Recurring concern
Unreliable sharing of safety-critical risk information within prisons
Pin
Get email alerts
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.
-
Concerns raised1
Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff
This report raised 5 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
-
Action
Review NOMIS/DPS alerts later in 2026 with safety, digital and policy experts to improve their consistency, clarity, visibility and usability.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham Prison -
Action
Ensure findings from the NOMIS/DPS alerts review inform future enhancements addressing the identified concerns.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham Prison
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The Ministry of Justice is responsible for NOMIS/DPS alerts, so it will lead the response to concerns about their categorisation and visibility.
Stated by Northamptonshire Healthcare NHS Foundation Trust
-
Position
NOMIS/DPS already provides more granularity than a single “violent” categorisation, although improvements in consistency, clarity and visibility are needed.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham Prison
-
Concerns raised1
Failure to reliably consolidate and share relevant prisoner risk information
This report raised 15 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
-
Action
Revise handover documentation, including a prompt to identify information requiring sharing with prison colleagues.
Stated by Central and North West London NHS Foundation Trust -
Action
Ensure healthcare participation in multidisciplinary forums, weekly Safety Intervention Meetings and daily wing briefings.
Stated by Central and North West London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Healthcare services alone cannot mitigate all risks within custody.
Stated by Central and North West London NHS Foundation Trust
-
Concerns raised1
Failure to share critical suicide-risk information with prison staff
This report raised 13 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
-
Action
Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.
Stated by HCRG Care Group -
Action
Implement a formal Prisoner Warning Notice communication logbook and train relevant staff to record, communicate, and acknowledge custody-related risks.
Stated by HCRG Care Group
-
Concerns raised1
Failure to notify prison staff or healthcare of high or unusual prisoner telephone-call volumes
This report raised 1 other concern. 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 raised1
Failure to share risk pertinent information with all staff caring for a prisoner
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.1
-
Action
Use a trigger database accessible to all staff to share pertinent risk information about individuals in crisis.
Stated by HM Prison and Probation Service
-
Concerns raised3
Failure to routinely brief Prison Officers about prisoners’ previous significant self-harm in custody
Unclear threshold for informing prison staff about significant self-harm risk
Failure to routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm
This report raised 1 other concern. 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.3
-
Action
Implement ACCT version 6 across the male estate, including strengthened risk-identification requirements and revised staff training and awareness materials.
Stated by HM Prison and Probation Service -
Action
Provide and routinely use an updated safety diagnostic tool consolidating violence, self-harm and other relevant risk information for staff.
Stated by HM Prison and Probation Service -
Action
Operate the Key Worker scheme, providing each person in custody with a dedicated worker and weekly meetings to identify risks, triggers and changes in self-harm or suicide risk.
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.2
-
Position
Previous self-harm incidents will not always be relevant to identifying current self-harm risks and triggers.
Stated by HM Prison and Probation Service
-
Position
Existing risk-recognition practices focus staff on current self-harm and suicide risks and changes indicating increased risk.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff
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.1
-
Action
Implement a revised immediate-needs form with clearer guidance for identifying, communicating and documenting suicide or self-harm risks.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to make significant relevant prisoner information available to all 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
-
Action
Automate patient administration data transfer from NOMIS to SystmOne through phase-one interoperability development.
Stated by HM Prison and Probation Service -
Action
Implement phase-three interoperability to share risk information between NOMIS and SystmOne.
Stated by HM Prison and Probation Service -
Action
Operate the Safer Custody Zone to enable prison, mental health and substance misuse staff to collaborate and routinely share key information.
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.2
-
Position
NHS England and NHS Improvement lead implementation of the information-sharing project and should provide further updates.
Stated by HM Prison and Probation Service
-
Position
Further information-sharing project work is temporarily halted because the supplier was directed to prioritise COVID-19-related work.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to highlight the higher risk of self-harm or suicide among remand prisoners to prison and healthcare staff
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.3
-
Action
Disseminated guidance identifying remand status as a suicide and self-harm risk factor.
Stated by HM Prison and Probation Service -
Action
Provided staff training based on guidance recognising remand status as a suicide and self-harm risk factor.
Stated by HM Prison and Probation Service -
Action
Revise suicide and self-harm prevention training and update its risk-and-trigger recognition module to reflect the new policy framework and ACCT changes.
Stated by HM Prison and Probation Service
-
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.
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
-
Action
Develop escalation procedures with Care UK and the prison for occasions when healthcare cannot attend an ACCT review.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Embed the new ACCT case-management process, including dedicated case managers, review booking oversight and daily healthcare attendance allocation.
Stated by HM Prison and Probation Service
Data last updated 7 September 2026