Recurring concern
Unreliable ACCT suicide and self-harm prevention processes
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Request correctionFirst reported 16 Sep 2013•Latest report 29 Jun 2026
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
- Individual concerns
- 184
- Date range
- 2013–2026
- Stated actions
- 276
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
Lack of clarity in PSI64/2011 guidance on first case review of an ACCT assessment
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 conduct ACCT reviews during required periods
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.
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Concerns raised6
Failure to identify and record prisoner-specific trigger factors on ACCT records
Failure to consider relevant ACCT file material when determining observation frequency
Failure to involve prison staff who know the prisoner in ACCT reviews
Failure to share relevant healthcare information on prisoners’ ACCT records
Failure to read recent risk-relevant ACCT daily record entries during case reviews
Poor understanding of when to contact a prisoner’s family during ACCT reviews
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
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Action
Embed procedures for identifying and sharing relevant prisoner risks and triggers with prison staff, supported by senior-management audits.
Stated by Care UK
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Concerns raised1
Intermittent night welfare checks and ACCT observations
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
Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.
Stated by Care UK -
Action
Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
Stated by Care UK
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
HMPPS owns and operates the ACCT process; healthcare staff contribute risk information but do not oversee or monitor it.
Stated by Care UK
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Concerns raised1
Failure to provide ACCT training to all relevant prison staff
This report raised 12 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
Deliver SASH suicide and self-harm prevention training to new prisoner-facing staff and roll out refresher training to existing staff.
Stated by HM Prison and Probation Service -
Action
Train additional staff as SASH trainers to increase capacity for course delivery.
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
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Position
Refresher-training figures do not mean prisoner-facing staff have never been trained or are deployed unable to recognise suicide and self-harm risk.
Stated by HM Prison and Probation Service
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Position
Refresher-training completion was delayed because the longer course, resourcing challenges and limited availability of qualified trainers constrained delivery.
Stated by HM Prison and Probation Service
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Concerns raised1
Inability to carry out risk assessments with mental health input during patrol state
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.
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
Risk-based ACCT observation levels already account for increased night-state risk when full review and mental-health input are unavailable.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to place prisoners at risk of suicide or self-harm on 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 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 raised2
Failure of ACCT Review team members to fully review the ACCT document
Failure to conduct ACCT reviews on a multidisciplinary basis
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
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Action
Redesign the ACCT document for nationwide reintroduction, including consideration of a summary sheet of observations and conversations.
Stated by HM Prison and Probation Service -
Action
Issue learning bulletins reinforcing multidisciplinary ACCT reviews, required timescales, written contributions and prompt recording of observations.
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
ACCT policy permits reviews and necessary decisions to proceed without waiting for a particular attendee, while requiring multidisciplinary continuity.
Stated by HM Prison and Probation Service
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Concerns raised2
Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment
Inadequate training of healthcare/mental healthcare staff on the ACCT process
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
Deliver the rolling SASH programme, mandate existing healthcare staff attendance, and provide new starters with training within six months.
Stated by Inspire Better Health -
Action
Incorporate an ACCT overview into the induction process for new staff, including documented acknowledgement of understanding.
Stated by Inspire Better Health -
Action
Reinforce SASH requirements through monthly team meetings using bite-sized ACCT-opening scenarios and discussion.
Stated by Inspire Better Health
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Concerns raised2
Failure of prison officers to understand ACCT contents
Failure to review and record events in the ACCT document
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 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