Poor prisoner suicide risk assessment
Inadequate assessment of self-harm/suicide risk for prisoners, particularly those without existing care plans.
339 items
10 sources
Source spread
Where this theme appears
Poor prisoner suicide risk assessment has been flagged across 10 independent accountability sources:
99 PFD reports
3 committee recs
116 PPO recs
10 IOPC recs
21 IMB reports
72 IMB recs
2 Scottish FAIs
10 Article 2 learning points
3 detention investigation recs
3 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (99) — showing 50 strongest matches
Luke Ashcroft
Concerns: 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.
Overdue
Ronald Meikle
Concerns: Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.
Overdue
Thomas Ruggiero
Concerns: Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of deaths in custody.
Overdue
Thomas Ruggiero
Concerns: Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion regarding emergency 'Code Blue' protocols.
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
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
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.
Response (Care UK): Care UK has implemented protocols for summoning ambulances, disseminated to staff via a Governor's notice and staff briefings. NOMS has implemented ACCT training, with further training for healthcare staff commencing …
Overdue
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.
Response (HM Prison and Probation Service): HMP Manchester reception staff now record ROSH document existence and consideration of ACCT in NOMIS. Healthcare staff scan paper documents onto SystmOne. Weekly assurance checks of NOMIS entries are conducted …
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
Carl Morris
Response (PADI Europe): PADI will include an additional statement in the 'Learning Agreement' to further enforce the issue of medical illness to both the Instructor and student diver with regards to doctor's approval …
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
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.
Response (HM Prison and Probation Service): Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is …
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.
Response (HM Prison and Probation Service): HMP Woodhill reviewed the local ACCT process in December 2013, revised the case review process, and issued guidance to staff. A governor grade is appointed to manage the case of …
Responded
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
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.
Response (Department of Health): The Department of Health states that NHS England has identified the need for both a Mental Health Patient Safety Expert Group and an Expert Safety Primary Care Group to improve …
Overdue
David O’Garro
Concerns: 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.
Overdue
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
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.
Response (HM Prison and Probation Service): HM Prison and Probation Service is trialling revised Prisoner Escort Records including a 'Red Flag' page to highlight key risk/vulnerability information. They also highlight existing protocols for screening prisoners returning …
Responded
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.
Response (Leicestershire Partnership NHS Trust): Leicestershire Partnership NHS Trust has implemented a robust system for seeking clinical information and has a flowchart identifying team member responsibilities. However, following review of the case notes, it was …
Response (HM Prison and Probation Service): HM Prison and Probation Service has reinforced local policies to ensure ACCTs are opened on reception after a self-harm attempt, launched a new Safer Prisons strategy, provided training on recording …
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.
Response (NHS England): Greater Manchester West Mental Health Foundation Trust have commissioned a review of available assessment tools for the prison setting. NHS England are re-procuring the healthcare electronic healthcare system, SystmOne, which …
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.
Response (HM Prison and Probation Service): The prison has implemented mandatory verbal handover of SASH form information from reception staff to healthcare staff. All staff working in reception must complete an online training course, managed by …
Response (HMP Durham): Nursing staff have been instructed to review all documents when completing reception screening, and staff have been reminded of the importance of ensuring all paperwork accompanies an individual. All initial …
Response (Care UK): Care UK is no longer the healthcare provider at HMP Durham. It will forward the concerns to heads of healthcare at other facilities where it interacts with GEO Amey and …
Response (GEOAMEY): GEOAmey provided refresher training to over 90% of their officers regarding the completion of Prisoner Escort Records (PER) and Self Harm and Suicide Warning Forms (SASH Forms), following concerns raised …
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
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.
Response (Steven May): HMP Ranby reminded staff about comprehensive record-keeping for ACCT interviews, reinforced elements of its Local Security Strategy regarding night-time incidents, and provided access to the LSS with annual knowledge testing. …
Response (Nottingham Healthcare NHS Trust): The Trust has already addressed concerns by obtaining additional funding from NHS England for new posts at HMP Ranby to meet healthcare demands.
Overdue
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.
Response (London Ambulance Service NHS Trust): The London Ambulance Service updated its Computerised Gazetteer to include multiple entrances to HMP Pentonville, and included specific reference to HMP Pentonville in refresher training for EOC staff, requiring confirmation …
Response (Care Uk): Care UK refers to the response provided by BEH-MHT for some concerns, and states they will collaborate with them to ensure their action plan is implemented. They have implemented a …
Response (HM Prison and Probation Service): NOMS states that the local risk assessment at Pentonville is up to date, and there is a sufficient number of staff trained in first aid. Prison control room staff have …
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.
Response (HM Prison and Probation Service): HMP Leicester reminded staff about conducting observations at unpredictable times, management checks are in place, ACCT documents are quality assured, the contingency plan was revised, and staff were trained to …
Responded
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.
Response (Care UK): Care UK will remind staff to check they have had sight of the core record and any accompanying information including the PER, relating to history, index offence, sentence status, clinical …
Overdue
Stephen St Clair
Concerns: 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.
