Recurring concern

Unreliable recording of prisoner risk assessments and decisions

First to latest report 16 Jun 2014 — 20 Apr 2020

Reports that mention this concern
5
Times this concern has been raised
7
Stated actions linked to this concern
5

What this concern includes

Includes failures to record, update or attribute prisoner risk assessments, placement or deselection decisions and associated risk-management discussions where the records are needed for later review, handover or protective action, including RSU decisions and prison healthcare or custody risk assessments.

What is not included
  • Excludes failures to perform or clinically assess prisoner risk where the recording process is not itself deficient.
  • Excludes generic prison record-keeping failures unrelated to risk assessments or consequential risk-management decisions.
  • Excludes failures to communicate or act on complete and accessible risk records where recording and attribution were reliable.
  • Excludes broader prison information-sharing, ACCT or multidisciplinary-review failures unless the specific unsafe condition is missing, incomplete or unattributed recording of the risk assessment or decision.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Andrew Patrick Jones · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record RSU deselection discussions and risk assessments

    Wider context from the report

    “████████ had discussed Andrew Jones deselection from the RSU in the week before the altercation with the two SOs on the wing and that there was no entry in any prison record to reflect the discussion or an assessment of risk. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record transfer decisions and pre-transfer checks

    Wider context from the report

    “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera; d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer; e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death; g. Inconsistent medication regimes without explanation; h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred; i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place; j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delayed recording of post-closure risk interviews after substantial risk change

    Wider context from the report

    “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera; d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer; e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death; g. Inconsistent medication regimes without explanation; h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred; i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place; j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 8 · concerns

    Open source report

  2. Manchester City

    AI-generated summary

    Tomasz Nowosad · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of written rationale for self-harm and suicide risk assessments

    Wider context from the report

    “5 3 It is suggested that whenever an assessment of risk of self-harm or suicide is undertaken there is a written record made of the factors or issues involved in this or what weight or consideration was given to them and how the risk assessment was arrived at It is suggested that it would be appropriate for GMMH and HMPS to ensure that this is introduced ”

    Source location

    Tomasz Nowosad · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.

    Verbatim wording from the response

    “A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020.”

    Source location

    2019-0445-Response-from-HMPPS
    Page 1 · response
    Published 8 January 2020

    Open published response

  3. Inner North London

    AI-generated summary

    MARK ANTHONY DOYLE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing prison officers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of process for recording transfer decisions, reasons and decision-maker identity

    Wider context from the report

    “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise. ”

    Source location

    MARK ANTHONY DOYLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use a Patient Wing Movement Assessment requiring senior clinical review, documented fitness decisions and reasons, regular review meetings, and communication of outcomes before transfers.

    Verbatim wording from the response

    “Response: We agree the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 12 February 2018

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Steven James May · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to prepare sufficiently full ACCT assessment notes

    Wider context from the report

    “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible. For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview; ”

    Source location

    Steven James May · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind staff to make comprehensive records of ACCT assessment interviews.

    Verbatim wording from the response

    “Staff at HMP Ranby were reminded of the need to make comprehensive records of all such interviews at a briefing on 23 March 2016. All ACCT documents at the prison are now being monitored by the Head of Safer Custody and the quality assurance check that is conducted addresses this point.”

    Source location

    Steven-May-Response
    Page 1 · response
    Published 16 March 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor ACCT documents through Head of Safer Custody oversight and quality assurance checks.

    Verbatim wording from the response

    “Staff at HMP Ranby were reminded of the need to make comprehensive records of all such interviews at a briefing on 23 March 2016. All ACCT documents at the prison are now being monitored by the Head of Safer Custody and the quality assurance check that is conducted addresses this point.”

    Source location

    Steven-May-Response
    Page 1 · response
    Published 16 March 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue notice requiring relevant information to be recorded in ACCT documents, wing observation books and P-NOMIS.

    Verbatim wording from the response

    “At HMP Ranby a notice was issued in February 2016 reminding staff that those responsible for a prisoner on an open ACCT must record all relevant information in the ACCT document, the wing observation book and on the P-NOMIS system. Both the prison and the healthcare provider have recently reviewed their procedures to ensure that systems are in place for information to be shared between prison and healthcare staff and recorded appropriately. In order further to improve information sharing, meetings of the multi-disciplinary team for prisoners identified as being vulnerable or at risk of harm are held every two weeks, and any ongoing concerns are discussed and recorded.”

    Source location

    Steven-May-Response
    Page 2 · response
    Published 16 March 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Healthcare concerns are assigned to NHS England and Nottinghamshire Healthcare NHS Foundation Trust, which addressed them separately.

    Verbatim wording from the response

    “You will be aware that healthcare at HMP Ranby is commissioned by NHS England and provided by Nottinghamshire Healthcare NHS Foundation Trust, and I understand that the matters of concern that you have raised at points 1, 2 and 10 have been addressed separately by the Chief Executive of the Trust in a letter dated 13 April 2016, and by the Clinical Quality Manager at NHS England in a letter dated 5 May 2016. This response therefore addresses the matters of concern at points 3 to 9.”

    Source location

    Steven-May-Response
    Page 1 · response
    Published 16 March 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The remaining seven concerns were matters for HM Prison Service and other parties, so the Trust could not respond to them.

    Verbatim wording from the response

    “The Trust cannot respond to the other 7 concerns highlighted in the Prevent Future Death report as they are matters for HM Prison Service and/or other parties.”

    Source location

    2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 March 2016

    Open published response

  5. Inner North London

    AI-generated summary

    David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Andrew Llewellyn O’Garro suffered a sudden death in epilepsy while occupying a single cell at HMP Pentonville, with nobody present to raise the alarm during what was likely his final seizure. Concerns included the failure to complete or locate a cell sharing risk assessment and a lack of clarity and shared understanding among prison staff about ensuring prisoners with epilepsy had a cellmate.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to accurately record cell occupancy suitability

    Wider context from the report

    “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy. No HMP Pentonville CSRA was ever found for Mr O’Garro. During the inquest: - one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate; - a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works; - one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book. Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville. ”

    Source location

    David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026