Poor prisoner suicide risk assessment
Inadequate assessment of self-harm/suicide risk for prisoners, particularly those without existing care plans.
339 items
10 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
93match
Callum Smith
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.
Matched on
terms: assessment, prisoner, suicide
PPO recommendation
89match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with policy, in particular staff should: • consider using enhanced ACCT case management where there has been a pattern of serious self-harm; • have had appropriate ACCT training before taking on the role of ACCT case manager; •...
Matched on
terms: assessment, prisoner, suicide
PPO recommendation
89match
The Governor
The Governor should ensure that prison staff manage prisoners identified as at risk of suicide or self-harm in line with PSI 64/2011, including that: • the ACCT assessment interview and first ACCT case review are completed within 24 hours of the start of ACCT procedures; • first ACCT case reviews are multidisciplinary and always include a member of...
Matched on
terms: assessment, prisoner, suicide
PPO recommendation
89match
The Operational Manager and Head of Healthcare
The Operational Manager and Head of Healthcare should ensure that staff conducting reception assessments always examine and consider the Person Escort Record, and any other documents that arrive with the prisoner, to assess whether the prisoner has any risk factors for suicide and self-harm.
Matched on
terms: assessment, prisoner, suicide
IMB recommendation
88match
Bedford (2020)
Initiate a fundamental review of the assessment, care in custody and teamwork (ACCT; the care planning process for prisoners identified as being at risk of suicide or self-harm) process – is it ‘fit for purpose’?
Matched on
terms: assessment, prisoner, suicide
PFD report
81match
Kirk Duboise
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.
Matched on
terms: assessment, prisoner
PFD report
81match
Levi Cronin
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.
Matched on
terms: assessment, poor
PFD report
81match
John Wright
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.
Matched on
terms: poor, prisoner
PFD report
81match
Shaun Dewey
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.
Matched on
terms: prisoner, suicide
Article 2 learning point
80match
Mr Quartz — HMP Doncaster - LP 5
We recommend that there should be modifications to the ACCT process nationally. In particular, there should be a comprehensive suicide risk assessment for all prisoners and young offenders on ACCT, with recognition of risk factors, appropriate interventions and contingency planning. The triggers and risk factors should be reviewed utilising the CAREMAP process and the ACCT should not be...
Matched on
terms: assessment, prisoner, suicide
PFD report
77match
Stephen St Clair
Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for a prisoner at risk.
Matched on
terms: prisoner, suicide
PFD report
77match
Tomasz Nowasad
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.
Matched on
terms: assessment, prisoner
PPO recommendation
77match
The Governor and Head of Healthcare at Risley
The Governor and Head of Healthcare at Risley should ensure that reception staff have a clear understanding of their responsibilities and the need to share all relevant information about risk, and that they consider and record all the known risk factors of a newly arrived prisoner when determining the risk of suicide and self-harm.
Matched on
terms: prisoner, suicide
PPO recommendation
77match
The Head of Healthcare and the Mental Health Services Manager
ensure that healthcare staff share information that may be relevant to a prisoner’s risk of suicide or self-harm with prison staff.
Matched on
terms: prisoner, suicide
PPO recommendation
77match
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that all staff have a clear understanding of their responsibilities to manage prisoners at risk of suicide and self-harm in line with national guidelines and, in particular understand: • the need to record, share and consider all relevant information about risk, and start ACCT procedures when indicated; and •...
Matched on
terms: prisoner, suicide
PPO recommendation
77match
The Operational Manager
The Operational Manager should ensure that staff manage prisoners at risk of suicide and self-harm in line with PSI 64/2011, in particular staff should: • identify caremap actions that are detailed, time-bound and tailored to reduce the prisoner’s risk; • ensure that the ACCT document accompanies the prisoner when they move around the prison; and review the prisoner’s...
Matched on
terms: prisoner, suicide
PPO recommendation
77match
The Director General of HMPPS
The Director General of HMPPS should review PSO 3050 and PSI 07/2015 to ensure that prisoners who attend court by video link are assessed for their risk of suicide and self-harm and seen by healthcare staff in the same way as prisoners attending court in person.
Matched on
terms: prisoner, suicide
PPO recommendation
77match
The Governor and Head of Healthcare of HMP Swansea
The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, in particular that reception staff should: have a clear understanding of their responsibilities to identify prisoners at risk of suicide and self-harm; examine all relevant information that arrives with the prisoner, in particular the PER...
Matched on
terms: prisoner, suicide
PPO recommendation
74match
The Governor of HMP Holme House
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines. In particular, staff should: ▪ hold multi-disciplinary ACCT reviews which take place within the set timescales. ▪ set effective caremap objectives which are specific, time-bound and meaningful, aimed at reducing risk and updated at each case review. ▪ carry...
Matched on
terms: prisoner, suicide
PFD report
73match
Damion Anthony Andre Martin
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.