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
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.
Response (HM Prison and Probation Service): Following the death, a Safer Custody toolkit was introduced, and staff were reminded of ACCT document completion and prisoner supervision. Additional funding was received for security measures and partnership working. …
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.
Response (HM Prison and Probation Service): HMP Winchester is providing local ACCT refresher training and Safety Awareness training, including lessons learned from previous deaths in custody. Wing Supervising Officers are informed of ACCT post closure reviews, …
Overdue
Simon Turvey
Concerns: The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.
Overdue
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.
Response (Prison Health Services): Following the inquest, all healthcare staff will revisit the Prison Service Instruction (PSI) through Suicide and Self Harm (SASH) training and local training/meetings to ensure staff are fully aware of …
Overdue
Daniel Dunkley
Concerns: The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
Overdue
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.
Response (HM Prison Probation Service): All staff at HMP Bedford were reminded of the importance of considering all available information prior to changing a prisoner's location, with monthly checks to ensure accurate record keeping. Staff …
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.
Response (HM Prison Probation Service): The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff and reception staff have been made aware of this process. The individual …
Responded
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.
Response (HM Prison Probation Service): HMPPS details actions taken including; NHS England Commissioners, Mountain Healthcare, and the liaison and diversion service have been informed of the process for contacting the prison healthcare team. The courts …
Response (CARE UK): Care UK provides details of actions taken including; Healthcare staff attending prison morning meetings, maintaining a register of staff who have completed SASH training and providing ASIST training to all …
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
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.
Response (HM Prison and Probation Service): HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks …
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.
Response (NHS England): NHS England published guidelines and supporting documents for Health and Justice Clinical Reviewers in Sept 2018 and has published an amended specification for the provision of mental health services in …
Response (HM Prison and Probation Service): HM Prison and Probation Service are rolling out improvements to the ACCT process and are increasing the numbers of safer cells available to governors, including at HMP Manchester.
Responded
Daniel Akam
Concerns: ACCT observations were missed and recorded as completed, officers did not appear to know their obligations and responsibilities, and there was inadequate ACCT training for officers.
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.
Response (Cardiff and Vale NHS Trust): Cardiff and Vale NHS Trust has reviewed the records, processes, and systems related to the death, noting a difference between NHS Wales and England regarding GP record access for prisoners. …
Responded
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
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
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.
Response (Metropolitan Police Service): The MPS emailed all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from …
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.
Response (United Lincolnshire Hospitals NHS Trust): The Consultant and Clinical Lead for A&E reviewed Mr Murfet's previous attendances at Pilgrim Hospital A&E Department and stated that on both occasions, Mr Murfet was seen and referred to …
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.
Response (Birmingham and Solihull Mental Health NHS Foundation Trust): The Trust has taken steps to reduce risk from ligatures, including installing pressure sensor alarms on en-suite bathroom doors, removing door furniture, and establishing a rolling capital programme for ligature …
Response (Health and Safety Executive): HSE states that the safety of the environment for patients, including management of ligature points, falls within the remit of CQC, not HSE, according to a Memorandum of Understanding.
Response (NHS Birmingham and Solihull ICB): NHS Birmingham and Solihull ICB provides supplementary information to the Coroner, in support of the information provided by Birmingham and Solihull Mental Health Foundation Trust, in response to the Regulation …
Response (CQC): The CQC has asked for weekly reports on ward improvements, sought an independent review from NHS England, and will share learning from the inquest with inspectors and registered persons. They …
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.
Response (HM Prison and Probation Service): HMP Elmley has equipped nearly all cells with in-cell phones and ensures access to Samaritans. ACCT version 6 has been rolled out across the male estate and training modules and …
Responded
Committee Recommendations (3)
#3 — IPP sentences inflict psychological harm, creating barriers to prisoner progression and trust
Recommendation: 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 …
Gov response: Reasoning: The Government recognises that the remittance back to prison, following a period in a secure hospital, can be difficult for the prisoner, and we have processes in place to support the progression of those …
Accepted
#5 —
Recommendation: Self-harm across the youth secure estate is alarmingly high. There has been a welcome reduction in consecutive months since January, but self-harm is at the highest level in the last five years. The Ministry of Justice and Youth Custody Service …
Gov response: 15. It is important that children and young people have access to support that aid them in dealing with issues of self-harm and mental health. It is well recognised that children and young people in …
Under Consideration
#6 —
Recommendation: The Ministry of Justice and Youth Custody Service must also seek to understand why self-harm appears to have reduced during the Covid-19 pandemic, and what can be learned from that.
