Prison ACCT process flaws
Insufficient multi-disciplinary input at Assessment, Care in Custody and Teamwork (ACCT) reviews, and over-reliance on the process.
Source spread
Where this theme appears
This theme appears across 8 independent accountability sources, so the source mix matters as much as the headline total.
86 PFD reports
3 committee recs
133 PPO recs
76 IMB recs
16 IMB reports
59 Article 2 learning points
1 detention investigation rec
26 LGO/SPSO decisions
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.
Prevention of Future Deaths reports(86)— showing 50 strongest matches
Reggie John
Concerns: Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or updating crucial risk documents.
Response (Worcestershire Health Care NHS): The trust reiterated expectations regarding ACCT documents for prisoners arriving at HMP Hewell, and reviewed Prison Service Instruction 64/2011 to identify and address areas of non-compliance.
Response (HM Prison and Probation Service): HMP Bristol introduced a system to contact receiving establishments about prisoners on open ACCTs, and HMP Hewell issued a notice reminding staff to report information indicating a change in a …
Overdue
Adrian Johnson
Concerns: The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in case management, with no handover from case manager to case manager.
Response (HM Prison and Probation Service): NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject …
Overdue
Ryan Clark
Concerns: Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.
Response (HM Prison and Probation Service): HMP and YOI Wetherby implemented a revised personal officer scheme in October 2013 to ensure greater continuity in the allocation of staff to young people, including a 'relief' arrangement and …
Response (Leeds City Council): Leeds City Council has agreed on a procedure between Children's Social Work Service and Youth Offending Service to share all relevant information about a young person going into custody with …
Responded
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
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
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
Yohannes Kidane
Concerns: Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.
Response (HM Prison and Probation Service): NOMS reviewed the night staffing level for HMP Birmingham and found it acceptable, noting G4S's deployment of a Prison Custody Officer. They state that the Night Orderly Officer arranges cover …
Response (Birmingham Solihull NHS): The Trust has liaised with Birmingham Community Healthcare Trust and G4S to address staffing concerns and is considering options for staff breaks, including administrative duty sharing. They are engaging the …
Responded
Seweryn Glowinski
Concerns: Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Overdue
Cherylin Norrell-Goldsmith
Concerns: Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on non-medical records. Data retention issues also exist.
Response (HM Prison and Probation Service): The Ministry of Justice Estate Directorate is providing 'safer cells' in new construction and refurbishment projects. HMP Downview's local policies and procedures have been reviewed and strengthened, and the NHS …
Overdue
Geraldine Kilborn
Concerns: There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.
Response (HM Prison and Probation Service): An amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective …
Response (Care UK): From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model. Daily reviews will be undertaken by a member of …
Response (Tess Esk Wear Valleys NHS Trust): TEWV has already made changes to the availability of Mental Health Team staff over the weekend. Staff are on duty between 9.30 am - 1230pm Saturday and Sunday, with a …
Responded
Alex Kelly
Concerns: A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.
Response (Tower Hamlets): Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a …
Response (Central North West London NHS Trust): Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state …
Response (Oxleas NHS Trust): Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff …
Response (Medway Youth Offending Service): The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission …
Response (Ministry of Justice): The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm …
Responded
Stuart Baumber
Concerns: Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.
Overdue
Greg Revell
Concerns: Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information systems were insufficient, leading to missed opportunities for vital medication and treatment.
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
Carl Smith
Concerns: Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
Response (Dorset Healthcare University NHS Foundation Trust): Dorset HealthCare NHS Trust implemented new policies and procedures to improve the quality of service in Devon Prisons. An education package has been put in place for all staff regarding …
Overdue
Andrew Frere
Concerns: A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read ongoing observations during ACCT reviews, risking missed critical information.
Overdue
Liam Smith
Concerns: Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.
Response (HM Prison and Probation Service): HM Prison and Probation Service has reiterated the professional obligation of clinical staff to review relevant parts of prisoner's notes and has changed practices relating to high risk drug users …
Overdue
Samuel Gale
Concerns: A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.
Response (Serco): Policy changes have been made so that only a manager grade can close an ACCT, and ACCTs cannot be closed unless the case review comprises at least two people and …
Response (NHS England): NHS England is reviewing templates for first night screening and risk assessment as part of the deployment of a new Health & Justice Information System, with rollout expected from July …
Responded
Lee Rushton
Concerns: There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring single cell occupancy for prisoner protection.
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
Matthew Sargent
Concerns: Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.
Response (Matthew Sargent): Care UK notes the concerns raised but states that the role and responsibilities of Personal Officers fall within the remit of the Prison Service. They note that PSI 74/2011 sets …
Response (HM Prison and Probation Service): Following concerns regarding the Personal Officer scheme, the prison will ensure that all staff are reminded of the policy. In response to concerns about historical information, a process has been …
Responded
Sheldon Woodford
Concerns: Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.
Overdue
Ian Brown
Concerns: Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and self-harm due to inadequate ACCT case management.
Response (HM Prison and Probation Service): NOMS has introduced a monthly forum to monitor progress on actions taken in response to recommendations relating to recent deaths in custody, delivered case management training to 90% of managers …
Overdue
Kevin Dermott
Concerns: While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was never completed; inadequate mental health cover at HMP Haverigg and a lack of suitable psychiatric care facilities at HMP Kirkham contributed to a failure to recognise relapse into depression at HMP Risley.
Response (NHS England): NHS England is working with other organisations to address the lack of secure psychiatric beds. Updated guidelines for transferring prisoners to secure mental health hospitals are due for final consultation …
Response (HM Prison and Probation Service): HMP Risley has increased the level and depth of management checks on ACCT documents, will issue a Governor's Order clarifying staff responsibilities, and has informed staff to contact the Safer …
Response (Department of Health): The Department of Health acknowledges the concerns, highlights its commitment to working with NOMS and NHS England, and notes that NHS England and NOMS will be responding separately.
Responded
John Betteridge
Concerns: Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
Overdue
Warren Sampson
Concerns: Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Response (Care UK): Discipline staff now email healthcare each day with the ACCT reviews they are intending to hold and invite the appropriate healthcare professional to input into the process. A Second Health …
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
Margaret Atkinson
Concerns: Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking signs of increased risk.
Response (Tees Esk & Wear Valley NHS Foundation Trust): The prison Mental Health services are using more specific language than "ligature" to describe observations, discussed in team meetings. The Trust will work with partners to agree and promote a …
Overdue
Matthew Russell
Concerns: Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.
