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 14 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
81 PFD reports
3 committee recs
133 PPO recs
76 IMB recs
16 IMB reports
6 Scottish FAIs
59 Article 2 learning points
1 detention investigation rec
1 DHR rec
26 LGO/SPSO decisions
6 CJINI reports
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.
Inquiry recommendations(2)
73 — Reception health screen referral to mental health
Recommendation: The first reception health screen questionnaire should be revised so as to trigger a referral to a mental health professional on the healthcare team even if the prisoner has only self-harmed in prison. A referral should also be triggered where …
Unknown
52 — Guidance for duty governors on risk assessment
Recommendation: 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.
Unknown
Prevention of Future Deaths reports(81)— showing 50 strongest matches
Reggie John
Concerns: Concerns included insufficient communication between prisons regarding the prisoner's constant watch status, a lack of robust multi-disciplinary ACCT review processes, and instances where the Prison Service Order 2700 policy was not followed, impacting healthcare documentation.
Response (Worcestershire Health Care NHS): • The Trust stated it would ensure appropriate information is communicated to receiving prisons upon prisoner transfer. • The Trust confirmed that expectations for nurses reviewing and documenting Assessment, Care … (AI summary)
Response (HM Prison and Probation Service): • HMP Bristol implemented a system for its safer custody team to contact receiving establishments and escort contractors regarding prisoners on open ACCTs, with these communications recorded on Prison-NOMIS. • … (AI summary)
Overdue
Adrian Johnson
Concerns: The coroner identified gaps in the assessment and management of tobacco withdrawal by healthcare professionals during initial prison screenings, which elevated the prisoner's vulnerability. Concerns also included insufficient healthcare input into ACCT reviews and inconsistent information sharing.
Response (HM Prison and Probation Service): • HM Prison and Probation Service (NOMS) and NHS England stated they would give further consideration to identifying tobacco withdrawal risks in screening processes and develop a care pathway, including … (AI summary)
Overdue
Ryan Clark
Concerns: The coroner noted that the Personal Officer Scheme was not effectively implemented, ACCT checks were not conducted as prescribed, and prison officers lacked full conversancy and regular refresher training in first aid and CPR.
Response (HM Prison and Probation Service): • HMP YOI Wetherby implemented a revised personal officer scheme in October 2013, which includes a 'relief' arrangement and staff briefings. • Staff received briefings on ACCT check timings and … (AI summary)
Response (Leeds City Council): • Leeds Children's Social Work Service and Leeds Youth Offending Service agreed a procedure for sharing information about young persons entering custody. • YOS Court Officers will collate relevant information … (AI summary)
Responded
Michael James Meyler
Concerns: 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.
Response (HM Prison and Probation Service): • The Governor of HMP Manchester issued a notice to staff in January 2013 to remind colleagues of the need to make regular entries on NOMIS. • The Governor of … (AI summary)
Overdue
Matthew Purser
Concerns: The coroner noted a doctor lacked required ACCT training and concerns were raised about the subjective wording of ACCT trigger events, which led to inconsistent officer assessments due to insufficient detail in records. There was also a lack of clarity on how to obtain community mental health records.
Overdue
Yohannes Kidane
Concerns: Concerns were noted regarding inadequate night staffing on healthcare wards, which compromises the ability to conduct effective ACCT observations and affects staff welfare due to staff not taking breaks.
Response (HM Prison and Probation Service): • HM Prison and Probation Service reviewed night staffing levels at HMP Birmingham and concluded they were acceptable. • A Prison Custody Officer is deployed to patrol the healthcare centre … (AI summary)
Response (Birmingham Solihull NHS): • Birmingham Community Healthcare Trust reviewed its skill mix for Ward 1, which will result in the conversion of funding for unqualified staff into qualified nurses, with recruitment for an … (AI summary)
Responded
Seweryn Glowinski
Concerns: The coroner identified a lack of communication between prison units regarding a prisoner's transfer plan and risk assessment. Documentation for detention contained errors due to copying, and senior managers were unaware of rules for transferring ACCT prisoners to segregation.