Gov response: 20. We welcome the decline in the rates of self-harm during the covid-19 pandemic and agree we must seek to understand the reasons for the decline. As the Committee will be aware, at the start …
Under Consideration
PPO Death in Custody Recommendations (116) — showing 50 strongest matches
The Governor
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, in particular that they: assess risk based on a prisoner’s risk factors rather than what the prisoner tells them; invite healthcare …
The Governor
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with national instructions, including that: support actions are set that are specific, meaningful and identify all of the issues identified at assessment interviews and …
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 …
The Governor and Head of Healthcare
reception and healthcare staff assess and identify prisoners at increased risk of suicide and self-harm, including those who have returned from court;
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 …
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 Governor
there are regular wellbeing checks on prisoners subject to possible extradition or deportation to assess whether their risk to themselves has changed.
The Governor
staff understand the importance of having regular, meaningful conversations with prisoners to identify changes in appearance, behaviour or mood that may indicate increased risk;
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.
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 …
The Governor
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 instructions and, in particular, the need to record, share and consider all relevant …
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; • …
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 …
The Home Office
The Home Office should amend DSO 09/2016 so that it: • is clear about what suicidal intentions means; • requires nurses and other healthcare professionals to report to a doctor any detainee who is showing suicidal intentions.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide or self-harm in line with policy, and in particular, staff should: ensure relevant staff involved in the prisoner’s care, including healthcare staff where appropriate, …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff assess prisoners’ risk of suicide and self-harm based on their risk factors and not solely on their presentation and what the prisoner tells them.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including that: • staff have a clear understanding of their responsibilities and the need to record relevant …
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.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with PSI 64/2011, including: • that prison and healthcare staff share all information that affects risk and do not …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review the training for reception and induction staff to ensure they understand how to identify prisoners at risk of suicide and self-harm, including that all relevant risk information, including the PER, is properly …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review the training for Reception and Induction staff to ensure they: • understand how to identify prisoners at risk of suicide and self-harm, and • know how to provide appropriate support to those …
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 …
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 …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should implement a robust quality assurance process of reception and FNIP records to ensure that staff are following the agreed processes and recording and considering all risk factors for suicide and self-harm.
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 …
The Executive Director of Transforming Delivery Directorate, HMPPS
The Executive Director of Transforming Delivery Directorate, HMPPS, should ensure that national policy and guidance are clear that a request to see a Listener may be an indication of increased risk of self-harm or suicide, and that staff are required …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that reception and induction staff: • consider all information that arrives with the prisoner, particularly the PER and suicide and self-harm warning alerts when assessing risk of suicide and self-harm; • assess …
The Governor
The Governor should ensure that all staff understand their responsibility to immediately open an ACCT if they hear or observe anything to suggest a person might be at risk of self-harm or suicide.
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 national guidance, including that: • ACCT case reviews are multidisciplinary and include all relevant people involved in the prisoner’s …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that reception staff: • have a clear understanding of their responsibilities and the need to share all relevant information about risk; • do not rely solely on what a prisoner says or …
The Director and Head of Healthcare at Altcourse
The Director and Head of Healthcare at Altcourse should ensure that staff: Have a clear understanding of their responsibilities and the need to share all relevant information about risk. Start ACCT procedures when a prisoner has recently self-harmed or expressed …
The Governor
The Governor should ensure that a multidisciplinary ACCT review is held when there is evidence of a significant change in circumstance and that the frequency of observations should reflect a prisoner’s risk and be adjusted when that risk changes.
The Governor
The Governor should ensure that key workers understand the need to alert wing staff if a prisoner may be at increased risk of suicide or self-harm.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that reception staff thoroughly check the person escort record for all relevant risk information about newly arrived prisoners and where appropriate, clarify risk information with escort staff.
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 …
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
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 …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners appearing in court by video link in line with national instructions, including that: • prison records (NOMIS) are updated with details of the hearing and the outcome; • …
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 national instructions, including that: • ACCT case reviews are multidisciplinary and include all relevant people involved in a prisoner’s …
The Home Office
The Home Office should review the training provided to IRC staff on Rule 35 reports, particularly for those at risk of suicide.
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 …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prisoners are screened after an interview with the police to assess their risk of suicide or self-harm.
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 …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff have a clear understanding of their responsibilities to identify prisoners at risk of suicide and self-harm, including that: segregation unit staff consider and record all the known risk factors …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff take into account all relevant risk information about prisoners when assessing their risk of suicide and self-harm and start ACCT procedures when appropriate.
The Governor and Head of Healthcare at HMP Lincoln
ensure staff know the red flags for suicide and self-harm and, where they are present, document their reasoning for not starting ACCT procedures.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff working with prisoners have an understanding of risk factors for suicide and self-harm and are vigilant about any changes that might indicate an increased risk.