Response (Central and North West London NHS Foundation Trust): The Trust has introduced Complex Case Review Meetings at HMP Highdown, to commence in February 2017, to include GPs, Primary Care, Mental Health, Substance Misuse; Social Care, Safer Custody and …
Overdue
Roy Hoey
Concerns: Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.
Response (HM Prison and Probation Service): NOMS acknowledges potential confusion regarding ACCT guidance and will resolve this in the revision of PSI 64/2011, due for completion by the end of April 2017; the revised version will …
Responded
Dean Saunders
Concerns: Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Response (NHS England): NHS England states that Care UK circulated a document with contact details of medical staff who can sign Mental Health Assessment documents, and a new provider will deliver healthcare at …
Response (Essex Partnership NHS Trust): Essex Partnership NHS Trust has submitted its admissions protocol for regional review by the Secure Services Catchment Group for East of England and will inform the coroner of the outcome; …
Response (Care UK): Care UK developed a new Mental Health Pathway, formally signed off on 28 March 2017, and is rolling it out across all Care UK sites via mental health workshops to …
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
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
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
Mark Doyle
Concerns: Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
Response (Care UK): Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared …
Overdue
Robert McLoughlin
Concerns: The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.
Overdue
John Mayhew
Concerns: Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.
Overdue
John Delahaye
Concerns: National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Response: NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as …
Overdue
Nicky Reilly
Concerns: The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.
Response (Greater Manchester Mental Health NHS Foundation Trust): Prison psychology teams can request access to patient's clinical records and have been informed how to gain access. A rewritten guidance document for staff addresses patients who are non-concordant with …
Response (HM Prison and Probation Service): HMPPS provides a Care and Management Plan for prisoners managed by the Managing Challenging Behaviour Strategy (MCBS). They are rolling out 'Working with Challenging Behaviour' training, have developed a toolkit …
Responded
Kelvin Speakman
Concerns: The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings are recurring despite previous assurances.
Response (HM Prison and Probation Services): HMPPS will deliver coaching sessions to ACCT case managers at HMP Hewell, emphasizing information sharing and accurate recording. A updated ACCT case management system is being piloted and will be …
Overdue
Marcus McGuire
Concerns: HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Response (HM Prison and Probation Service): HMP Birmingham has trained additional case managers, monitors compliance with the single case manager model daily, reviews it monthly, and has introduced further quality assurance of every ACCT document.
Response (G4S): G4S states that actions at HMP Birmingham are not within its remit as the prison is now operated and managed by HMPPS, but they reflect on every death in custody …
Responded
Ryan Trimmer
Concerns: The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.
Response (HM Prison and Probabtion Service): HMPPS piloted a revised version of ACCT and will roll out a new version nationally in early 2020, and two on-site first aid trainers will deliver first aid training to …
Overdue
Daniel Davey
Concerns: Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.
Response (Care UK): Care UK updated its Local Operating Procedure in February 2019 to ensure a member of healthcare staff attends planned ACCT reviews daily. In-possession risk assessments are completed at various points …
Response (HM Prison Probation Service): HMP Bullingdon implemented a new ACCT case management system with a case manager assigned to each case. The prison issued guidance stating in-possession medication is a topic for ACCT reviews, …
Response (Midlands NHS Trust): The Trust has reminded staff to update Medication In Possession risk assessments, ensuring updates feed into the ACCT. Staff were reminded that changes in presentation regarding serious self-harm should trigger …
Overdue
Amir Siman-Tov
Concerns: Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.
Overdue
Harold Uzomechina
Concerns: Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.
Overdue
David Kirsch
Concerns: A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and critical information about the deceased's deteriorating mental state and specific concerns not being recorded.
Response (HM Prison and Probation Service): HMPPS has revised training for ACCT case managers, emphasising consistency, Caremap completion, and information sharing, with guidance sent to existing case managers at Long Lartin and training for all Band …
Responded
Darren Williams
Concerns: ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were opened.
Overdue
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
Carl Newman
Concerns: Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.
Response (HM Prison and Probation Service): Following the inquest, the Governor of HMP Liverpool issued a staff information notice promoting the use of the myLearning system for accessing training records, and a comprehensive guide on how …
Responded
Select committee recommendations(3)
#19 — Set out complementary work being done alongside ACCT to prevent over-reliance on the process.
Recommendation: Although many witnesses have welcomed the revised ACCT process, we note the concern expressed by some that there may be an over-reliance on ACCT, and a perception that it is seen as an outcome in itself. Whilst the ACCT should …
Gov response: We do not accept this recommendation. A cross-agency group, established by MoJ, carried out extensive work to explore potential data sources to better understand the circumstances in which these powers are used. The group concluded …
Under Consideration
#18 — Set out clear evaluation methods for the new ACCT process's success in reducing self-harm.
Recommendation: The increasing level of self-harm in the female estate over the last decade is alarming and while the number of self-inflicted deaths is low, even one death is one too many. We recognise that the MoJ and HMPPS are working …
Gov response: We accept this recommendation. MoJ has now concluded its internal review into the use of the power to remand defendants for their own protection under the Bail Act 1976. The Government has set out proposed …
Accepted
#7 —
Recommendation: The Ministry and HMPPS have a duty of care to those in prisons. We have reported in the past that improving the mental health of prisoners is a difficult and complex task, and that it is essential to reducing reoffending …
Gov response: 2: PAC conclusion: The pandemic has significantly impacted the wellbeing and life chances of prisoners, making it critical that the Ministry and HMPPS accelerate their work to improve the mental health of prisoners. 2: PAC …
Not Addressed
PPO death in custody recommendations(133)— showing 50 strongest matches
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 Prison Group Director for Devon and North Dorset
The Prison Group Director for Devon and North Dorset should assure herself that meaningful action is being taken to ensure that ACCT procedures at Channings Wood improve.
The Governor
The Governor should ensure that ACCT post-closure reviews are conducted in line with Prison Service instructions and should be held to check the prisoner’s progress and to decide whether further monitoring is needed.
The Governor
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with national instructions. In particular, staff should: • hold multidisciplinary ACCT reviews; and • set effective caremap objectives which are specific, time-bound, meaningful, aimed …
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 Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff hold an urgent ACCT case review whenever information is received that a prisoner’s risk might have increased, in line with the requirements of PSI 64/2011.
