First reported 16 Sep 2013•Latest report 29 Jun 2026
Definition
What this concern includes
Includes deficiencies in controls dedicated to the ACCT process, including quality assurance, observations, reviews, documentation, information sharing, staffing or training, where the failure undermines reliable ACCT risk prevention or management.
Not included
Excludes generic organisational quality assurance, staffing or training failures that are not explicitly tied to ACCT.
Excludes unrelated prison, healthcare or mental-health processes that do not form part of ACCT.
Excludes outcomes, individual clinical judgments or underlying causes unless the assertion identifies a failure of an ACCT control.
Reports
92
Distinct published reports
Individual concerns
184
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
276
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.
HM Prison and Probation Service41
Ministry of Justice27
NHS England15
Care UK6
Department of Health and Social Care6
HM Prison Service6
Central and North West London NHS Foundation Trust5
Hewell Prison5
Oxleas NHS Foundation Trust5
HM Inspectorate of Prisons4
Practice Plus Group4
Birmingham and Solihull Mental Health NHS Foundation Trust3
Birmingham Prison3
G4S3
Greater Manchester Mental Health NHS Foundation Trust3
Prison or young offender institution51
Executive agency41
NHS trust32
Ministerial department29
Executive non-departmental public body15
Sub-organisation8
Multi-service care provider6
Independent healthcare provider5
Prison operator5
Justice inspectorate4
Private limited company4
Type not available4
Community interest company3
Advisory non-departmental public body2
Ombudsman2
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.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to maintain and monitor staff competence in opening an ACCT where required
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 concerns
Each 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
Introduce daily mandatory knowledge-check sessions for operational and non-operational staff, recording attendance, completion and understanding to reinforce ACCT and welfare-check practice.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2026.
Action
Secure additional staffing resources to support delivery of the daily knowledge-check sessions.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2026.
West Yorkshire Eastern
Concerns raised1
Failure to provide a mental health assessment within 24 hours of transfer to the Segregation Unit for prisoners on an open ACCT document
Responses linked to these concerns
Each 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.10
Action
Revise the national mental health policy to require 24-hour mental health assessments for relevant ACCT prisoners placed in segregation.
Stated by Ministry of Justice and Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Communicate the PSO1700 assessment requirement to regional managers and mental health leads, requesting consistent implementation across services.
Stated by Ministry of Justice and Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Work with HMPPS nationally and locally to establish communications identifying ACCT patients moved to segregation.
Stated by Ministry of Justice and Practice Plus GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2026.
Action
Obtain site-level confirmation that the communication was actioned and monitor compliance regionally through the mental health steering group.
Stated by Ministry of Justice and Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Update the Take ACCTion audit to check compliance with PSO1700 and whether required mental health assessments occurred.
Stated by Ministry of Justice and Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Complete the comprehensive review of the segregation policy.
Stated by HM Prison and Probation Service and Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2026.
Action
Align the Segregation Policy Framework with the Safety Policy Framework to improve clarity and consistency, including healthcare provisions.
Stated by HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Publish the revised Segregation Policy Framework.
Stated by HM Prison and Probation Service and Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Publish supporting tools and learning resources for implementing the updated Segregation Policy Framework.
Stated by HM Prison and Probation Service and Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Deliver scheduled briefing sessions to familiarise staff, including healthcare professionals, with the revised policy and its application.
Stated by HM Prison and Probation Service and Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The PS1700 requirement is an HMPPS policy outside PPG’s control, so PPG limits its response to healthcare matters.
Stated by Ministry of Justice and Practice Plus GroupOutside remitThe respondent said that this matter was outside its role or authority.
Position
Practice Plus Group is responsible for responding separately to concerns about mental health assessment requirements for prisoners in segregation under ACCT.
Stated by HM Prison and Probation Service and Ministry of JusticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised8
Premature closure of ACCT processes
ACCT reviews lacking structure and consistency
Inappropriate reduction of ACCT observations
Failure to complete handovers between ACCT staff
Expired ACCT training
Failure of supervising officers to acquaint themselves with case notes or history when completing ACCT reviews
Inaccurate ACCT sign-offs
Inadequate ACCT record keeping
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 concerns
Each 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.4
Action
Automatically enrol newly promoted Senior Officers in national ACCT Case Review training.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 April 2026.
Action
Operate a structured ACCT quality-assurance framework covering opening checks, targeted case-review sampling, ongoing review assurance and final documentation compliance checks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 April 2026.
Action
Deliver continuous suicide and self-harm prevention training through the reintroduced Pentonville Speed School.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 April 2026.