The Governor and Head of Healthcare
The Governor and 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, including that: • staff understand that they need …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prison staff manage prisoners at risk of suicide and self-harm in line with PSI 64/2011, in particular that they: remove ligatures from prisoners at the earliest opportunity; hold multidisciplinary case reviews …
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 …
IOPC Learning Recommendations (10)
Recommendations - Sussex Police, August 2025
The IOPC recommends that Sussex Police should create a policy which determines the offences for which a suicide risk assessment must be completed and formally recorded. This recommendation has arisen as a result of a Death or Serious Injury where …
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 …
Recommendation - Greater Manchester Police, July 2024
The IOPC recommends that Greater Manchester Police (GMP) review their custody policies and processes on managing the risk of suicide and self-harm to ensure they are clear and in line with the College of Policing’s Authorised Professional Practice. This follows …
Recommendation - Greater Manchester Police, July 2025
The IOPC recommends that Greater Manchester Police (GMP) should, as part of their action to replace their custody system, review their provision for risk assessment completion. This includes consideration of adding prompts for custody officers to carry out risk assessments …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should take steps to ensure that custody officers follow Authorised Professional Practice when determining and recording levels of obsevation for detainees. This should include consideration of whether: This follows an incident where a man …
Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, …
The IOPC recommends that the National Police Chiefs Council (NPCC) shares the learning from this IOPC investigation with all force custody leads, asking them to take steps to ensure custody staff understand the ligature risk associated with plimsolls provided to …
Recommendation - Kent Police, February 2021
The IOPC recommends that Kent Police reviews its domestic abuse policy and includes clear guidance for officers dealing with cases where they are informed by the victim of the perpetrators suicidal threats or ideation. The guidance should detail how officers …
Recommendation - Humberside Police, February 2021
The IOPC recommends that Humberside Police reviews its domestic abuse policy and includes clear guidance for officers dealing with cases where they are informed by the victim of the perpetrators suicidal threats or ideation. The guidance should detail how officers …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This should include consideration of; …
Recommendation - Avon and Somerset Constabulary, August 2022
Avon and Somerset Police amend their policy to require that all suspects in cases relating to alleged child sexual abuse or exploitation are provided with the same level of suicide risk assessment, regardless of whether they attend voluntarily or are …
IMB Annual Reports (21)
Send (2022)
HMP Send is a closed prison for adult women with an operational capacity of 191, holding 182 prisoners at the end of the reporting year, including 63 ISPs. The Board considers Send a safe prison but highlights a significant increase in self-harm incidents (837) and one death in custody. Key concerns include the need for specialist mental health provision for prolific self-harmers, slow progress on digital in-cell technology, and persistent staffing shortages.
PRISON
Key concerns
Lowdham Grange (2022)
HMP Lowdham Grange, a Category B training prison, experienced a challenging year marked by the continued impact of Covid-19 restrictions, which limited board visits and significantly affected the regime. The prison leadership was successful in controlling infections, and healthcare provision was largely efficient despite severe staffing shortages. However, the report highlights a significant increase in prisoner-on-prisoner assaults and self-harm, alongside critical concerns regarding delayed inquests, inadequate mental health transfers, and a persistent lack of resolution for property management issues during transfers.
PRISON
Key concerns
Norwich (2022)
HMP/YOI Norwich faced significant challenges in 2021-2022 due to ongoing Covid-19 restrictions and chronic staff shortages, impacting regime, safety, and humane treatment. Despite dedicated local leadership and staff efforts, the prison grappled with high self-harm incidents, violence, and inadequate ACCT management. Key issues highlighted include overcrowding, dilapidated facilities, insufficient rehabilitative programmes for long-term prisoners, and concerns regarding the detention of individuals with severe mental health needs and foreign nationals past their sentences.
PRISON
Key concerns
New Hall (2022)
HMP New Hall operated under significant Covid-19 restrictions, with staff commended for their professionalism in maintaining safety. While safety metrics showed a notable increase in self-harm and use of force incidents, many were attributed to a small number of individuals and Covid-related confinement. Key areas for development include estate maintenance on Rivendell Unit and improving the quality of CSIP investigations, alongside addressing consistent prisoner complaints regarding healthcare and property.
PRISON
Key concerns
Manchester (2022)
HMP Manchester navigated a challenging year with ongoing Covid-19 restrictions and its transition to a Category B training prison. While commendations were noted for efforts in safety and equality, persistent staffing shortages severely impacted regime consistency, prisoner treatment, and access to services. Key concerns highlighted delays in vital estate improvements, an unacceptable wait for dental care, and significant issues with prisoner property and escorts to healthcare appointments.
PRISON
Key concerns
Charter Flight (2022)
The CFMT monitored 12 charter removal and relocation operations in 2022, finding that returnees were generally treated kindly but experienced significant issues. Key concerns included prolonged confinement in vehicles, inconsistent use of force, and inadequate interpreting services, often exacerbating detainee distress. Despite some positive changes in escorting practice, the Board raised recommendations for HOIE and its contractor, particularly regarding vulnerability, financial preparation, and transit times.