Overdue
Cherylin Norrell-Goldsmith
Concerns: The coroner raises concerns about open pipe work in cells as potential ligature points for vulnerable prisoners. Additionally, there are concerns regarding insufficient multi-disciplinary input at ACCT reviews and a lack of accessible recording of significant medical events on non-medical records for prison staff.
Response (HM Prison and Probation Service): • HMP Downview's local policies and procedures have been reviewed and strengthened. • A system to inform staff of ACCTs will be reintroduced, and new recording and communication practices for … (AI summary)
Overdue
Geraldine Kilborn
Concerns: The coroner noted insufficient information sharing from the mental health team with other staff and that mental health input was not always given sufficient weight in ACCT reviews. Concerns were also raised that ACCT review members often did not read relevant documents beforehand.
Response (HM Prison and Probation Service): • An amended arrangement has been put in place to facilitate the presence of a mental health team member at weekend ACCT reviews. • Briefing sessions have been introduced to … (AI summary)
Response (Care UK): • Care UK stated that from April 2015, daily reviews would be undertaken by a mental health team member for patients with mental health issues, and all complex ACCT cases … (AI summary)
Response (Tess Esk Wear Valleys NHS Trust): • The Trust increased Mental Health Team staff availability over weekends to attend ACCT reviews and support prisoners in crisis. • The Mental Health Team Manager attends daily healthcare and … (AI summary)
Responded
Alex Kelly
Concerns: The coroner identified concerns regarding the absence of forensic psychiatric assessments for vulnerable children entering custody, deficiencies in the ACCT process regarding external agency input and interpretation of distress, and issues with social worker allocation and documentation practices.
Response (Tower Hamlets): • The council confirmed that systems are in place to ensure all looked after children have an allocated social worker, including monthly reporting and an escalation policy for Independent Reviewing … (AI summary)
Response (Central North West London NHS Trust): • The Trust's new service has improved partnership working and information exchange among professionals. • Healthcare staff are required to share knowledge of medication non-compliance and have completed information governance … (AI summary)
Response (Oxleas NHS Trust): • The Trust confirmed that every child arriving at Cookham Wood is assessed using a Comprehensive Health Assessment Tool (CHAT), with staff trained in its use and monitoring standards implemented. … (AI summary)
Response (Ministry of Justice): • The Comprehensive Health Assessment Tool (CHAT) has been rolled out across the Young People's Estate for new admissions, with staff trained and standards in place for its use. • … (AI summary)
Responded
Stuart Baumber
Concerns: The coroner identified that many prison cell doors lack current anti-ligature strips due to no national retrofit programme. There is also an absence of a national pro forma for the ACCT process, leading to over-reliance on current risk assessment.
Overdue
Greg Revell
Concerns: The coroner identified a lack of ACCT initiation despite clear self-harm indications, an over-reliance on verbal information rather than documented risks, and an insufficiently robust system for capturing healthcare information, which resulted in a missed opportunity to restart antidepressant medication.
Response (Leicestershire Partnership NHS Trust): • A robust system for seeking clinical information has been implemented, including a flowchart detailing team member responsibilities. • The flowchart outlines staff responsibilities for escalating concerns regarding clinical notes … (AI summary)
Response (HM Prison and Probation Service): • Local policies and procedures have been reinforced to ensure an ACCT is opened on reception whenever there is evidence of a recent self-harm attempt. • A new Safer Prisons … (AI summary)
Responded
Carl Smith
Concerns: The quality of custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing regarding these checks appeared deficient.
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust implemented joint reviews for patients on drug treatment programmes, with shared access to caseload details and clear communication of observation level decisions. • An education package on … (AI summary)
Overdue
Andrew Frere
Concerns: The coroner noted the impracticability of Prison Service Instruction 64/2011 on daily doctor visits for prisoners under continuous observation, and a lack of national guidance to address this. ACCT review attendees lack specific instruction to read ongoing observations, risking missed information.
Overdue
Liam Smith
Concerns: The coroner identified non-adherence to mandatory ACCT procedures for prisoners at risk of inadvertent self-harm, inadequate dissemination of medical information upon arrival, and gaps in healthcare staff's access to patient notes. There were also concerns about limited interaction with high-risk drug users.
