Recurring concern
Unreliable sharing of safety-critical risk information within prisons
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Request correctionFirst reported 14 Aug 2013•Latest report 8 Apr 2026
What this concern includes
Includes failures within prison processes to communicate, transfer, receive, read or make available safety-critical risk information to staff responsible for a prisoner's care, supervision or risk management, including verbal and written information and information shared during custody or care handovers.
Not included
- Excludes the separate prison healthcare-to-prison-staff interface when that narrower named process is the supported concern.
- Excludes generic staff training, communication or documentation deficiencies unless they directly impair sharing safety-critical risk information within a prison.
- Excludes failures to assess or manage risk after relevant information was reliably shared.
- Excludes information-sharing with probation, families or external agencies unless the assertion also concerns the internal prison sharing process.
- Excludes general prison staffing, supervision or observation deficiencies where no risk-information-sharing failure is identified.
- Reports
- 19
- Individual concerns
- 25
- Date range
- 2013–2026
- Stated actions
- 32
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports 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.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to ensure that reception staff have access to all available prisoner information
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Implement a reception communication process using direct telephone alerts, secure email, acknowledgement and routine inbox checks for incoming patient risk information.
Stated by Care UK -
Action
Provide NHS email accounts to all reception staff, including agency staff, to securely access incoming risk information.
Stated by Care UK -
Action
Remind escort contractors to alert reception staff when constant supervision preceded a prisoner’s arrival.
Stated by HM Prison and Probation Service
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Action
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Stated by HM Prison and Probation Service -
Action
Remind reception staff to share and record risk information on prisoner passports, and audit passport recording and use.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to routinely share prisoner self-harm and well-being information with reception healthcare staff
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Provide reception staff with PSI 07/2015, require them to read and comply with it, and monitor completion through performance records.
Stated by HM Prison and Probation Service -
Action
Routinely pass PER forms to the reception nurse and require documentation in SystemOne that each form was received and considered.
Stated by North Cheshire and Mersey NHS Foundation Trust -
Action
Explore incorporating a PER-form receipt check into the existing reception health-screen template.
Stated by North Cheshire and Mersey NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
CNomis is not managed by healthcare, and reception nurses are not routinely granted access to it.
Stated by North Cheshire and Mersey NHS Foundation Trust
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Concerns raised1
Failure to inform staff of the manner of unnatural prisoner deaths
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Failure to train Listeners to pass information about imminent suicide risk to prison staff
Failure to make Case Notes for all ACCT plans
Failure of the Listener Scheme protocol to specify an exception to confidentiality for imminent suicide risk
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Operate additional management assurance and quality checks of ACCT documentation, care, case management, Caremap actions and NOMS records, with monthly trend review and follow-up.
Stated by HM Prison and Probation Service -
Action
Implement and embed a post-closure ACCT process requiring daily notification, plan circulation, interview updates, core-record filing and NOMS recording of ACCT openings and closures.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Winchester will not add an exception to Listener confidentiality because national confidentiality arrangements are considered necessary to preserve prisoners’ trust.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to disseminate relevant medical risk information to staff involved in prisoner care
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Review reception procedures and establish recorded communication between reception staff and escort providers.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Hewell Prison and HM Prison and Probation Service
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Concerns raised1
Failure to record relevant inmate behaviour and presentation information in the Wing Observation Book
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised3
Failure to circulate Risk of Self-Harm / Suicide information promptly to relevant prison functions
Failure by Healthcare to read and disseminate important Risk of Self-Harm / Suicide documents
Failure to ensure that Risk of Self-Harm / Suicide information is read and considered by Senior Wing Officers after prisoner moves
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate constant watch status to relevant prison staff
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Ensure appropriate information is communicated to receiving prisons when prisoners transfer from Trust-supported prisons.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing healthcare, discipline-team and prison-transfer communication arrangements are considered sufficient to address information-sharing concerns.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
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Concerns raised1
Failure to share relevant verbal and written risk information with prison staff
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026