
Concerns: A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.
Responded
Margaret Stringer
Concerns: The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff training on isolation's impact. Crucially, there were significant failures in transferring vital suicide risk information between agencies during patient handover.
Overdue
Nicholas Rose
Concerns: Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or incapacitation.
Responded
Vijaykumar Gadhavi
Concerns: Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family involvement, and breaches of the Enhanced Care Policy.
Overdue
Amanda Gibbens
Concerns: Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.
Overdue
Mark Castley
Concerns: The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.
Responded
Connor Hoult
Concerns: Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or concerns.
Responded
Joel Robinson
Concerns: Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening for soldiers outside their chain of command were identified.
Responded
Richard Franks
Concerns: Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary support measures.
Responded
Colin Blackburn
Concerns: Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.
Overdue
Chloe English
Concerns: Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.
Responded
Carl Walters
Concerns: The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
Responded
Kesia Waller
Concerns: Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure staff understanding and practical application.
Responded
James Devenny
Concerns: Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on prisoners' significant self-harm history.
Responded
Azra Hussain
Concerns: Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.
Responded
Imane Bouasbia
Concerns: Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct suicidal text message.
Overdue
Christopher Murfet
Concerns: Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a risk of suicide.
Responded
Brett Marrs
Concerns: Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.
Overdue
Andrew Jones
Concerns: The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.
Overdue
Ian Weeks
Concerns: Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy workloads, and the absence of a "red flag" warning system for suicide risk.
Responded
Tomasz Nowasad
Concerns: There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.
Responded
Daniel Akam
Concerns: Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.
Overdue
Shaun Dewey
Concerns: The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.
Responded
David Bird
Concerns: Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.
Overdue
John Wright
Concerns: Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps in IT and manual communication methods mean vital data is not consistently accessible to staff.
Responded
Vilhelmas Borkertas
Concerns: A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
Overdue
Mark Vagnoni
Concerns: Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.
Overdue
Levi Cronin
Concerns: Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on prison wings also hindered effective dynamic risk assessments.
Overdue
Edwin O’Donnell
Concerns: Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Responded
Callum Smith
Concerns: There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.
Overdue
Daniel Dunkley
Concerns: The provided text outlines the circumstances of the deceased being found hanging in his cell and his subsequent death, but details no specific systemic failures or coroner's concerns.
Overdue
Haydn Burton
Concerns: Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS database inadequately records past ACCT information.
Overdue
Liam Lambert
Concerns: ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.
Overdue
Peter Lawrence
Concerns: The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
Overdue
Terence Adams
Concerns: Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Overdue
Michael Williams
Concerns: Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, indicating a lack of clear training.
Responded
Samuel Blair
Concerns: Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.
Responded
Steven May
Concerns: Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First Aid/CPR training and poor weekend/Bank Holiday healthcare access also posed significant risks.
Overdue
Mark Holdsworth
Concerns: Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.
Overdue
Derek Thomas
Concerns: Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting understanding between prison and escort staff regarding critical safety form procedures.
Responded
Richard Green
Concerns: Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.
Overdue
Greg Revell
Concerns: Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information systems were insufficient, leading to missed opportunities for vital medication and treatment.
Responded
Marcin Stoga
Concerns: Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed upon return from court, leaving significant gaps in their care and safety.
Responded
Jake Hardy
Concerns: Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.
Overdue
David O’Garro
Concerns: A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff unfamiliarity and unclear communication regarding such assessments, created an unsafe cell allocation system.
Overdue
James Boylan
Concerns: Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.
Overdue
Matthew Purser
Concerns: A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.
Overdue
Kevin Scarlett
Concerns: The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
Responded
Andrew Hall
Concerns: Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Overdue
Carl Morris
Responded
Lee MacPherson
Concerns: Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Overdue
Lee Curran
Concerns: PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Overdue
Lisa Inkin
Concerns: A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of suicidal intent and insufficient supervision for eating disorder patients.
Overdue
Kirk Duboise
Concerns: There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Pending
Michael James Meyler
Concerns: Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack of accountability for information review.
Pending
Damion Anthony Andre Martin
Concerns: Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
Overdue
Jordan Buckton
Concerns: Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.
Overdue