The Governor of HMP Nottingham
The Governor should ensure that staff manage ACCT procedures in line with prison policy including that: • There is a consistent ACCT case coordinator and case review team wherever possible. • A case review is held shortly before an identified …
The Director at Parc
The Director at Parc should ensure that staff obtain appropriate clinical input where appropriate before deciding to stop ACCT procedures.
The Director at Parc
The Director at Parc should ensure that staff ensure that caremap actions are created and reviewed in line with national guidance and are specific, meaningful and time-bound, aimed at reducing prisoners’ risks;
The Director at Parc
The Director at Parc should ensure that staff mark caremap actions as completed only once they have been actioned fully;
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should ensure that SLPs are properly completed and shared with operational staff and are taken into account when providing care to prisoners.
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 Centre Manager
The Centre Manager should ensure that staff understand their responsibilities when carrying out ACDT observations, including that they: • obtain a clear visual sighting of the detainee using a torch if necessary; and • accurately record the time of the …
The Governor of HMP Holme House
The Governor should ensure that staff: record the agreed frequency of ACCT observations on the front of the ACCT document and in the case review notes; carry out observations at the correct frequency; and vary times of ACCT checks, while …
The Governor
The Governor should ensure that when carrying out an ACCT check, the staff member satisfies themselves that the prisoner is alive and well and if they have any concerns, they enter the cell or summon assistance immediately.
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 Head of Healthcare
Mental health staff assessing prisoners verify whether that prisoner is under ACCT management.
The Governor of HMP Bristol
The Governor should ensure that staff manage ACCT procedures in line with prison policy, in particular staff should: • invite all relevant staff that are involved in supporting the prisoner to case reviews; • fully acquaint themselves with the prisoner’s …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff responsible for ACCT procedures comply with the following national policy requirements: • assessing a prisoner’s risk based on their risk factors and not solely their presentation; • reassessing risk and …
The Director and Head of Healthcare
The Director 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
The Governor should review the quality and compliance with policy of ACCT management in the previous 12 months, identify any improvements required, and devise a plan to deliver those improvements.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff have received full (two day) ACCT training and that they are satisfied that staff can appropriately assess a prisoner’s risk to themselves.
The Governor
The Governor should ensure that prison staff manage prisoners at risk of suicide and self-harm in line with national guidelines, including that: • ACCT monitoring does not stop until all support actions have been completed and their risk is no …
The Governor
The Governor should investigate the quality of and compliance with policy of ACCT management, including the use of alternative clothing and special accommodation, in the previous 12 months, identify any improvements required, and devise a robust plan to deliver those …
The Governor
The Governor should ensure that where a prisoner on ACCT is moved from segregation and there is a concern regarding a potential risk created by a return to normal location, then wider consultation should be sought prior to the move …
The Governor
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with policy guidance, in particular that they: fill out the ACCT care plan correctly so that it shows the date by which the care …
The Governor of HMP Liverpool
The Governor should ensure that welfare checks are clearly defined in Liverpool’s Safer Strategy, that staff complete welfare checks in line with this strategy and that there is a robust quality assurance process in place to ensure these checks are …
The Governor of HMP Wandsworth
The Governor should introduce a robust audit process to check the accuracy of recorded ACCT checks against CCTV to assure herself that there is not a systemic issue with false entries.
The Governor
The Governor should introduce a robust audit process to check the accuracy of recorded ACCT checks against CCTV to assure herself that there is not a systemic issue with false entries or missing checks.
The Deputy Director of Immigration Prison Teams (North and South)
The Deputy Director of Immigration Prison Teams (North and South) should ensure that HOIE staff: are involved in the ACCT process, including reviews, if there are concerns about a prisoner’s immigration or deportation status, and
The Deputy Director of Immigration Prison Teams (North and South)
The Deputy Director of Immigration Prison Teams (North and South) should ensure that HOIE staff: share and record their contact with prisoners (and detainees) in prison records, including ACCT documents;
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 guidelines, including that: staff ensure ACCT documents travel with prisoners when they leave the wing.
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 guidelines, including that: staff consistently invite the HOIE team to contribute to ACCTs where immigration issues are relevant; …
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 guidelines, including that: staff set specific and meaningful caremap actions, identifying who is responsible for them and reviewing …
The Prison Group Director for Avon, South Dorset and Wiltshire
The Prison Group Director for Avon, South Dorset and Wiltshire should satisfy himself that meaningful improvements have been made to the management of ACCT procedures at Bristol.
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 issue guidance to staff to ensure that they properly consider and record the range of risk factors when a prisoner harms themselves, and that they always start ACCT procedures unless there has been …
The Governor
The Governor should ensure that urgent case reviews take place when a prisoner monitored under ACCT procedures harms themselves or other indicators of increased risk emerge.
The Director of HMP Fosse Way
The Director should undertake a review of the ACCT quality assurance process to satisfy himself that when issues are identified, appropriate remedial actions are taken in response.
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
The Governor should ensure that prison staff understand and know how to implement national HMPPS policy requirements for the management of prisoners at risk of suicide and self-harm, including: • ensuring that staff are clear on who is responsible for …
The Head of Healthcare
The Head of Healthcare should ensure that staff understand and know how to implement their mandatory duty to document their interactions with prisoners under ACCT management.
The Governor and Head of Healthcare at Risley
The Governor and Head of Healthcare should ensure that where staff have information about a prisoner’s risk, they should share it appropriately, respond proactively to identified risks, fully record actions taken and where necessary, start ACCT procedures without delay.
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 Head of Healthcare
The Head of Healthcare should ensure that all staff make an entry in the ACCT record after intervention with a prisoner to ensure continuity of care.
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 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 Operational Manager
The Operational Manager should ensure that prisoners in segregation are managed in line with PSO 1700, in particular: • Prisoners on an ACCT are segregated only in exceptional circumstances. • Where a segregated prisoner becomes subject to ACCT procedures, a …
IMB annual reports(16)
Wetherby (2021)
This report highlights HMYOI Wetherby's effective management of the Covid-19 pandemic and positive staff-prisoner relationships, alongside significant improvements in facilities and family contact. However, it raises serious concerns, particularly the chronic shortage of secure mental health beds, delays in transferring young adults, and persistent issues with maintenance. The Board also notes challenges in staffing stability, ACCT application, and high levels of violence, urging action from the Minister, Youth Custody Service, and Governor.