Response (HM Prison and Probation Service): • A review of the Assessment, Care in Custody and Teamwork (ACCT) process is ongoing to inform changes to the current policy. • The prison and healthcare provider have reviewed … (AI summary)
Overdue
Samuel Gale
Concerns: The coroner noted an ACCT was closed without consultation with healthcare, chaplaincy, or management. Concerns were also raised about whether only the person primarily responsible for a prisoner's ACCT should be authorised to close it.
Response (Serco): • Policy changes have been made to ensure only manager grade staff can close an ACCT, and ACCTs cannot be closed without a review by at least two people and … (AI summary)
Response (NHS England): • NHS England stated it is reviewing templates for the new Health & Justice Information System, including those for first night screening and risk assessment. • Deployment of the new … (AI summary)
Responded
Lee Rushton
Concerns: The coroner raised concerns about the consideration given to ACCT care plans when a Cell Sharing Risk Assessment (CSRA) indicates a prisoner should be in a single cell for the protection of others, questioning if existing policy adequately covers this.
Response (Lee Rushton Liverpool Regulation 28): • NOMS completed a review of compliance and delivery of the Assessment, Care in Custody and Teamwork (ACCT) process. • NOMS will publish the findings of the ACCT review and … (AI summary)
Overdue
Steven May
Concerns: The coroner identified insufficient mental health training and medical note review by reception staff, alongside deficiencies in the ACCT process. Further concerns included inadequate First Aid training and emergency response by prison staff, and limited weekend healthcare access for inmates.
Response (Steven May): • HMP Ranby staff were reminded of the need for comprehensive record-keeping in ACCT documents, and these documents are now subject to quality monitoring. • The prison and healthcare provider … (AI summary)
Response (Nottingham Healthcare NHS Trust): • The Trust reminded staff of the importance of reviewing patient notes during reception health screens and introduced a keyword search facility for medical records. • Following a Healthcare Needs … (AI summary)
Overdue
Matthew Sargent
Concerns: The coroner noted insufficient processes for sharing and reviewing historical prisoner information and risks between staff and healthcare departments. Specifically, healthcare staff were not consistently informed of prisoners with an ACCT history or provided with Prisoner Escort Records upon arrival.
Response (Matthew Sargent): • Care UK will share and roll out its Suicide Prevention Strategy across all sites. • Care UK plans to review the reception screening process to introduce a standard template … (AI summary)
Response (HM Prison and Probation Service): • The prison stated it would remind all staff of the Personal Officer policy through communications including a Safer Custody Bulletin. • A process was established for Offender Management Unit … (AI summary)
Responded
Sheldon Woodford
Concerns: The coroner identified that the SASH document is not consistently identifiable to all relevant staff during the reception process, and noted insufficient training for officers in ACCT processes.
Overdue
Ian Brown
Concerns: The coroner identified that previous recommendations regarding ACCT case management for prisoners at risk of self-harm had not been rigorously implemented. This contributes to the continuing rise in suicides at HMP Woodhill, and there are concerns that a new prison-wide strategy will also not be adopted.
Response (HM Prison and Probation Service): • A monthly forum, chaired by the Deputy Governor, has been introduced to monitor progress on actions related to deaths in custody. • A whole establishment action plan is in … (AI summary)
Overdue
Kevin Dermott
Concerns: The report highlights inadequate mental health care, incomplete care planning, and significant communication deficits during multiple prison transfers, which led to a failure to recognise a relapse in the deceased's condition and properly observe ACCT procedures.
Response (NHS England): • NHS England developed national service specifications for mental health services in prisons in December 2013, outlining an integrated stepped care model. • The Health & Justice Indicators of Performance … (AI summary)
Response (HM Prison and Probation Service): • Management checks on the Assessment; Care in Custody and Teamwork (ACCT) process are being increased, including daily checks by Offender Supervisors and weekly checks by Custodial Managers. • A … (AI summary)
Response (Department of Health): • The Department of Health ensured that colleagues at the National Offender Management Service (NOMS) received a copy of the report and requested a direct response. • The Government announced … (AI summary)
Responded
John Betteridge
Concerns: Insufficient or absent ACCT training for healthcare and prison staff meant mandatory provisions of the ACCT process were not being adhered to. This indicated a clear training need within the system.
