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.
Milton Keynes
Concerns raised1
Failure to maintain adequate ACCT case management documentation
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.
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
Deliver Case Management training to managers who chair ACCT case reviews.
Stated by National Offender Management Service Equality, Rights and Decency GroupStatus at responseThe respondent said that this action was partly complete when they made their response on 26 May 2016.
Action
Operate a case-review booking system to improve case-manager continuity and multidisciplinary team attendance.
Stated by National Offender Management Service Equality, Rights and Decency GroupStated completedThe respondent said that this action was complete when they made their response on 26 May 2016.
Action
Implement a designated case-manager system for each offender supported through the ACCT process while the ACCT remains open.
Stated by National Offender Management Service Equality, Rights and Decency GroupStated in progressThe respondent said that this action was in progress when they made their response on 26 May 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing prison governance and monitoring processes are considered sufficient to deliver action on HMIP, PPO and Regulation 28 recommendations.
Stated by National Offender Management Service Equality, Rights and Decency GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Central Hampshire
Concerns raised1
Lack of training of officers in ACCT processes
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised1
Failure to inform Healthcare staff when prisoners arrive with an ACCT history
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
Review the reception screening process to develop a standard first-reception screening template across prison healthcare settings.
Stated by Practice Plus Group Hospitals LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
Action
Update the SystemOne reception template to require staff to seek available information and record reasons when it is unavailable.
Stated by Practice Plus Group Hospitals LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
Action
Ensure reception information-gathering processes are clear and effective.
Stated by Practice Plus Group Hospitals LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Prison Service staff are responsible for examining and sharing PER and ACCT information with healthcare staff.
Stated by Practice Plus Group Hospitals LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised2
Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Failure to prepare sufficiently full ACCT assessment notes
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.6
Action
Issue improved operational guidance for ACCT processes.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby PrisonStated in progressThe respondent said that this action was in progress when they made their response on 16 March 2016.
Action
Improve safer custody training content and delivery.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby PrisonStated in progressThe respondent said that this action was in progress when they made their response on 16 March 2016.
Action
Clarify band and grade requirements for ACCT assessor and case manager roles.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby PrisonStated in progressThe respondent said that this action was in progress when they made their response on 16 March 2016.
Action
Remind staff to make comprehensive records of ACCT assessment interviews.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby PrisonStated completedThe respondent said that this action was complete when they made their response on 16 March 2016.
Action
Monitor ACCT documents through Head of Safer Custody oversight and quality assurance checks.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby PrisonStated in progressThe respondent said that this action was in progress when they made their response on 16 March 2016.
Action
Issue notice requiring relevant information to be recorded in ACCT documents, wing observation books and P-NOMIS.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby PrisonStated completedThe respondent said that this action was complete when they made their response on 16 March 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The remaining seven concerns were matters for HM Prison Service and other parties, so the Trust could not respond to them.
Stated by Nottinghamshire Healthcare NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Healthcare concerns are assigned to NHS England and Nottinghamshire Healthcare NHS Foundation Trust, which addressed them separately.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby PrisonRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Milton Keynes
Concerns raised1
Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
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.12
Action
Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Train reception-screening staff, including agency staff where used, to apply the strengthened screening tool.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Provide daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Provide ongoing support for prison ACCT training and prison-led ACCT management.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Check daily information-sharing and review ACCT records at each planned review meeting.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Audit and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NOMS holds policy responsibility for suicide prevention and self-harm management.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The prison leads the ACCT process and is responsible for regularly assessing prisoners’ risk.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Eastern)
Concerns raised1
Failure to consult relevant healthcare, chaplaincy, unit management or ACCT review officers before closing an ACCT
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Limiting ACCT closure to the primarily responsible person may reduce scrutiny and support in ways detrimental to prisoner wellbeing.
Stated by Serco Home AffairsDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Staff sickness, annual leave and lost days make limiting ACCT closure to the primarily responsible person impractical.
Stated by Serco Home AffairsUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Worcestershire
Concerns raised1
Failure to follow mandatory ACCT procedures for prisoners at risk of self-harm
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.1
Action
Review the ACCT process to inform changes to PSI 64/2011.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Hewell Prison and HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 18 September 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
ACCT procedures do not require automatic opening whenever risk may be indicated; staff must assess risk, consult appropriately and record their decision.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Hewell Prison and HM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised1
Failure to ensure that ACCT review attendees read recent ongoing observations
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised2
Ad hoc attendance of representatives from all disciplines, especially Healthcare, at ACCT reviews
Lack of written evidence of contributory input from other agencies in ACCT documentation
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.
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
Require daily email invitations to healthcare professionals for ACCT reviews and record their attendance or other input in ACCT documentation and SystmOne.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 September 2016.
Exeter and Greater Devon
Concerns raised1
Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme
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
Review patients on drug treatment programmes jointly with prison staff, agree observation arrangements, and share caseload information.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 July 2015.
Action
Introduce a robust system for monitoring patients arriving at HMP Exeter who require night welfare checks.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 July 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The action plan addressed identified care issues, with ongoing compliance audit and executive review providing sufficient assurance.
Stated by Dorset Healthcare University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NOMS at HMP Exeter is responsible for training and auditing operation of the ACCT document system.
Stated by Dorset Healthcare University NHS Foundation TrustRedirects 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.