PRISON
Key concerns
Erlestoke (2024)
HMP Erlestoke, a Category C prison, experienced significant increases in self-harm (468) and violence (153 incidents, 111 prisoner-on-prisoner) during the reporting year, with no deaths in custody. Key concerns include inconsistent welfare checks, persistent illicit substances, and the inadequate delivery of key working. While positive developments like a neurodiversity support manager and improved staff-prisoner relations were noted, healthcare provision is strained, and time out of cell remains limited for a quarter of the population. The Board highlights an urgent need for improved mental health provision and clarity for IPP prisoners.
PRISON
Key concerns
Leeds (2024)
HMP Leeds, a local reception prison with an operational capacity of 1110, reported 8 deaths in custody during 2024, six of which were self-inflicted. Overcrowding, persistent staff shortages leading to regime curtailments, and significant delays in transferring prisoners with severe mental health issues were key concerns. Despite these challenges, the Board highlighted positive staff-prisoner relationships, efforts in drug rehabilitation, purposeful activity, and initiatives to maintain family contact.
PRISON
Key concerns
Durham (2025)
HMP Durham, a reception and resettlement prison, housed an average of 961 men against an operational capacity of 985 during the reporting year. The Board observed improvements in first-night healthcare screening and a reduction in self-harm incidents, alongside a significant increase in overall deaths in custody. Persistent overcrowding, inadequate regime delivery with prisoners spending 21.5 hours in cells, and critical staffing shortages impacting key working and healthcare access remain significant concerns.
PRISON
Key concerns
Lancaster Farms (2024)
HMP Lancaster Farms, a Category C prison for up to 560 men, maintained a largely safe and humane environment despite operating at maximum capacity. The report highlights successes in healthcare provision and purposeful activity, alongside ongoing issues with staffing shortages that curtail the regime. Key concerns include high self-harm rates, increased violence, estate maintenance, ineffective key worker schemes, and significant waiting times for healthcare and mental health transfers.
PRISON
Key concerns
Lewes (2024)
HMP Lewes is a Category B local prison facing significant challenges in safety, healthcare, and infrastructure, despite some positive developments. Self-harm incidents and prisoner-on-prisoner violence have increased substantially, while time out of cell remains limited. Persistent issues with the estate, healthcare staffing, and disproportionality in treatment continue to impact prisoner welfare, necessitating ongoing Board scrutiny and recommendations to the Minister, Prison Service, and Governor.
PRISON
Key concerns
Moorland (2024)
HMP/YOI Moorland is a Category C training and resettlement prison facing challenges including a substantial increase in self-harm incidents and prisoner assaults on staff. Overcrowding has led to dignity concerns with single cells being doubled, and the regime remains restrictive for many, despite efforts to expand activities. The Board continues to highlight issues with purposeful activity, IPP progression, and the need for consistency in monitoring and educational offerings.
PRISON
Key concerns
Five Wells (2024)
HMP Five Wells, a privately run Category C prison, increased its population to 1,700 by March 2024, leading to the doubling up of some cells. While the Board noted significant operational improvements under new leadership and generally good accommodation, it raised serious concerns about the prevalence of illicit substances, self-harm, and the management of use of force incidents. Challenges persist in staff recruitment, education provision, and the under-resourcing of the IMB itself.
PRISON
Key concerns
Pentonville (2024)
HMP Pentonville, a Category B local prison, experienced significant challenges in the reporting year, marked by overcrowding with a population of 1,195 against a CNA of 909. The prison saw a 28% increase in violence and a 13% rise in self-harm incidents, alongside chronic issues with infrastructure, pest infestations, and limited time out of cell for prisoners. Staffing shortages impacted key services, and critical concerns included the lack of mental health secure beds and the unsatisfactory conditions of worship areas.
PRISON
Key concerns
Whitemoor (2024)
HMP Whitemoor, a high-security Category B training prison, faced significant challenges in the reporting year (June 2023 - May 2024), particularly due to staff shortages and a changing prisoner demographic. These issues led to curtailed regimes, limited purposeful activity, and inadequate access to family and legal visits. While the prison made efforts in areas like property handling, cleanliness, and managing self-harm incidents, key concerns persist regarding the appropriateness of holding Category B prisoners in Category A conditions and the quality of purposeful engagement.
PRISON
Key concerns
Thameside (2024)
HMP Thameside is a privately operated local Category B/C prison for adult male prisoners, often occupied close to its operational capacity of 1232, with a 75% remand population. The IMB reports persistent concerns regarding healthcare provision, increasing delays in mental health transfers, and issues with the maintenance of the estate including lifts and in-cell technology. While some improvements have been noted in areas like reception, significant challenges remain in staffing, violence reduction, and ensuring fair and humane treatment, particularly concerning property management and the disproportionate disciplining of Black/mixed race prisoners.
PRISON
Key concerns
Channings Wood (2024)
HMP Channings Wood has navigated a challenging year following the closure of HMP Dartmoor, resulting in significant population changes and regime disruptions. While staff resilience and a downward trend in self-harm and assaults are positive, the prison faces persistent issues with property loss, inadequate infrastructure maintenance, and delays in access to purposeful activity. Concerns also remain regarding the care of an expanding ageing population and the plight of IPP prisoners.
PRISON
Key concerns
Durham (2024)
HMP Durham, a Category B reception and resettlement prison, faced significant challenges in the reporting year ending October 2024. The prison, operating at 98.9% of its operational capacity with 974 prisoners, saw a concerning decline in safety, marked by substantial increases in self-harm (34%), assaults (52%), and use of force (76%). Overcrowding and a deteriorating estate were persistent issues, alongside critical failures in healthcare provision, an inconsistent regime, and poor engagement in education, leading to an overall reduction in prisoners feeling safe.
PRISON
Key concerns
Lewes (2025)
HMP Lewes saw improvements in its regime, leading to increased time out of cell and a fall in prisoner-on-prisoner violence. Healthcare provision also improved, with reduced waiting times for routine appointments. However, significant challenges persist with the prison's heating system, gaps in mental health services, and a worrying increase in self-harm and assaults on staff. The Board highlighted ongoing concerns regarding disproportionality in the use of force and adjudications against certain prisoner groups.
PRISON
Key concerns
Bedford (2021)
HMP Bedford operated under severe Covid-19 restrictions, largely maintaining safety against the virus. However, the prison continues to face significant challenges with unacceptably high violence levels, exacerbated by overcrowding and prolonged cell confinement. While healthcare provision was generally good, mental health services remained a concern, and resettlement planning was ineffective. Staffing issues, including an inexperienced workforce, also impacted overall performance during this challenging period.