Action
Complete refresher and additional upskilling for all ACCT Case Coordinators.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
Stated by Practice Plus GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Kent and Medway
Concerns raised1
Failure to secure attendance of the mental health team at required ACCT reviews
Responses linked to these concerns
Each 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.7
Action
Revise mental-health staffing rotas to provide skilled practitioners during peak ACCT review periods.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Run a daily multidisciplinary safety huddle to review ACCT patients, prioritise reviews, escalate risks, allocate actions and share information.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Circulate and embed the Kent ACCT Standard Operating Procedure through local induction and mandatory training, including exceptional non-attendance requirements.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Introduce an escalation and contingency process for missed healthcare attendance, including senior notification, alternative staffing, documentation and risk mitigation.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Strengthen forward planning for high-risk ACCT cases and monitor healthcare representation through daily operational meetings.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Audit healthcare attendance at ACCT reviews and oversee compliance through clinical governance, PSIRF, risk-register and executive assurance arrangements.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Disseminate learning across offender healthcare through reflective practice sessions reinforcing healthcare input in ACCT processes.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Kent and Medway
Concerns raised1
Failure to complete ACCT care plan documentation
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 concerns
Each 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.6
Action
Provide rolling weekly refresher training on the ACCT process to operational staff.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Use two Safety Flowerwalkers to support ACCT documentation and identify staff upskilling and training needs for the Safety Team.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Introduce scenario-based learning within local ACCT refresher training.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Continue partnership working with Oxleas NHS Foundation Trust to strengthen multidisciplinary care and planning for prisoners with complex needs.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Carry out monthly local ACCT quality audits, disseminate learning through staff briefings and meetings, and apply accountability measures where standards are unmet.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Embed the national ACCT quality-assurance process at HMP Swaleside and review all open ACCTs daily.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Inner West London
Concerns raised2
Lack of training in the principles of risk formulation during ACCT induction
Lack of mandatory ACCT refresher training for prison officers
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 concerns
Each 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
Action
Commission training modules examining self-harm and suicide risk formulation beyond the ACCT process.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Facilitate a two-day Mindworks module developing risk-practice and risk-assessment skills for managing self-harm and suicide risk.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 February 2026.
Action
Make risk-formulation training part of future core training for all staff.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 February 2026.
Action
Appoint three dedicated safety floorwalker officers to oversee ACCT processes, coach assessors and deliver targeted refresher training.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Extend ACCT process coaching and refresher training to non-operational colleagues, including healthcare staff.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
HMPPS does not mandate how staff awareness and confidence in delivering ACCT should be maintained.
Stated by HM Prison and Probation ServiceOutside remitThe respondent said that this matter was outside its role or authority.
Worcestershire
Concerns raised1
Failure to record and implement support actions in ACCT care plans
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 concerns
Each 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.7
Action
Implement the Prison Safety Policy Framework requiring ACCT teams to identify, review and record support actions and care-plan decisions.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Introduce and complete four local ACCT quality-assurance checks covering opening, reviews, complex-case oversight and closure.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Monitor and upload ACCT assurance findings, sharing them for follow-up through case management and monthly Safety Meetings.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Implement a single ACCT case-management allocation system assigning open cases to trained Supervising Officers or Custodial Managers.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Schedule ACCT reviews around allocated coordinators’ duties and use a buddy system to maintain continuity and prevent over-allocation.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Book refresher training for staff who misunderstood care-plan requirements when prisoners missed reviews.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Action
Provide one-to-one ACCT coaching to 21 Case Coordinators with support from Safety Leads.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Lancashire and Blackburn with Darwen
Concerns raised1
Lack of ACCT training and awareness of ACCT responsibilities among prison officers
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 concerns
Each 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
Provide all new entry officers with suicide and self-harm prevention training covering ACCT and changes in risks, triggers and protective factors.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Maintain an accessible online Safety Learning Reference Library, including ACCT guidance, templates and training materials, and promote it to HMP Garth staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Issue HMP Garth staff instructions reiterating when and how to open ACCTs, who should open them, and how to complete ACCT records.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ACCT training, induction and accessible guidance are considered sufficient to address concerns about staff suicide and self-harm prevention training.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Bedfordshire and Luton
Concerns raised1
Failure to escalate risk after incidents requiring review of observations or ligature controls
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 concerns
Each 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
Remind staff and provide additional training and support on escalating incidents and conducting ACCT reviews when risk increases.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
Kent and Medway
Concerns raised1
Insufficient ACCT process training and competence among frontline and civilian 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 concerns
Each 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
Continue rolling out SASH, speed training and ACCT upskilling to improve staff recognition of suicide and self-harm risks and case management.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Attend ACCT case reviews to share experience and guidance with staff.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 30 July 2025.
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Includes deficiencies in controls dedicated to the ACCT process, including quality assurance, observations, reviews, documentation, information sharing, staffing or training, where the failure undermines reliable ACCT risk prevention or management.
