Poor prisoner suicide risk assessment
Inadequate assessment of self-harm/suicide risk for prisoners, particularly those without existing care plans.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
93match
Shaun Dewey
The coroner raises concerns that the elevated risk of self-harm and suicide among remand prisoners is not adequately incorporated into staff training, highlighted to care teams, or reflected in national guidance and risk assessment documents.
Matched on
terms: assessment, prisoner, suicide
PFD report
89match
Tomasz Nowasad
The coroner noted an over-emphasis on prisoner assertions of no self-harm intent, insufficient consideration of all risk factors during assessments, and a lack of written records detailing how self-harm and suicide risk assessments were conducted.
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
87match
Michael James Meyler
The coroner noted inadequate circulation of self-harm/suicide risk documents to healthcare and wing officers within the prison, alongside a failure to attach these to ACCT plans. There were also no clear procedures for logging that wing officers had reviewed relevant prisoner information.
Matched on
terms: prisoner, suicide
PFD report
85match
Andrew Jones
The coroner noted inadequate assessment and management of self-harm risk in prison, particularly a failure to update a prisoner's risk profile after significant changes and to communicate this altered risk to the receiving wing.
Matched on
terms: assessment, prisoner
Scottish FAI
81match
Katie Allan; William Brown
1. Double bunk beds should be removed from all cells in any wing or hall within Polmont in which young prisoners are accommodated. SPS must take all necessary measures to ensure that no young prisoner is in future accommodated on a single occupancy basis in a cell in which there is a double bunk bed. 2. All door...
Matched on
terms: assessment, 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
Inquiry recommendation
77match
52 - Guidance for duty governors on risk assessment
The instructions for completing the form should give duty governors guidance on how to exercise the options available to them when dealing with prisoners who are both at risk of self-harm and a risk to their cellmate.
Matched on
terms: assessment, prisoner
Inquiry recommendation
77match
4 - Placing at-risk prisoners with a cellmate
The Prison Service should retain its practice of placing prisoners who are at risk of suicide or self-harm, but who are not so vulnerable as to require being on suicide watch at all times or accommodated in a safer cell, in a cell with another prisoner who they can talk to in times of crisis. The practice should...
Matched on
terms: prisoner, suicide
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
Scottish FAI
77match
William Lothian
in the following terms: (i) The reception process should be reviewed by SPS at the earliest convenient opportunity (and if possible within the scope of the current review of prevention of suicide policy) with a view to considering whether there should be an automatic referral to the Talk to Me process where a new prisoner is a first...
Matched on
terms: assessment, prisoner, suicide
IOPC learning recommendation
76match
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 an IOPC review of a local death or serious injury (DSI) investigation where an individual took their own...
Matched on
terms: assessment, 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
Jordan Buckton
Concerns were raised regarding inadequate information sharing within the prison about a person's history of self-harm and the lack of follow-up care, including a PHQ9 assessment, after antidepressant medication was prescribed.
Matched on
terms: assessment
PFD report
73match
Callum Smith
The coroner identified a possible conflict between healthcare staff's risk assessment methods and ACCT policy requirements for prisoners. Concerns were raised that healthcare staff required clearer training on the ACCT process and its lower threshold for intervention.
Matched on
terms: assessment, prisoner
Committee recommendation
73match
#11 - Fifteenth Report - Improving the prison estate
We asked HMPPS why it tolerated such unacceptable levels of prisoner assaults on staff and what it was doing to reduce levels of assaults on staff and self-inflicted deaths. HMPPS asserted that it was very concerned by the number of assaults on staff and was working to reduce this through more staff, the introduction of key workers to...
Matched on
terms: assessment, prisoner
Committee recommendation
73match
#10 - Fifteenth Report - Improving the prison estate
Research commissioned by HMPPS found that the prison environment, including the condition of accommodation, played a role in how prisoners behave.20 Between 2015 and 2018, among adult prisoners, key indicators of poor safety in prisons reached all- time highs. This included a 110% increase in prisoner assaults on staff; a 63% increase in prisoner-on-prisoner assaults; and an alarming...