PRISON
Key concerns
London STHF (2024)
The London STHF IMB report highlights significant concerns regarding the treatment and conditions of detainees for the reporting year ending January 2024. Despite some positive observations in staff conduct and minor amenity improvements, critical issues persist with data provision for vulnerable adults and use of force, extended detainee waits in unsuitable facilities, and systemic failures in interpretation services and access to medication. The Board urges resolution of these long-standing problems.
PRISON
Key concerns
IMB individual recommendations(76)— showing 50 strongest matches
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
Partially Accepted
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
Partially Accepted
Lewes (2021)
The IMB urges the Governor to take steps to reduce the number of men on an assessment, care in custody and teamwork (ACCT) plan and on constant watch in the care and separation (CSU) unit.
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
Norwich (2022)
The Board asks the Governor to provide information on plans for proper completion of ACCT documents and the management of the ACCT process.
Governor / Director
In Progress
Durham (2022)
The Board regularly reviews ACCT documents and is concerned at the number of them that do not have supervisors’ daily checks completed (see 4.2.10).
Governor / Director
Durham (2023)
How will you reduce the level of open and post ACCT documents that present with omissions/administrative errors? (4.2.8)
Governor / Director
Wetherby (2024)
The IMB recommends that the YCS reconsiders the appropriateness of the ACCT format.
HMPPS
Wealstun (2024)
How will the Governor ensure that information in an ACCT file only includes paperwork for one week whilst archiving and storing the remainder, as stated in the response to the 2022-2023 annual report (see ‘response to the last report’, below)?
Governor / Director
Pentonville (2024)
The ACCT documentation (revised in 2022) is poorly drafted, overly complicated and many staff are not able to complete it adequately. Will HMPPS commit to an urgent review of this essential, potentially lifesaving, documentation?
HMPPS
In Progress
Elmley (2024)
Address the inconsistency in the quality of ACCT documents through effective quality assurance.
Governor / Director
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
Implemented
Norwich (2025)
The Board still has concerns about ACCT documents. What action will the Governor take to ensure further improvements in the management of the ACCT process and completion of documents by staff?
Governor / Director
Norwich (2020)
How does the Prison Service plan to improve the design of the recently piloted ACCT document, to make it more user-friendly, cohesive, and easier to follow the journey and needs of the individual at risk?
HMPPS
In Progress
Gartree (2020)
Will the Governor continue to ensure that monitoring and quality assurance checks of all ACCT documents are carried out by a dedicated safer custody custodial manager, and that all documentation is of the required standard and all post-closure reviews are undertaken?
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
In Progress
Winchester (2021)
Can ACCT review be planned so that daily demands on prison and healthcare staff are manageable, thereby improving the quality of reviews? (See section 6.4).
Governor / Director
Wetherby (2021)
The completion of the new ACCT v6 document presents, for many staff, a substantial challenge and too many completion errors and omissions still remain. Can the Governor reassure the Board that sufficient quality assurance procedures are in place to improve understanding of the ACCT document across the prison?
Governor / Director
Grendon (2021)
Restrictions due to Covid-19 and project work notwithstanding, the Board looks forward to: the delivery of timely training for ACCTs, and control and restraint (see 4.2.4 and 4.4.2)
Governor / Director
Gartree (2021)
Will the Governor continue to ensure that monitoring and quality assurance checks of all ACCT and CSIP documents are carried out by a dedicated custodial manager, and that all post-closure reviews and documentation are of the required standard?
Governor / Director
Foston Hall (2021)
The IMB is concerned about: high use of segregation, and the increase in prisoners segregated on an open ACCT
Governor / Director
Wakefield (2022)
The ACCT ‘system’ remains wholly paper based. This means that ACCT data produced by staff and IMB members in the form of contemporaneous notes and entries into a prisoner's ACCT file are disaggregated from healthcare data contained in NHS SystmOne and operational data in HMPPS Digital Prison Services (formerly C-NOMIS). This inhibits information sharing between prison officers, governors, registered nurses …
HMPPS
Partially Accepted
Swaleside (2022)
The Board has concerns regarding the mental health of prisoners who have suffered long-term lockdown as evidenced by the high number of assessment, care in custody and teamwork (ACCTs) cases, self-harm cases and general violent incidents. The necessity for increased psychology and psychiatric services should be assessed.
HMPPS
In Progress
Isle of Wight (2022)
we acknowledge efforts to improve systems and process key to safety but note the need to ensure timely and full compliance with requirements of ACCTs, CSIPs and Use of Force reviews.
Governor / Director
Isis (2022)
Provide training and/or supervision of officers completing ACCT documents to ensure consistently accurate good quality entries.
Governor / Director
Foston Hall (2022)
Delays in investigating challenge, support and intervention plan (CSIP) referrals, and the high number resulting in no further action (see paragraph 4.3.6)
Governor / Director
Erlestoke (2022)
Over 40% of first assessment, care in custody and teamwork (ACCT) reviews do not have the benefit of healthcare input, which impacts on the safety of prisoners – how will this issue be addressed?
NHS / Healthcare Provider
In Progress
Bedford (2022)
The layout of the ACCT form does not facilitate care coordinators to summarise the prisoner’s story to bring together a description of triggers, coping strategies and other relevant factors into an individual ‘formulation’. We believe this remains a fundamental flaw in the ACCT process.
HMPPS
Wealstun (2023)
To carry out a review of the Assessment in Care in Custody and Teamwork (ACCT) documentation introduced in 2021 as it is cumbersome and difficult to review.
HMPPS
Noted
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
Garth (2023)
Whilst it is recognised that the ACCT process works well, the incidence of self-harm continues to be a cause for concern.
Governor / Director
Erlestoke (2023)
Over 40% of first assessment, care in custody and teamwork (ACCT) reviews do not have the benefit of healthcare input, which impacts on the safety of prisoners – how will this issue be addressed?
Governor / Director
Thameside (2024)
The Board has concerns about how some ACCT documents are being completed, especially the lack of healthcare attendance at first case reviews (FCRs) in over half of the audited documents seen.
Governor / Director
Norwich (2024)
The Board still has concerns about ACCT documents and would like to see further improvements in the management of the ACCT process and completion of documents by staff.
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2024)
We recommend that Swinderby RSTHF urgently reviews the requirements of the Detention Services Order covering ACDT (DSO 01/2022 Assessment Care in Detention and Teamwork/ACDT, October 2022) and implements the safer detention practices contained therein within the centre.