Overdue
Warren Sampson
Concerns: The coroner noted inconsistent Healthcare attendance and documentation in ACCT reviews, a lack of process for following up missed first-night healthcare screenings, and no system to ensure officers are familiar with local directives.
Response (Care UK): • Healthcare staff are now invited to ACCT reviews daily, and their input is recorded in ACCT documents and SystmOne. • A second health screen is now undertaken within 72 … (AI summary)
Overdue
Liam Lambert
Concerns: The ACCT document process was incomplete, with information not fully used and appropriate individuals not always invited to reviews. Additionally, resourcing pressures were noted to affect officers' ability to ensure prisoner safety from self-harm.
Response (HM Prison and Probation Service): • A Safer Custody toolkit was introduced in August 2016, and staff received reminders and new templates for ACCT document completion and review procedures. • Management checks are regularly undertaken … (AI summary)
Overdue
Haydn Burton
Concerns: Prison staff at Winchester Prison were not implementing ACCT plans in line with national policy, including inadequate observations. There were also unclear confidentiality rules for Prison Listeners regarding suicide threats and limitations in the NOMIS database for recording closed ACCT plans.
Response (HM Prison and Probation Service): • HMP Winchester committed to ensuring all operational staff are trained in ACCT procedures, with refresher training scheduled monthly, and a plan developed for ACCT case managers and assessors. • … (AI summary)
Overdue
Margaret Atkinson
Concerns: The coroner identified issues with describing prisoner behaviour and selecting appropriate language, which impacted risk assessment. There were also concerns about the normalisation of unusual behaviour, leading it not to be considered indicative of increased risk.
Response (Tees Esk & Wear Valley NHS Foundation Trust): • Mental Health services staff have been instructed to describe observations more specifically, moving away from the general term 'ligature'. • The Trust will work with partners to agree a … (AI summary)
Overdue
Matthew Russell
Concerns: The coroner noted insufficient monitoring of repeat prescriptions, a lack of structured care plans, and ineffective follow-up for missed appointments. Concerns also included inadequate staff training in the ACCT procedure and unclear procedures for prison gatehouse staff regarding prisoner safety alerts.
Response (Central and North West London NHS Foundation Trust): • CNWL undertook audits of anti-depressant prescribing and care plans, and implemented a new daily process for following up missed appointments. • A mandatory e-learning module for suicide prevention, including … (AI summary)
Overdue
Roy Hoey
Concerns: The coroner noted ambiguity in the interpretation of national and local safer custody guidance regarding the conditions and process for initiating an ACCT plan when a prisoner is identified as being at risk of suicide or self-harm.
Response (HM Prison and Probation Service): • The National Offender Management Service (NOMS) stated it would revise PSI 64/2011 by the end of April 2017. • The revision aims to resolve potential confusion among staff regarding … (AI summary)
Responded
Dean Saunders
Concerns: The coroner identified lacunas in the admissions protocol for transferring mentally disordered individuals from police custody and a lack of clarity in hospital transfer processes. Concerns were also raised regarding ACCT process training, family involvement, and the resilience of psychiatric cover at Chelmsford prison.
Response (NHS England): • Care UK circulated a document to staff providing contact details for medical staff authorised to sign Mental Health Assessment documents. • A new provider will deliver healthcare at HMP … (AI summary)
Response (Essex Partnership NHS Trust): • The Trust submitted its admissions protocol for regional review and referred the issue of best practice for the forensic pathway for regional discussion. • The Trust engaged with NHS … (AI summary)
Response (Care UK): • Care UK revamped its national Mental Health Pathway and adapted it to incorporate best practice. • The new Mental Health Pathway was formally signed off on 28 March 2017. … (AI summary)
Overdue
Callum Smith
Concerns: 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.
Response (Prison Health Services): • The organisation stated that all healthcare staff would revisit the Prison Service Instruction (PSI) 64/2011 through Suicide and Self Harm (SASH) training and local meetings. • It confirmed that … (AI summary)
Overdue
Mark Vagnoni
Concerns: 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.