Matched on
terms: assessment, suicide
PFD report
73match
Kevin Scarlett
The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
Matched on
terms: assessment, suicide
PFD report
73match
James Boylan
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.
Matched on
terms: assessment, poor
PFD report
73match
Marcin Stoga
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.
Matched on
terms: assessment, prisoner
PFD report
73match
Greg Revell
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.
Matched on
terms: prisoner, suicide
PFD report
73match
Mark Vagnoni
Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.
Matched on
terms: assessment, prisoner
PPO recommendation
73match
The Governor of HMP Berwyn
The Governor should review the first night assessment booklet to assist staff in identifying other risk factors or triggers that could indicate risk of suicide and self-harm.
Matched on
terms: assessment, suicide
Article 2 learning point
73match
AA — HMP & YOI Holloway - LP 7
We recommend that physical as well as mental health is fully assessed during periods subject to suicide and self-harm monitoring and that consideration is always given to the most appropriate location for a prisoner, in particular whether a move to a dormitory is desirable and the outcome of such consideration recorded.
Matched on
terms: prisoner, suicide
Committee recommendation
73match
#3 - IPP sentences inflict psychological harm, creating barriers to prisoner progression and trust
The psychological harm caused by IPP sentences is a considerable barrier to progression for some IPP prisoners. The indefinite nature of the sentence has contributed to feelings of hopelessness and despair that has resulted in high levels of self-harm and some suicides within the IPP population. In addition to this, IPP prisoners distrust the people and services that...
Matched on
terms: prisoner, suicide
PPO recommendation
72match
The Head of Healthcare
conduct a review of the mental health risk assessment process for identifying prisoners at risk of death by self-harm to ensure that it is fit for purpose; and
Matched on
terms: assessment, prisoner
PPO recommendation
72match
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, including that staff: set effective caremap actions that are specific and meaningful, aimed at reducing risk, and update them at each review;
Matched on
terms: prisoner, suicide
PPO recommendation
72match
The Operational Manager and the Head of Healthcare
The Operational Manager and the Head of Healthcare should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including: reviewing and update the prisoner’s caremap at every case review; involving the prisoner’s family in the ACCT process when appropriate, and including family contact issues in the caremap; recording all relevant...
Matched on
terms: prisoner, suicide
PPO recommendation
72match
The Governor of HMP Channings Wood
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, including that staff set effective caremap actions that are specific and meaningful, aimed at reducing risk, and update them at each review.
Matched on
terms: prisoner, suicide
IOPC learning recommendation
72match
Recommendation - Hampshire Constabulary, September 2023
The IOPC recommends that Hampshire Constabulary amends its policy on voluntary attendance interviews to ensure that: A) Officers investigating allegations of sexual offences involving children, in particular child sexual exploitation and abuse (CSEA) or indecent images of children (IIOC), consider all suspects as potentially vulnerable and at risk of suicide. B) Officers carry out a self-harm and suicide...
Matched on
terms: assessment, suicide
PFD report
69match
Jordan Buckton
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.
Matched on
terms: prisoner
PFD report
69match
David O’Garro
The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity and shared understanding regarding the assessment process for prisoners with epilepsy.
Matched on
terms: assessment, prisoner
PFD report
69match
Derek Thomas
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.
Matched on
terms: poor, suicide
PFD report
69match
Mark Holdsworth
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.
Matched on
terms: assessment, suicide
PFD report
69match
Vilhelmas Borkertas
A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
Matched on
terms: assessment, prisoner
PFD report
69match
Imane Bouasbia
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.
Matched on
terms: assessment
PFD report
69match
Azra Hussain
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.
Matched on
terms: assessment, suicide
PPO recommendation
68match
The Governor of HMP Liverpool
The Governor should ensure that all staff have a clear understanding of their responsibilities to identify prisoners at risk of suicide and self-harm in line with national guidelines and, in particular, the need to record, share and consider all relevant information about risk, and start ACCT procedures when indicated.
Matched on
terms: prisoner, suicide
IMB annual report
68match
Bedford (2023)
HMP Bedford, a Category B reception and resettlement prison, continues to face significant challenges, particularly high levels of violence and self-harm, overcrowding, and an inconsistent regime with prisoners spending excessive time locked in cells. While education and family visits have seen improvements, the mental health team remains under-resourced, and staffing issues impede purposeful activity and the full implementation...
Matched on
terms: poor, prisoner
PFD report
65match
Luke Ashcroft
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support services.
Matched on
terms: prisoner
PFD report
65match
Michael James Meyler
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.
Matched on
terms: suicide
PFD report
65match
Andrew Hall
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.
Matched on
terms: assessment
PFD report
65match
Jake Hardy
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.
Matched on
terms: suicide
PFD report
65match
Steven May
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.
Matched on
terms: poor
PFD report
65match
Terence Adams
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.
Matched on
terms: assessment
PFD report
65match
Haydn Burton
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.
Matched on
terms: suicide
PFD report
65match
Andrew Jones
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.
Matched on
terms: assessment