PRISON
Key concerns
Erlestoke (2023)
HMP Erlestoke, a Category C training prison, held 467 prisoners with an operational capacity of 468 during the reporting year ending March 2023. The prison experienced a reduction in self-harm incidents to 215 and violent incidents to 102 (65 prisoner-on-prisoner, 37 prisoner-on-staff), with no deaths in custody. Key improvements included enhanced gate security and the introduction of in-cell laptops for prisoners. However, significant challenges persist, notably chronic staff shortages across healthcare, education, and key working, persistent issues with illicit substances, and an inadequate constant watch cell. Delays in essential building works and national issues like parole restrictions for IPP prisoners continue to impede progression and resettlement efforts.
PRISON
Key concerns
Downview (2023)
HMP/YOI Downview experienced a challenging reporting year marked by significant operational changes and an increase in prisoners with complex mental health needs, leading to increased self-harm and use of force incidents. While staff demonstrated compassion, issues like delayed mental health transfers, inconsistent medication distribution, and an un-embedded key worker scheme persisted. The Board expressed concerns about population pressures, property loss during transfers, and a reactive approach to the new transgender policy.
PRISON
Key concerns
Leeds (2022)
The IMB report for HMP Leeds covering 2021-2022 found the prison to be generally safe, although expressing concern over 24 deaths in custody and incidents of unsecured doors. While staff-prisoner relationships were mostly satisfactory, issues with staff conduct and an inability to deliver key worker sessions due to shortages were noted. Accommodation remains unsatisfactory, particularly due to cell sharing, and the lack of external mental health places means many prisoners with severe needs are held inappropriately. Positive aspects included healthcare provision, commended catering staff, and successful prisoner engagement in projects like the Lock-In cafe and bird of prey care.
PRISON
Key concerns
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 of the key worker scheme. The IMB raises concerns about the dilapidated infrastructure, poor property management, and calls for HMPPS and the Governor to address these long-standing issues.
PRISON
Key concerns
Dovegate (2023)
HMP Dovegate, a Category B training prison managed by Serco, reported a generally calm and settled environment with good staff-prisoner relationships. Key challenges include persistent long waiting times for mental health transfers and dental appointments, along with concerns about lost prisoner property during transfers and staffing shortages affecting healthcare and education. The Board highlighted the need for improved strategies for IPP prisoners and more secure mental health spaces.
PRISON
Key concerns
Eastwood Park (2023)
HMP/YOI Eastwood Park, a closed local prison for women, faced significant challenges in staffing, self-harm, and the management of complex mental health needs during the reporting year. Despite positive recruitment efforts and a new regime increasing time out of cell, the Board highlighted concerns regarding delays in mental health transfers, a substantial rise in use of force, and the under-utilisation of new facilities. The report also commended improvements in social visits and property management, while calling for better support for remand and short-sentence prisoners and more reliable resettlement data.
PRISON
Key concerns
Drake Hall (2023)
Drake Hall continues to provide a largely safe and humane environment, with commendable support for vulnerable women and effective management of challenging behaviours, although self-harm and violence have increased. Key concerns persist regarding the poor condition of Richmond and Plymouth houses, systemic issues with property, and healthcare resources being outstripped by the increasing complexity of the population's needs. The Board also highlights issues around staffing, regime restrictions, and the halting of planned capacity improvements.
PRISON
Key concerns
Exeter (2023)
HMP Exeter faced another challenging year, operating under an Urgent Notification due to high levels of violence and self-harm, alongside significant staffing instability, particularly in healthcare. Major refurbishment projects continued, impacting operational capacity and regimes, compounded by persistent overcrowding and unsuitable conditions in the temporary Care and Separation Unit. While improvements were noted in induction processes and use of force governance, critical issues like security vulnerabilities, challenges in purposeful activity due to high turnover, and deficiencies in property management remained key concerns.
PRISON
Key concerns
Charter Flight Monitoring Team (CFMT) (2023)
The Independent Monitoring Board's Charter Flight Monitoring Team observed nine charter operations to Albania, primarily involving individuals transferred from prisons to immigration detention before removal. The report highlights significant concerns regarding the humane treatment of returnees, particularly excessive in-vehicle confinement during night operations, and issues with interpretation provision and the handling of vulnerable individuals. While positive engagement from escorts was noted, the Board raised concerns about medical confidentiality, increasing use of restraint, and some coach safety incidents.
PRISON
Key concerns
Coldingley (2023)
HMP Coldingley, a Category C training prison, maintains a relatively open regime and positive staff-prisoner relationships, contributing to low self-harm levels. However, the Board notes a concerning rise in violence, use of force, and illicit substances, often linked to population pressures and insufficient new arrival checks. Significant challenges remain, including dilapidated older wings lacking in-cell sanitation, a struggling kitchen, and persistent issues with lost property and perceived disproportionality in treatment for some ethnic minority groups.
PRISON
Key concerns
Bullingdon (2023)
HMP Bullingdon continues to grapple with chronic overcrowding and persistent staff shortages, impacting regime delivery, purposeful activity, and key worker provision. While self-harm, violence, and use of force incidents remain high, the prison has made some progress in healthcare provision and reducing outstanding OASys plans. Education and resettlement efforts are hampered by prisoner churn and staffing, but new initiatives like the Employment Hub show potential for improvement.