Matched on
terms: poor, 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
IOPC learning recommendation
73match
Recommendations - Devon and Cornwall Police - April 2022
The IOPC recommends that Devon & Cornwall Police review their processes when informing a suspect of a charging decision in cases where is an increased risk of suicide (either due to the suspect’s circumstances and/or the alleged offence), to ensure: a) an assessment is completed regarding whether it is appropriate to send a postal requisition b) a decision...
Matched on
terms: assessment, suicide
Scottish FAI
73match
Dylan Evan Brian Stickle
I realise that the doctor’s ACT risk assessment is but a part of a general health assessment but recommend that consideration be given to making the PER together with any accompanying information relevant to the issue of suicide or self harm (such as social work department or procurator fiscal letters) available to the examining doctor at least in...
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
Marcin Stoga
The Prisoner Escort Record containing a previous overdose history was not available during Mr Stoga's initial assessment. Additionally, prisoners with mental health issues are not routinely or thoroughly assessed upon return from court hearings.
Matched on
terms: assessment, prisoner
PFD report
69match
Mark Vagnoni
The coroner identified gaps in risk assessment for prisoners during the patrol state when an ACCT is opened, noting a lack of mental health input. Further concerns included the unhelpful NOMIS layout regarding past ACCTs and the absence of wing transfer documentation for risk factors.
Matched on
terms: assessment, prisoner
PFD report
69match
John Wright
The coroner identified gaps in how information about a heightened risk of self-harm for incoming prisoners is received and shared by both prison and healthcare staff due to system limitations and inconsistent practices.
Matched on
terms: prisoner
PFD report
69match
Ian Weeks
Healthcare staff did not adequately review Mr. Weeks' medical records upon admission to HMP Cardiff, leading to a failure to provide prescribed anti-depressants. The report identified a need for a 'red flag' system for suicide/self-harm and a clear process for reviewing all medical records upon prison admission.
Matched on
terms: suicide
PFD report
69match
Azra Hussain
The coroner noted that family concerns about a patient's reported suicide attempt were not recorded, shared, or acted upon, nor included in the MDT meeting. There were also unmitigated ligature risks identified in an en-suite bathroom following an assessment.
Matched on
terms: assessment, suicide
PFD report
69match
James Devenny
The coroner identified a lack of direct telephone access for prisoners to contact Samaritans, particularly for violent individuals. Prison Officers are also not routinely briefed on prisoners' significant self-harm history or antecedent patterns.
Matched on
terms: prisoner
PFD report
69match
Richard Franks
Information about Mr Franks' stated intent to commit suicide and distress at court was not communicated to prison staff, which prevented an ACCT assessment and increased monitoring. The coroner noted that sharing such protective information does not breach professional privilege.
Matched on
terms: assessment, suicide
Scottish FAI
69match
Christian Douglas McIntosh
Where credible information is received by a prison official that a prisoner has threatened to commit suicide the Scottish Prison Service should review their procedures to ensure that the information:- (i) is recorded in the prisoner’s record together with the details of any action taken and the reasons for any decision not to invoke the ACT 2 CARE...
Matched on
terms: prisoner, 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
Concerns were raised about the self-harm risk posed by corded telephones suspended at head height in anti-ligature cells and the potential for limited telephone access in the CSU to hinder prisoners in crisis from contacting support services.
Matched on
terms: prisoner
PFD report
65match
Kirk Duboise
The coroner noted a delay in summoning an ambulance and that relevant forms were not seen by staff assessing the risk of self-harm for a new prisoner.
Matched on
terms: prisoner
PFD report
65match
Richard Green
Concerns were raised that previous self-harm incidents recorded on SystmOne were not identified by prison medical staff due to insufficient review of records and usability issues with the system, leading to a lack of awareness of the prisoner's risk.
Matched on
terms: prisoner
PFD report
65match
Mark Holdsworth
Critical information regarding threats of self-harm was not effectively communicated from the incident log to arresting officers, custody staff, or the custody sergeant, impacting their risk assessment.
Matched on
terms: assessment
PFD report
65match
Peter Lawrence
The coroner identified that risk factors may be missed or inadequately recorded for new prisoners, particularly those with limited background information. Further concerns included insufficient interaction with a personal officer, a missed opportunity for risk identification.
Matched on
terms: prisoner