Response (HM Prison Probation Service): • HM Prison and Probation Service issued a learning bulletin in July 2017, and HMP Bedford issued a staff notice in October 2017, reminding staff about setting appropriate ACCT observation … (AI summary)
Overdue
Edwin O’Donnell
Concerns: The coroner identified that the nurse undertaking initial health screening lacked access to pertinent prisoner documentation, including the Prisoner Escort Report and digital medical records. Concerns were also raised about the recording of such documentation and the sufficiency of ACCT training for probation staff.
Response (HM Prison Probation Service): • The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff. • Revised procedures will be implemented to ensure second health screenings … (AI summary)
Responded
Robert McLoughlin
Concerns: The coroner noted low staffing at HMP Leeds on the evening of 19th February 2016. On the morning of 20th February, low staffing levels meant no Landing Officer was present, preventing ACCT reviews for several hours.
Overdue
John Mayhew
Concerns: The coroner identified a need for clarification on how to interpret the "whenever possible" proviso in PSI64/2011 concerning ACCT first case reviews. Consideration should be given to re-drafting this part of the PSI and providing guidance on its practical application by prison staff.
Overdue
John Delahaye
Concerns: The coroner identified confusion over a risk assessment question for in-possession medication, potentially leading to incorrect authorisations. Further concerns included unreliable 'read coding' in prison healthcare records and insufficient healthcare attendance at ACCT reviews.
Response: • Birmingham and Solihull Mental Health NHS Trust and Birmingham Community Healthcare NHS Trust committed to reminding clinical staff about System1 record review procedures and collaborating with NHS England on … (AI summary)
Overdue
Nicky Reilly
Concerns: The coroner noted the discontinuation of the Care Program Approach upon prison transfer, inadequate psychological support and record-keeping, and limited quality of documentation and attendance at multi-disciplinary care plan meetings.
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust informed the prison psychology team about the process for accessing patients' clinical records. • Mental Health and psychology staff now participate in weekly multi-disciplinary team meetings to … (AI summary)
Response (HM Prison and Probation Service): • The Challenge Support Intervention Plan (CSIP) has been implemented, providing guidance and templates for multi-disciplinary engagement and record-keeping. • HMP Manchester holds weekly multi-disciplinary meetings to manage complex prisoners, … (AI summary)
Responded
Kelvin Speakman
Concerns: The coroner identifies inadequate ACCT documentation, absent healthcare input in reviews, and inconsistent staff communication, resulting in an incomplete understanding of the prisoner's condition at HMP Hewell. These issues have persisted despite prior assurances.
Response (HM Prison and Probation Services): • HMP Hewell implemented a new daily quality assurance process for ACCT documents in January 2019, including checks on healthcare staff attendance at first case reviews. • In March 2019, … (AI summary)
Overdue
Marcus McGuire
Concerns: The coroner identifies deficiencies in ACCT plans from the absence of a single case manager, affecting care and follow-up. Concerns were also raised about a disparity between evidence and inspection findings on implementing single case management at HMP Birmingham.
Response (HM Prison and Probation Service): • HMP Birmingham has trained additional case managers to improve consistency in single case management and reduce caseloads. • The prison has introduced daily monitoring and monthly reviews of single … (AI summary)
Response (G4S): • G4S stated that decisions regarding actions at HMP Birmingham are not within its remit, as the prison is now operated and managed by HMPPS. • G4S indicated that it … (AI summary)
Responded
Ryan Trimmer
Concerns: The coroner noted inadequate ACCT reviews at HMP Lewes and identified that not all prison staff, who act as first responders, had received first aid training, with one staff member lacking training for 16 years.
Response (HM Prison and Probabtion Service): • A revised version of the ACCT process is undergoing evaluation following a pilot, with national implementation intended for early 2020. • HMP Lewes will introduce monthly first aid training … (AI summary)
Responded
Daniel Davey
Concerns: The coroner noted it was not routine for healthcare staff to attend ACCT reviews, which was a concern relating to both prison and healthcare operations despite improvements introduced after the death.