PRISON
Key concerns
Bure (2023)
HMP Bure, a Category C prison primarily for older prisoners, maintains a calm and safe environment with good staff-prisoner relationships and effective healthcare, including a fully staffed mental health team. Key concerns include insufficient purposeful activity, inconsistent key worker engagement, and the significant impact of not having formal medical care on-site at night. Persistent estate maintenance issues and a call for the re-sentencing of IPP prisoners highlight areas requiring urgent attention from both the prison and the Ministry of Justice.
PRISON
Key concerns
Channings Wood (2023)
HMP Channings Wood, a Category C prison, faces significant challenges due to overcrowding, impacting safety, regime stability, and the delivery of purposeful activity. Self-harm and assaults have risen, and the Board remains concerned about drug availability and the inappropriate use of segregation for mental health cases. Persistent issues with property loss on transfer and delays in estate repairs further exacerbate prisoner conditions, alongside ongoing staffing shortages that hinder key work and offender management.
PRISON
Key concerns
Chelmsford (2023)
HMP Chelmsford is a Category B local prison that faces significant challenges, particularly with overcrowding where 49% of prisoners share single cells, and an increasing use of force attributed to inexperienced staff. While positive developments include improved staff-prisoner interactions and an increase in key worker sessions, persistent issues like inadequate property safeguarding, frequent missed healthcare appointments due to officer shortages, and difficulties in transferring mentally ill prisoners require urgent attention. The IMB highlights these concerns and makes recommendations to the Minister, Prison Service, and Governor to address systemic failings.
PRISON
Key concerns
Cardiff (2023)
HMP Cardiff, a Category B local training prison, maintained a relatively safe environment with one death in custody and 374 self-harm incidents, matching the previous year. However, it faced increasing population pressures and a rise in illicit substance use. The Board noted positive developments in healthcare staffing, family services, and education provision, alongside the opening of a Neurodiversity Hub and an Incentivised Substance-Free Living unit. Key concerns include ongoing staffing shortages in offender management, the impact of old infrastructure on living conditions, and significant delays in visits booking and mental health transfers.
PRISON
Key concerns
IMB Recommendations (72) — showing 50 strongest matches
Thameside (2020)
The Board would like to see more targeted understanding of the triggers to self-harm.
Governor / Director
Onley (2020)
The Board is concerned at the number of self-harm incidents in the reporting year (4.8), and we would like assurances about the actions being taken.
Governor / Director
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’?
HMPPS
Foston Hall (2021)
The IMB is concerned about: the continued high level of self-harm
Governor / Director
Bronzefield (2021)
The number of self-harm incidents has escalated to an average of 220 incidents each month in the reporting year. How is the prison service supporting the prison to manage this high level of risk on an urgent and long-term basis?
HMPPS
Eastwood Park (2022)
What action is being taken to reduce the exceptionally high levels of self-harm in the prison?
Governor / Director
Bullingdon (2022)
What plans does the Governor have to address the continuing high number of cases of self-harm in the prison?
Governor / Director
Bronzefield (2022)
The number of self-harm incidents has continued to rise to an average of 238 incidents a month. Given that a few prolific self-harmers account for a high proportion of these incidents, how does the Prison Service plan to provide support to the prison to manage these extremely challenging prisoners? (See section 4.2.)
HMPPS
Long Lartin (2023)
Self-harm. What further measures can be to be taken to reduce self-harm?
Governor / Director
Nottingham (2024)
To consider what further steps can be taken to address the increase in self-harm.
Governor / Director
Holme House (2024)
Can the Governor advise what is happening in response to the increased level of prisoner self-harm?
Governor / Director
Swinfen Hall (2020)
The number of self-harm incidents increased this year, from 803 to 881. While the Board acknowledges that some of this increase derives from a small number of prisoners repeatedly self-harming, it commends the efforts of staff supporting these prisoners. The Board welcomes regular updates on new initiatives to reduce the extent of self-harm and their impact and would like to …
Governor / Director
Lincoln (2020)
Although it is noted that there was no further increase in the number of self-harm incidents reported in 2019, the Board remains concerned about the high level of self-harm (see paragraph 4.5).
Governor / Director
Isis (2020)
ensure that plans are in place to prevent a return to the levels of self-harm over the first three months of the year, when a normal regime is resumed (see section 4.2)
Governor / Director
Gartree (2020)
Will the Governor take all measures necessary to reduce the levels of violence, self-harm, bullying, drug taking and drug smuggling, including adequate staffing and resource continued being allocated to the safer custody team?
Governor / Director
Channings Wood (2020)
While the Board very much welcomes the continued downward trend in many key safety indicators, progress in reducing levels of self-harm and the use of psychoactive substances is slower. What steps are planned to further reduce the number of prisoners self-harming at Channings Wood? Despite successes in the interception of drugs, can even more effective measures be taken to reduce …
Governor / Director
Bedford (2020)
In the review of the ACCT process, consider the two main drivers: (a) clinical need; and (b) achievement of personal goals or redress of perceived procedural injustice. Can these be addressed separately?