Other
Leeds (2024)
Certain Prisons and Probation Ombudsman (PPO) reports highlight concerns that staff are not always following correct procedure, particularly in relation to ACCT prisoners. Is the Governor monitoring that this is being actively addressed?
Governor / Director
In Progress
Five Wells (2024)
How will the prison improve its management of ACCT cases to reduce the frequency of self-harm incidents?
Governor / Director
Erlestoke (2024)
Just over 60% of first Assessment Care in Custody and Teamwork (ACCT) reviews do not have the benefit of healthcare input. This negates the multidisciplinary ethos behind the intended strategy of the ACCT process and which impacts on the safety of prisoners – how will this important issue be addressed?
Governor / Director
In Progress
Wandsworth (2025)
The number of ACCTs opened increased by over 20% during the reporting period, reflecting the severity of the mental health crisis and inadequacy of support. How is the Prison Service addressing this major issue?
HMPPS
In Progress
Thameside (2025)
The Director should ensure that processes are in place for routine regular audits of ACCT documentation and that all staff are aware of their responsibilities in completing these documents.
Governor / Director
Erlestoke (2025)
While there has been considerable improvement in the attendance of healthcare at first ACCT reviews; just over one fifth still lack this essential input. How is this to be addressed, especially when reviews occur over weekends?
NHS / Healthcare Provider
In Progress
Eastwood Park (2025)
How will you ensure that ACCT plans are written clearly and in a way that fully explains the care being provided?
Governor / Director
Durham (2025)
Given the Board’s observations regarding the high level of administrative errors, as seen in section 4.2, does the Prison Service believe the ACCT document in its current form is fit for purpose? What evidence does HMPPS have to support its conclusions?
HMPPS
Durham (2025)
Given the Board’s observations regarding the high level of administrative errors, as seen in section 4.2, does the Prison Service believe the ACCT document in its current form is fit for purpose? What evidence does HMPPS have to support its conclusions?
HMPPS
Belmarsh (2025)
Will the Governor continue to reinforce programmes across the prison to improve the quality of assessment, care in custody and teamwork (ACCT) plan reporting, as well as the procedures for managing prisoners who self-isolate?
Governor / Director
In Progress
Brinsford (2023)
Challenge, support and intervention plans (CSIPs) are a good deterrent when they are working properly. Sadly, the Board recognises that they are often seen as less important as other processes & strategies such as assessment, care in custody and teamwork documents (ACCTs). Often the work involved is not completed within a timely manner. Some managers are totally on board with …
Governor / Director
Risley (2020)
There have been instances of untimely attendance by healthcare staff to prisoners on ACCT documents following self-harm incidents. How does the prison intend to ensure that all incidents of self-harm are attended to promptly?
Governor / Director
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
Lancaster Farms (2020)
The Board is also concerned that the FNU is used to accommodate a range of prisoners when other suitable accommodation has not been found, including some on assessment, care in custody and teamwork (ACCT) documents, and with restricted access to regular exercise for extended periods (see paragraph 4.6).
Governor / Director
Article 2 learning points(59)
— LP 7
We recommend that, nationally, regarding prisoners on an ACCT, (a) all staff, whatever their profession, having contact with them should record this contact in the ACCT document and (b) that all staff, whatever their profession, involved in their care should attend ACCT reviews.
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 8
We recommend that HMP Pentonville’s Healthcare unit takes steps to understand why ACCT triggers are not always given due consideration in prompting Case Conferences and documented discussions among staff. With this understanding, steps should be taken to improve the current situation. We recommend that any steps identified go beyond simply …
PPG
Accepted
— LP 6
We recommend that part of the ACCT training (Foundation and Case Manager) should be modified by the Prison Service to convey an understanding of prisoner non‐communication and how this should be interpreted, particularly when formulating risk assessments.
HMPPS
Accepted
— LP 5
(a) We recommend that a single system be introduced at HMP Pentonville that records who has received ACCT training and when the training took place. This system should cover both staff in the main prison and those working on the Healthcare unit. It should also cover both temporary and permanent …
HMPPS
— LP 4
Assuming that it’s impractical for non‐permanent clinical staff to attend an ACCT training course as permanent staff members do and long‐term bank and agency nurses could, we recommend that a protocol be developed at HMP Pentonville to ensure that these staff are at least provided with a systematic ACCT briefing. …
HMPPS
Accepted
— LP 4
Where prisoners can be shown through review to have become dependent on the added support the ACCT process provides, consideration should be given to withdrawing the process more gradually as part of the closure plan.
HMPPS
— 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 2
The CARATS teams should record information about their interviews with prisoners in unit history sheets, and share assessments with staff who are managing prisoners, particularly when an ACCT (formerly F2052SH) process has been opened. These records should be available when required for any future investigations.
HMPPS
Implemented
— 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 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 3
I recommend that the Governor of HMP Ranby establishes: that the prison’s current practice complies with the requirement to check the OASys risk assessment of newly admitted prisoners and to inform their location of any identified risk of harm to self or others; and that residential staff at Ranby are …
The Governor (HMP Ranby)
— 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 12
There needs to be a clear policy on levels of observations to be used and the criteria for placement in a safer cell or under constant observation and these should be fully documented in an individual’s ACCT document and healthcare records.
HMP Altcourse and HMPPS
Accepted
— LP 11
There needs to be consideration of the value of input from peer supporters in all cases when someone is on an ACCT or vulnerable to self-harm and this should be documented in the ACCT document and healthcare records.
HMP Altcourse
Accepted
— LP 10
Where possible, families should be encouraged to input into the ACCT process.
HMP Altcourse and HMPPS
Accepted
— LP 16
(a) We recommend that guidelines be developed and implemented at HMP Pentonville as to what should and shouldn’t be recorded in ACCT and SystmOne. These guidelines could be integrated into existing documentation. To make it easier for staff, we recommend that these guidelines include examples of what should and shouldn’t …
HMPPS
— LP 13
(a) We recommend that more is done at HMP Pentonville to make it easier for staff conducting ACCT Case Reviews by clarifying for them what they are trying to achieve and how to fill in the form. We suggest this could be achieved by providing accompanying guidelines. Although it’s in …
HMPPS
— LP 10
We recommend that existing mechanisms for ensuring that quality ACCT entries are made at HMP Pentonville be enhanced. This process may involve: making the process easier for staff by OSRR providing guidance notes to accompany the ACCT document. These guidance notes should make explicit what is being looked for and …
HMPPS
Accepted
— LP 2
We recommend that at HMP Pentonville all temporary staff receive a prison induction before working in the prison for the first time. As well as covering safety and security issues, this induction should provide coverage of the ACCT Foundation training module (which has since been superseded by ‘Introduction to Safer …
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 L
Greater priority should be given to ensuring that prisoners with open ACCTs are allocated to a Personal Officer who attends or reports to all ACCT reviews.