Response (Care UK): • Care UK updated its Local Operating Procedure for healthcare attendance at ACCT reviews in February 2019. • A new electronic quality assurance process has been introduced to ensure continued … (AI summary)
Response (HM Prison Probation Service): • New electronic quality assurance checks, including healthcare attendance at reviews, are to be introduced by August 2019. • A new version of the ACCT form and guidance, piloted in … (AI summary)
Response (Midlands NHS Trust): • The Trust stated it continues to work with partners to support attendance at ACCT reviews, maintain improved processes, and will contribute to quality assurance checks. • The Trust indicated … (AI summary)
Overdue
Amir Siman-Tov
Concerns: The coroner noted insufficient involvement of healthcare staff in the ACDT process, inconsistent checks for medication swallowing, and a lack of clinical information sharing between Hillingdon Hospital and Colnbrook IRC following an overdose.
Overdue
Harold Uzomechina
Concerns: The coroner noted differential treatment for detainees on the substance misuse unit, specifically a lack of dedicated night-time prison officers. Concerns were also raised that this at-risk population did not receive the same level of care as detainees on formal ACCT plans.
Overdue
David Kirsch
Concerns: The coroner noted a lack of a dedicated Case Manager for Mr. Kirsch's ACCT document, leading to inadequate completion of the Caremap. This resulted in significant concerning behaviours and issues not being recorded or addressed within the ACCT process.
Response (HM Prison and Probation Service): • Revised national training for ACCT case managers has been introduced, with specific guidance provided to staff at HMP Long Lartin. • An online log of all open ACCT documents, … (AI summary)
Responded
Darren Williams
Concerns: The coroner noted that ACCT reviews were often conducted without healthcare staff present, and relevant information from previous ACCTs was not consistently considered when new ACCTs were opened.
Overdue
Tomasz Nowasad
Concerns: 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.
Response (NHS England): • NHS England published an amended specification for the provision of mental health services in prison, requiring provider compliance. • HMP Manchester audited its services against the new specification and … (AI summary)
Response (HM Prison and Probation Service): • The HM Prison and Probation Service has redesigned the Assessment, Care in Custody and Teamwork (ACCT) form and guidance, which was piloted in 2019 and is scheduled for national … (AI summary)
Responded
Daniel Akam
Concerns: Concerns were raised that ACCT observations were not conducted but recorded as completed. The coroner also noted officers' insufficient understanding of ACCT procedures and inadequate training, requiring refresher courses to safeguard vulnerable prisoners.
Overdue
Carl Newman
Concerns: Prison staff did not have ready access to current training records, specifically for ACCT and SASH, leading to officers working with outdated or absent training in safer custody processes.
Response (HM Prison and Probation Service): • The Governor of HMP Liverpool issued a staff information notice to promote the use of the myLearning system and reminded staff how to view their training records. • A … (AI summary)
Responded
Corin Bonaparte
Concerns: An ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor and revealing recent self-harm, suggesting inadequate training; the ambulance was kept waiting 8 minutes at the main gate, suggesting inadequate arrangements for swift ambulance departure in emergencies.
Response (HM Prison and Probation Service): • A new version of the Assessment Care in Custody and Teamwork (ACCT) system was rolled out, and associated training is being delivered to all staff, including healthcare colleagues. • … (AI summary)
Responded
Geoffrey Hutton
Concerns: The coroner noted the absence of an effective system for social care referrals at HMP Long Lartin and issues with ACCT Case Manager allocation. This led to a lack of oversight for vulnerable individuals and inaccurate care map documentation.