HMPPS
Dartmoor (2021)
Ensure that Listeners and the Samaritans services are available at all times of the day and night, including ensuring all staff understand that access to these services should be allowed, following occasions where prisoners have not been able to access them at night.
Governor / Director
Bedford (2021)
While there is a steady decrease in self-harm incidents, we feel that a better system of investigation of incidents, to understand the causal links, would lead to further improvements.
Governor / Director
Swaleside (2022)
Wellbeing checks for all prisoners must be increased and maintained regularly to prevent self-harm.
Governor / Director
Leeds (2022)
In respect of self-inflicted deaths in custody, is there more that could be done to reduce the likelihood of such incidents happening again?
Governor / Director
Grendon (2022)
Delivery of staff training e.g. suicide and self-harm (SASH) (4.2.6).
Governor / Director
Altcourse (2022)
The prison was designated a ‘cluster death site’ in October 2021 but no additional support/training was forthcoming from the centre which would have been helpful in identifying any areas for development.
HMPPS
Foston Hall (2023)
Self-harm levels continue to be high. What more can be done to support prisoners who harm themselves?
Governor / Director
Bure (2023)
The Board has noticed an increase in self-harm and this needs to be investigated by the prison.
Governor / Director
Bristol (2023)
The Prison Service should reduce the prison roll at Bristol to enable the prison to effectively address the increases in self-harm, violence and deaths in custody.
HMPPS
Hull (2024)
Continue to undertake trend analysis and proactive work to reduce self-harm and violent incidents (prisoner on prisoner and assaults on staff).
Governor / Director
Five Wells (2024)
How will the prison improve its management of ACCT cases to reduce the frequency of self-harm incidents?
Governor / Director
Durham (2024)
The prison was, again, designated as a cluster death site in July. What urgent steps will the Prison Service take to prevent deaths in custody?
HMPPS
Bure (2024)
The Board has noticed an increase in self-harm and this needs to be investigated by the prison.
Governor / Director
Swaleside (2025)
The Board shares the concerns expressed by the senior leadership team (SLT) that there have, again, been deaths in custody during the year, especially as only two were, apparently, due to natural causes. What specific, actions are being taken to prevent further fatalities and improve prisoner safety?
HMPPS
Pentonville (2025)
The ACCT documentation (revised in 2022) remains overly complicated and cumbersome. When will HMPPS revise this essential documentation, given its potentially life-saving importance?
HMPPS
Lewes (2025)
Will the governor renew efforts to reduce incidents of self-harm, which have gone up by around one third over the past two years?
Governor / Director
Five Wells (2025)
What steps will the prison take to reduce the frequency of self-harm incidents?
Governor / Director
Five Wells (2025)
What steps will the prison take to reduce the frequency of self-harm incidents?
Governor / Director
Durham (2025)
The prison was, again, designated as a cluster death site in July. What urgent steps will the Prison Service take to prevent deaths in custody?
HMPPS
Pentonville (2020)
What will you do to improve the quality assurance of assessment, care in custody and teamwork (ACCT) processes, as highlighted in the HMIP IRP report, and ensure that all relevant participants are included in reviews?
Governor / Director
Manchester (2020)
What measures are being introduced to reduce the risk of violence in the prison and support those prisoners at risk of self-harm?
Governor / Director
Cardiff (2020)
We applaud the establishment in its efforts to maintain key worker sessions during the restricted regime but would ask that consideration be given to whether the cross-deployment of key workers affected the incidence of self-harm (see paragraph 5.3.1).
Governor / Director
Bullingdon (2020)
How will the governor set out to address the changes in culture and practice that are required if assessment, care in custody and teamwork (ACCT) and associated procedures are to be used more effectively (see below, 4.2.5)?
Governor / Director
Bedford (2020)
Improve implementation of the current ACCT process.
Governor / Director
Elmley (2021)
There should be greater, more formal analysis of self-harm. The assessment, care in custody and teamwork (ACCT) documents are valuable for recording such events and their possible triggers, but the underlying causes seem never to be identified in their relation to the prison environment, which could be modified.
Governor / Director
Berwyn (2021)
The Board is concerned about the high levels of self-harm, assaults and use of force.
Governor / Director
Bedford (2021)
We echo the concerns of Her Majesty’s Inspectorate of Prisons (HMIP) regarding the implementation of the assessment, care in custody and teamwork (ACCT) process and would hope that the new version might lead to improvements. We can also see real value in involving prisoners in assessing the effectiveness of the ACCT system.
Governor / Director
Thameside (2022)
Address Listener call-out issues across the houseblocks (see section 4.2).
Governor / Director
Foston Hall (2022)
The continued high level of self-harm (see paragraph 4.2.1)
Governor / Director
Chelmsford (2022)
To continue to reduce the levels of violence, self-harm, bullying, drug use and drug smuggling.