HMPPS
Rejected
— LP K
Either higher priority should be given to case management or more realistic Guidance about ACCT Case management needs to be produced. There should be continuity of Case Manager in ACCT reviews, with consideration given to whether a review deadline might be relaxed if that permits a Case Manager to attend, …
HMPPS
Rejected
— LP H
We recommend that a more detailed policy is developed about the allocation of cells. For prisoners subject to ACCT monitoring, any cell moves should be agreed as part of the reviewing process, other than in an emergency when they should be reported to the Case Review.
HMPPS
Partially Accepted
— LP 4
I recommend that NOMS look into whether the requirement for early checking of OASys assessments for new prisoners is consistently observed in other prisons and consider whether further measures are necessary to ensure that the system is used and understood.
NOMS
— LP 8
From a systems point of view, nationally, we further recommend that consideration should be given (a) to the development of a multidisciplinary record, in which Education staff and Chaplains document significant encounters with prisoners, including those not on an ACCT, and (b) to how information systems and care-planning can become …
HMPPS
Accepted
— LP 5
If it has not already done so, NOMS should consider reviewing PSO 1700 relating to segregation. Any such review should consider including policy, procedural guidance and a risk assessment matrix for the occasions when prisoners return to main wings from Segregation outside of the main Segregation Review Board process.
NOMS
Accepted
— LP 9
Where possible, there should be consistency of attendance at ACCT reviews.
HMP Altcourse and HMPPS
Accepted
— LP 8
The ACCT assessor, where possible should attend the first review to pass on details of their findings and impressions to other staff.
HMP Altcourse and HMPPS
Accepted
— LP 7
As part of the mental health assessment post-reception, all prisoners should have an assessment of their risk to self and others. If they are thought to be a self-harm risk, either at this assessment or at a later stage in the prison term, then a full risk assessment should be …
HMP Altcourse and HMPPS
Accepted
— LP 5
A prisoner admitted as an in-patient to Healthcare should have a full assessment, with review of the case notes and a current mental state examination. Their needs and risks of self-harm and harm to others should be established and suitable care plans developed. This assessment should inform the ACCT process, …
HMP Altcourse and HMPPS
Accepted
— LP 18
We recommend that at HMP Pentonville recently‐made entries in the ACCT document, including triggers, are checked by a member of staff attending morning briefings so that any pertinent issues are identified and discussed in this forum.
The Governor
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 9
To improve current audit trails, we recommend making it a requirement at HMP Pentonville that all staff print their name on the ACCT On‐going Record rather than relying on initials or signatures to identify who has made each respective entry. We suggest that amendments are made to the prison’s ‘Guide …
The Governor
Accepted
— LP 7
We recommend that the views of clinical staff with respect to ACCT are sought when they attend ACCT training at HMP Pentonville. By understanding in what regard ACCT is held, ACCT trainers will be better placed to explore with those attending how shared ownership of ACCT might be best promoted. …
HMPPS
Accepted
— LP N
All action points in ACCT documents should be time-bound and the use of “ASAP” discouraged.
HMPPS
Accepted
— LP M
Greater efforts should be made to involve in ACCT reviews any of those who work in a prison who know a prisoner well, and to obtain their contributions if they cannot attend.
HMPPS
Partially Accepted
— LP J
Managers must ensure that any downgrading in Cell Sharing Risk Assessment is documented correctly, giving valid reasons for any decision.
HMPPS
Accepted
— LP I
Cell moves in F Wing should be better documented and countersigned by management. If prisoners are moved for their safety and wellbeing, this should be noted in their prison files and ACCT document.
HMPPS
Rejected
— LP A
The Police and the Prison Service should use the same scale and terms when assessing risk of self-harm.
HMPPS
Rejected
— 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 Q
Mechanisms should be developed so that in appropriate cases the views of cellmates can contribute to the assessment of risk.
HMPPS
Partially Accepted
— LP P
Training should be given to ACCT Case Managers to develop skills for use whenever prisoners are unwilling to discuss the trigger points or circumstances surrounding their self-harming.
HMPPS
Partially Accepted
— LP O
Further investigation of trigger points should be made where possible, such as the funeral of a victim, or events which carry particular significance in different cultures.
HMPPS
Accepted
— LP F
If a prisoner is initially considered for Potential “Cat A” status, but is subsequently downgraded, his closed visit status should be considered at the same time. The prisoner should be informed of the outcome of the review promptly.
HMPPS
Accepted
— LP E
Better documentation should be used for assessing prisoners for Potential “Cat A” status. A written algorithm should be produced to show the decision made to either submit or not and why. A copy should be placed in the prisoner’s record.
HMPPS
Rejected
— LP 10
We recommend that when prisoners believed to be at risk are allowed to work, they should undertake tasks in the company of other prisoners rather than alone and that staff should supervise their work as much as possible.
HMPPS
Rejected
— LP 2
We recommend that urgent priority is given to developing and implementing a system of assessing the needs of remand prisoners and those with short periods to serve and a fully functioning Personal Officer scheme.
HMPPS
Accepted
— LP 14
With the prisoner’s consent, a prisoner’s relatives should be contacted to gather information as a collateral history is extremely useful. They should also be given information, again with consent, about the prisoner’s condition. They should be included in care-planning meetings and the ACCT process where appropriate.