Response (HM Prison and Probation Service): • The prison undertook a review of its adult safeguarding policy and is developing a memorandum of understanding with Worcestershire County Council. • A revised version of ACCT (version 6) … (AI summary)
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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
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
Health investigations(6)
Independent investigation: Terry Radford, Mansfield Woodhouse (2019) — Rec Recommendation 5
Within six months the healthcare team should implement a system which ensures that the daily healthcare review for prisoners held in segregation takes into account observations and records made by both prison and healthcare staff and that the review assesses both risk to self and risk to others.
midlands
Independent investigation: Philip Silverstone, Belsize Park (2014) — Rec 3
The Governor should ensure that prisoners assessed as at risk of suicide or self-harm are not held in the segregation unit unless all other options have been considered and excluded and there are fully documented reasons, including at segregation reviews, to explain the exceptional circumstances. Segregated prisoners on an ACCT …
midlands
Independent investigation: Philip Silverstone, Belsize Park (2014) — Rec 2
The Governor and Head of Healthcare should ensure that staff open an ACCT whenever a prisoner has significant risk factors or potential triggers.
midlands
Independent investigation: Philip Silverstone, Belsize Park (2014) — Rec 1
The Governor should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including that: • ACCT assessors do not chair the first ACCT case review; • Multidisciplinary case reviews are held with all relevant people involved in a prisoner’s care; • Case …
midlands
Independent investigation: John Coxall, HMP Nottingham (2015) — Rec
The Governor should ensure that staff manage prisoners at risk of suicide or self-harm in line with national guidelines. In particular: Understanding their responsibilities and the need to share all relevant information about risk; Assessing the level of risk and recording the reasons for decisions; Conducting ACCT reviews as specified …
midlands
An independent investigation into the care and treatment of service … — Rec Recommendation 5
Within six months the healthcare team should implement a system which ensures that the daily healthcare review for prisoners held in segregation takes into account observations and records made by both prison and healthcare staff and that the review assesses both risk to self and risk to others.
midlands
Scottish Fatal Accident Inquiries(6)
April Adam
Should the Chair be the designated person to represent the prisoner (if there is to be such a designated person)? Independently of all staff seeking to make contact with/make friends with/care for prisoners, which seems to be accepted by all as necessary and good, if a prisoner is placed on timed Observations should there be a designated person to carry …
Dec 2003
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 procedure; (ii) …
Jun 2013
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 time offender, …
Aug 2024
Alec John Cowie
That the Scottish Prison Service, as part of the review of the services suicide prevention policy (currently called “Talk To Me”) which is currently underway, give consideration to ensuring that: i) the policy, whatever form it should take, specifies that all decisions of the Parole Board, however they have come about, result in a suicide risk assessment being undertaken; and …
Sep 2025
Michael Charlton
Recommendation 1 - As soon as reasonably practicable, the SPS should put in place a written system of work at HMP Barlinnie in relation to MORS that: • Requires a specific officer to observe prisoners that have been placed on MORS and complete the observation documentation. • Requires managers to actively monitor compliance with MORS to ensure that the required …
Apr 2026
Richard Angus Scott Farquhar
The sheriff, in terms of section 26(1)(b) of the 2016 Act, and having regard to the matters mentioned in section 26(4) of that Act, Recommends that the Scottish Prison Service: (1) Require Risk Management Teams to agree, and keep under review, timescales for the completion of actions which form part a prisoner’s progression plan, including those actions which are agreed …
Jun 2022
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
Independent reviews(2)
Shaw Detention Review — Rec 23
Recommendation 23: Once the NOMS review of ACCT is complete, there should be an urgent review of ACDT and DSO 06/2008, informed by the NOMS review and by the findings of this report.
Immigration
Corston Report — Rec 43
The management and care of self-harming women should be led by the NHS, either in an NHS resource or shared multi-disciplinary care in prison.
Justice & Legal
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
CJINI inspection reports(6)
Ash House (Hydebank Wood Women’s Prison) (14-17 March 2005)
Hydebank Wood Women’s Prison, Prisons
Nov 2004
Report on an announced inspection of Magilligan Prison (20-24 September 2004)
Prisons, Magilligan Prison
Mar 2005
Report of an announced inspection of Maghaberry Prison (10-14 October 2005)
Maghaberry Prison, Prisons
May 2006
An unannounced inspection of Magilligan Prison (10-19 May 2006)
Prisons, Magilligan Prison
Dec 2006
The Safety of Prisoners held by the Northern Ireland Prison Service
Prisons, Prisoner Safety
Nov 2019
A Review into the operation of Care and Supervision Units in the Northern Ireland Prison Service
Prisons, Prisoner Safety
Feb 2022