Governor / Director
Bedford (2022)
We believe that the formulation of ACCT care plans should begin by asking prisoners about their coping strategies and preferred sources of help. The care plan should proceed from there.
Governor / Director
Swaleside (2023)
The Board remains concerned regarding the mental health of prisoners who have suffered long-term lockdown. This is evidenced by the high number of ACCT cases, self-harm cases and violent incidents. The first indications from the recent improvement in regime are positive. However, the necessity for increased psychology and psychiatric services still needs to be assessed.
HMPPS
Stocken (2023)
The number of inappropriate transfers has risen over the last year. This includes prisoners who are transferred on open assessment, care in custody and teamwork (ACCT) documents and prisoners who have only been in prison for a few days or weeks. Hence, prisoner flow is still not working as it should.
HMPPS
Scottish Fatal Accident Inquiries (2)
Katie Allan; William Brown
Remove double bunk beds from young prisoner cells; replace door-stops with anti-ligature designs; pilot signs of life technology; restrict access to belts and cords; system for court documentation to reach SPS on admission; 24-hour family reporting number; 72-hour TTM presumption for all young admissions; enhanced risk assessment forms; improved electronic documentation; increased staff training frequency
Jan 2025
Custody
25 recs
Scotland
Sarah Jane Riley
1. The Scottish Ministers and SPS should consider (a) establishing a system in respect of prisoners who have been sentenced to an OLR to allow for a psychological formulation focussed on the prisoner's risk to themselves, based on the information already available from the Risk Management Plan, to be prepared and shared with the prisoner's personal officer and other SPS …
Nov 2025
Custody
8 recs
Scotland
Article 2 Learning Points (10)
— 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 …
HMPPS
Accepted
— 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 …
HMPPS
Accepted
— LP A
The Police and the Prison Service should use the same scale and terms when assessing risk of self-harm.
HMPPS
Rejected
— LP 8
I recommend to NOMS that: An inquiry into an incident of life-threatening self-harm should always include an examination of healthcare as well as the actions of the discipline staff. Findings and conclusions should take account of both aspects considered jointly.
NOMS
— LP 6
We recommend that the ACCT process includes regular assessment of potential triggers for self-harm, with the subsequent establishment of relapse prevention and contingency plans and identification of when risk may be particularly high. In our view, the most important risk factors for self-harm in Mr Quartz’s case were relationship difficulties …
HMPPS
Accepted
— LP 13
Prisoners on Level A of the Safe Supervision of Prisoners (in-patients) policy should be reviewed on a daily basis in accordance with that policy and these reviews should be documented.
The Governor
Accepted
— LP 3
A specialist service should be available to address the underlying social problems associated with risk of self-harm, where needed, for prisoners identified under ACCT (formerly F2052SH).
HMPPS
Accepted
— LP 11
We recommend that HMP Pentonville moves away from the regime of hourly ACCT entries to help encourage the recording of more meaningful entries.
The Governor
Accepted
— LP 1
It is noted that the Internal Investigation, 2002, recommended attendance by the Chaplaincy at F2052SH (now ACCT – Assessment, Care in Custody and Teamwork) reviews both locally and nationally, and this recommendation is supported. In cases where drug abuse is involved a CARATS representative should also attend, and Education staff …
HMPPS
Rejected
— LP N
We endorse the recommendation made by the Brixton internal investigation that, in the event of an incident of barricade or potential suicidal behaviour, contingency plans are managed by the Duty Governor. We would, however, add the proviso that this should not delay a response in an emergency.
HMPPS
Detention Investigations (3)
Assessment of government progress in implementing the report on the … — Rec 38
The Home Offce should devise and publish a strategy for reducing the number of deaths from natural causes and those that are self-infcted in, and shortly after, immigration detention.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 37
I recommend that the Home Offce commission research into deaths in immigration detention, ‘near misses’ and incidents of serious self harm.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 36
I recommend that IRC staff who have regular contact with detainees should receive mandatory safer detention training on an annual basis.
Immigration Detention
LGO / SPSO Decisions (3)
201802883 — Scottish Prison Service
Ms C complained about her treatment by the Scottish Prison Service (SPS). Due to her circumstances, Ms C's supervision level was raised to high. Ms C accepted the prison rules in relation to this, however, claimed that other prisoners under the same circumstances as her remained at a low supervision …
SPSO (Scottish Public Se…
Prisons
Not Upheld
May 2019
201303972 — Scottish Prison Service
Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) had decided that he no longer needed to be managed under their process for prisoners at risk of suicide or self-harm. Mr C had been managed under this process for a number of days, as he had …
SPSO (Scottish Public Se…
Prisons
Upheld
Aug 2014
201301310 — Scottish Prison Service
Mr C, who was a prisoner, complained because he did not think the prison followed the correct process when reviewing his supervision level. Our investigation confirmed that the prison reviewed it after he assaulted another prisoner and because of that incident, his supervision level was increased to high. The prison …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Oct 2013