HMP Altcourse and HMPPS
Accepted
— LP 6
There should be proportionate information sharing between healthcare and non-healthcare staff so that all staff are aware of the person’s needs, risks, risk factors and likely triggers. Some of this information exchange will be via the ACCT process but there should also be robust handovers at times when staff change …
HMP Altcourse and HMPPS
Accepted
LGO / SPSO decisions(26)
201103342 — Scottish Prison Service
Mr C, who is a prisoner, came to Scotland from another authority area. At that time, he had already served more than half of his sentence and was eligible to be considered for parole (early release). Parole was not granted so he was transferred to a maximum security prison. Mr …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Apr 2012
201203355 — Scottish Prison Service
Mr C, who is a prisoner, complained that there was an unreasonable delay in the prison referring him for a generic assessment (which identifies whether or not a prisoner should participate in offending behaviour programmes). In Mr C's case, in January 2012 the risk management team (RMT) considered whether he …
SPSO (Scottish Public Se…
Prisons
Upheld
Apr 2013
201301240 — Scottish Prison Service
Mr C, who is a prisoner in a closed prison, complained that the Scottish Prison Service were unreasonably holding him back from progressing to less secure conditions. A prisoner must meet standard criteria before the risk management team (RMT) will consider his application for progression. The RMT at the closed …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Nov 2013
201300527 — Scottish Prison Service
Mr C, who is a prisoner, progressed to the national top end (NTE) in January 2012. This is a less secure prison facility, to which prisoners can progress before moving to open prison conditions. The risk management team (RMT) there were concerned that Mr C had not been assessed for …
SPSO (Scottish Public Se…
Prisons
Upheld
Feb 2014
201304620 — Scottish Prison Service
Mr C complained that he was handcuffed in his cell and told by a manager that the handcuffs would be removed when his self-harming urges went away. Mr C said that he had not shown signs of aggression or self-harm, and that the type of handcuffs used were normally for …
SPSO (Scottish Public Se…
Prisons
Upheld
Feb 2015
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
202412046 — Scottish Prison Service
C complained that the Scottish Prison Service (SPS) failed to follow the appropriate procedure after they removed C from association (temporarily separated from the normal prison population. A Governor can order a prisoner be segregated from others for up to 72 hours if they believe it is in the interests …
SPSO (Scottish Public Se…
Prisons
Upheld
Feb 2026
201103477 — Scottish Prison Service
Mr C, who is a prisoner, complained because he was unhappy that he would be unable to access the Substance Related Offending Behaviour Programme (SROBP) before becoming eligible for consideration to progress to less secure conditions. SROBP is a programme focusing on the relationship between prisoners' substance use and their …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Apr 2012
201202302 — Scottish Prison Service
Mr C, who is a prisoner, complained about a delay in getting on to a particular behaviour course in prison. He thought the delay might hold up his release from prison. From previous complaints, we were aware that the Scottish Prison Service were dealing with a temporary backlog of people …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2012
201201815 — Scottish Prison Service
Mr C, who is a prisoner, complained that a prison officer inappropriately passed information about him to another prisoner. Mr C said that, as a result of this, he was assaulted and had to move to an alternative house block (prison accommodation). In addition, Mr C complained that he was …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Feb 2013
201305950 — Scottish Prison Service
Mr C complained that the Scottish Prison Service (SPS)'s arrangements in relation to Mr A's terminally ill mother were not handled properly. Mr C was concerned that Mr A was only allowed to spend 30 minutes with his mother at a hospice; that the security measures were excessive when Mr …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Aug 2015
201003798 — Scottish Prison Service
Mr C complained that the prison unreasonably delayed in assessing him for offending behaviour programmes. He said that he was concerned this would hold him back from progressing to the Open Estate when he becomes eligible. Mr C raised his concerns about delays with SPS officials. He was told that, …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2011
201100335 — Scottish Prison Service
Mr C was deselected from an offending behaviour programme. His solicitor contacted the prison about the deselection. When the prison responded, Mr C felt that the information that they provided to his solicitor about the reasons for his deselection was incorrect. As part of our investigation, we saw notes of …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Aug 2011
201004917 — Scottish Prison Service
Mr C, who is a prisoner, complained about a delay in being assessed for the Controlling Anger and Regulating Emotions (CARE) programme. The prison told Mr C that he was assessed as suitable for the programme in 2010 but that he had to wait for space on the programme to …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Aug 2011
201105297 — Scottish Prison Service
Mr C, who is a prisoner, complained about the process applied by the adjudicator at his disciplinary hearing. A disciplinary hearing is held to determine whether a prisoner has broken prison rules and to impose an appropriate punishment if proven. In particular, Mr C said the adjudicator told him he …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2012
201404285 — Scottish Prison Service
Mr C complained that the Scottish Prison Service failed to appropriately explain why he was returned to closed conditions. The decision was taken to remove Mr C from the open estate (an area with less secure prison conditions) because reports were received which indicated that he was refusing to engage …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2015
201400593 — Scottish Prison Service
Mr C was suspected of assaulting another prisoner (Mr B). A disciplinary hearing was held and Mr C was found guilty. Mr C appealed this finding on the basis that the adjudicator had accepted verbal evidence from two prison officers, which Mr C said had been fabricated. Mr C was …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jun 2015
201200955 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison unreasonably refused to allow him to purchase 3D puzzles. When Mr C complained to the prison, he said he was unhappy that he could not get puzzles handed in for him by family at visits. The prison said that was …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Sep 2012
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
201303515 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison did not follow procedures when they downgraded him from less secure conditions to more secure. He also complained about the prison’s handling of his complaint. Prisons are entitled to decide to downgrade a prisoner when evidence is available to suggest …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2014
201305996 — Scottish Prison Service
Mr C, who is a prisoner, complained because he said the prison inappropriately identified him as being suitable for the substance related offending behaviour programme. Mr C was unhappy with this because he said substance misuse was not part of his offence. The prison told Mr C that because of …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2014
201403945 — Scottish Prison Service
Mr C was placed on report for breaching prison rules, for which he was found guilty at a disciplinary hearing. Mr C complained that he did not think the prison followed the correct process because the officer that placed him on report was not called to the hearing. We obtained …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Feb 2015
201404247 — Scottish Prison Service
Mr C complained that the adjudicator's handling of his disciplinary hearing was inappropriate. We obtained a copy of the record taken at the hearing, and reviewed the relevant Scottish Prison Service guidance document to assess whether the hearing was carried out appropriately. We were satisfied that the adjudicator's handling of …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Mar 2015
201406077 — Scottish Prison Service
Mr C complained that the prison unreasonably refused to allow him to have a matchstick model kit in use. He said a manager approved his request to purchase the kit and other prisoners had the same kit in use. The prison is authorised in line with the prison rules to …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2015
201405772 — Scottish Prison Service
Mr C complained that his prison did not give him written notice explaining why he was being removed from his work placement. Mr C also complained that his prison did not use evidence in their decision to place him in secure conditions, did not follow the risk management process, and …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2015
201502634 — Scottish Prison Service
Mr C complained because he said the adjudicator failed to follow the proper process at his disciplinary hearing. In particular, Mr C said he was not allowed to cross-examine the first witness who was called to give evidence against him. He also said he had wanted to call three witnesses …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2015