Recurring concern
Unreliable prison staff communication during safety-critical situations
- Reports that mention this concern
- 5
- Times this concern has been raised
- 5
- Stated actions linked to this concern
- 8
What this concern includes
Includes failures in prison-based communication arrangements for conveying the severity, scope, changing circumstances and required response to safety-critical situations between prison staff and relevant healthcare or custodial functions, including communication that should trigger enhanced observations, healthcare notification or other protective action.
What is not included
- Excludes the narrower existing concern concerning sharing safety-critical risk information within prisons when the assertion is specifically about transfer of a defined risk record or risk-information field rather than broader communication of a safety-critical situation.
- Excludes generic prison staffing, training, documentation or leadership deficiencies unless they directly cause unreliable communication during a safety-critical situation.
- Excludes prison-to-probation, prison-to-community, court-to-prison and other external information-transfer processes unless the assertion concerns the same internal prison safety-communication control.
- Excludes clinical assessment or treatment failures after relevant prison staff communication has operated reliably.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Failure of prison staff communication to relay the severity and complete scope of situations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
HM Prison and Probation Service
Embed practical emergency-response simulations, including Code Blue scenarios, within local training and mentoring arrangements.
-
HM Prison and Probation Service
Continue joint emergency-response exercises with healthcare staff to strengthen shared understanding and multidisciplinary response.
-
Concerns raised1
Failure to establish a communication strategy during critical medical emergencies in custodial settings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Inadequate communication about prisoners’ health conditions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- HM Prison and Probation Service
- Practice Plus Group Health And Rehabilitation Services Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Practice Plus Group Health And Rehabilitation Services Limited
Implement Regional Multi Professional Complex Case Clinic escalation for the most complex patients.
-
HM Prison and Probation Service
Work with NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Practice Plus Group Health And Rehabilitation Services Limited
Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.
-
HM Prison and Probation Service
Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
-
Concerns raised1
Breakdown in communication among junior prison staff
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
HM Prison and Probation Service
Share the escort-review findings with healthcare staff to improve communication and clarify urgency during hospital escorts.
-
Concerns raised1
Inadequate advance notification and information sharing for ACCT reviews
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- HM Prison and Probation Service
- Midlands Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Midlands Partnership University NHS Foundation Trust
Develop escalation procedures with Care UK and the prison for occasions when healthcare cannot attend an ACCT review.
-
Midlands Partnership University NHS Foundation Trust
Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
-
HM Prison and Probation Service
Embed the new ACCT case-management process, including dedicated case managers, review booking oversight and daily healthcare attendance allocation.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026