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.
Buckinghamshire
Concerns raised3
Inadequate communication with families during the ACCT process
Insufficient detail in ACCT caremaps and post-closure reviews
Delays in completing ACCT post-closure reviews
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 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
Develop the family pathway during the May/June 2017 policy review to support active family involvement wherever possible.
Stated by Woodhill PrisonStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
Action
Undertake further Case Manager work using local examples and contributions from families and prisoners to promote family involvement.
Stated by Woodhill PrisonStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
Action
Implement weekly wing-manager and monthly Duty Governor quality checks of ACCT and post-closure reviews, including caremap assessment and corrective feedback.
Stated by Woodhill PrisonStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.
Action
Complete Safer Prisons post-closure checks using a quality-assurance template to verify timescales, caremap actions and closure-questionnaire invitations.
Stated by Woodhill PrisonStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The prison can only prompt family contact, and effective involvement depends on the prisoner’s consent.
Stated by Woodhill PrisonUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised2
Failure to meaningfully involve families in the ACCT process
Failure to provide effective ACCT process training
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Failure to open an ACCT for a person likely to be upset
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.2
Action
Remind ACCT case managers to open and accurately record ACCT documents and use multidisciplinary reviews when prisoners are at risk.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
Action
Issue and disseminate national guidance on multidisciplinary working and ACCT to support continuity of care.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
ACCT is intended for identified suicide or self-harm risk, while general distress is addressed through other existing support mechanisms.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised3
Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation
Failure of caseworkers to be aware of and attend ACCT Case Reviews
Inadequate foundation and ongoing ACCT-procedure training for staff
This report raised 8 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
Use a daily Open ACCT Log and morning briefing to identify open ACCTs, arrange assessments and ensure mental-health attendance at reviews.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Roll out mandatory e-learning on ACCT processes and healthcare roles and responsibilities to CNWL secure-settings staff.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
CNWL cannot always ensure mental health team attendance at every ACCT review because of mental health service capacity constraints.
Stated by Central and North West London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The prison is responsible for delivering ACCT training, so CNWL depends on the establishment’s training schedule for staff access.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Central Hampshire
Concerns raised2
Failure to implement ACCT plans in accordance with national policy
Inadequate observations under ACCT plans
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
Deliver local ACCT refresher training to 48 staff on 13 and 20 December 2016, then provide it at least monthly.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 4 October 2016.
Action
Develop a plan to provide refresher training for ACCT case managers and assessors and increase the number of staff trained in those roles.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2016.
Action
Recruit and deploy 12 new Prison Officers who complete entry-level training covering suicide, self-harm awareness and the ACCT process.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 4 October 2016.
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 ServiceStated completedThe respondent said that this action was complete when they made their response on 4 October 2016.
Leicester City and South Leicestershire
Concerns raised5
Premature closure of ACCTs before identified inadequacies are detected and needs are properly served
Failure of the ACCT document to accompany prisoners around the prison
Failure to read and use available documentary information in ACCT reviews
Failure to complete ACCT documentation fully
Failure to invite all appropriate individuals to ACCT reviews
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
Use the Safer Custody toolkit to provide local ACCT procedures aligned with national policy.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 20 September 2016.
Action
Conduct regular management checks and quality assurance of ACCT documentation and procedures.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 20 September 2016.
Action
Remind ACCT case managers to use multidisciplinary reviews, address prisoners’ needs in care maps, and complete actions before closure.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 20 September 2016.
Action
Implement national review recommendations, including revisions to ACCT policy and forms.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2016.
Action
Continue monitoring ACCT system performance to assess delivery of anticipated improvements.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2016.
Action
Remind staff to complete ACCT documents fully, record relevant information, and move documents with prisoners.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 20 September 2016.
Action
Use a local ACCT review template requiring confirmation that relevant documentation has been read before reviews.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 20 September 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The national ACCT policy and system are sound; the identified problems concern compliance with policy and quality of care delivery.
Stated by Glen Parva Young Offender Institution and Ministry of JusticeDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Isle of Wight
Concerns raised1
Failure to open an ACCT document when behaviour indicates a need for additional monitoring
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised2
Lack of sufficient ACCT training among staff
Failure to adhere to mandatory ACCT process provisions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Preston and West Lancashire
Concerns raised2
Failure of RMNs to record post-consultation and post-review information in ACC T documentation
Reliance by RMNs on summaries of ACC T documentation instead of independent review
This report raised 9 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cheshire
Concerns raised1
Failure to properly observe ACCT procedures
This report raised 7 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.7
Action
Check all ACCT documents daily through Officer Supervisors.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 June 2016.
Action
Introduce an additional weekly ACCT document check by a Custodial Manager.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.
Action
Conduct weekly sample checks of ACCT documents until standards improve and processes are embedded.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.
Action
Issue a Governor’s Order defining staff responsibility and accountability for ACCT documents.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 13 June 2016.
Action
Require staff to account for unsatisfactory ACCT documents and escalate appropriate cases through warnings or misconduct investigation.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 13 June 2016.
Action
Brief all Offender Supervisors and Custodial Managers on the importance of the ACCT process.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.
Action
Require staff to notify Safer Custody of prisoner concerns so an immediate ACCT review is organised, with escalation when responsible staff are unavailable.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 June 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational issues concerning proper observance of ACCT procedures should be addressed by NOMS.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
