First reported 13 Jan 2014•Latest report 20 May 2026
Definition
What this concern includes
Includes failures of the dedicated prison custody–healthcare interface, including incompatible or poorly understood procedures, unclear responsibilities, inadequate appreciation of each function's limitations, and failures to share safety-relevant information needed for coordinated prisoner care.
Not included
Excludes generic inter-agency cooperation or communication failures with no explicit prison custody and healthcare interface.
Excludes failures confined to a single healthcare process, such as clinical assessment or treatment, where cross-function interoperability is not the unsafe condition.
Excludes ordinary prison staffing, training or facility deficiencies unless they directly prevent custody and healthcare procedures from operating safely together.
Excludes custody-transition medical-information failures where the concern is limited to transferring or reviewing records rather than wider interoperability of procedures and responsibilities.
Reports
35
Distinct published reports
Individual concerns
40
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
88
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 Service17
Ministry of Justice10
Department of Health and Social Care4
Oxleas NHS Foundation Trust4
Care UK3
NHS England3
Northamptonshire Healthcare NHS Foundation Trust3
Pentonville Prison3
Prisons and Probation Ombudsman3
Government Legal Department2
Herefordshire and Worcestershire Health and Care NHS Trust2
HM Inspectorate of Prisons2
Lowdham Grange Prison2
Nottinghamshire Healthcare NHS Foundation Trust2
Practice Plus Group2
Prison or young offender institution20
NHS trust18
Executive agency17
Ministerial department12
Executive non-departmental public body3
Independent healthcare provider3
Multi-service care provider3
Ombudsman3
Private limited company3
Healthcare site2
Justice inspectorate2
Non-ministerial department2
Prison operator2
Type not available2
Company limited by guarantee1
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.
Nottinghamshire
Concerns raised1
Failure to ensure a safe and productive working relationship between prison and healthcare staff
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
Maintain Head of Healthcare leadership, cross-team meeting participation, strategic planning, and competent deputy cover to support integrated working.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Participate in prison-healthcare meetings, including violence-reduction and segregation meetings, to support safer custody and transitions.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Attend daily ACCT reviews with prison staff to identify prisoners who may require additional support.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Host Governor-grade prison colleagues in healthcare staff briefings at least monthly to reinforce integrated working.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Operate a joint Duty Manager Rota providing a senior-manager contact during core hours for resolving or escalating prison-healthcare issues.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Conduct daily healthcare-prison briefings and structured handovers to improve continuity of care and information sharing.
Stated by HM Prison and Probation Service and Lowdham Grange PrisonStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Nottinghamshire
Concerns raised3
Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff
Failure to equip operational prison staff to identify and report behavioural deterioration
Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare
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.12
Action
Establish regular information-sharing through daily briefings, SIM meetings, drug-strategy discussions, and communication across prison operational and healthcare teams.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Issue and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Ensure findings from the NOMIS/DPS alerts review inform future enhancements addressing the identified concerns.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Establish practical information-sharing arrangements and named contacts between community forensic and prison healthcare teams.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Healthcare information-sharing concerns have been referred to the relevant NHS trusts for separate consideration and response.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised1
Failure to maintain QEH staff awareness of the limits of prison healthcare
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised1
Failure to reliably consolidate and share relevant prisoner risk information
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 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
Revise handover documentation, including a prompt to identify information requiring sharing with prison colleagues.
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 March 2026.
Action
Ensure healthcare participation in multidisciplinary forums, weekly Safety Intervention Meetings and daily wing briefings.
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 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Healthcare services alone cannot mitigate all risks within custody.
Stated by Central and North West London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Kent and Medway
Concerns raised1
Failure of prison staff communication to relay the severity and complete scope of situations
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.2
Action
Embed practical emergency-response simulations, including Code Blue scenarios, within local training and mentoring arrangements.
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
Continue joint emergency-response exercises with healthcare staff to strengthen shared understanding and multidisciplinary response.
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.
Essex
Concerns raised1
Failure to share critical suicide-risk information with prison staff
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.2
Action
Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Implement a formal Prisoner Warning Notice communication logbook and train relevant staff to record, communicate, and acknowledge custody-related risks.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Kent and Medway
Concerns raised1
Unclear prison officer roles in conveying prisoners lacking capacity to hospital
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.
Inner West London
Concerns raised1
Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness
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.1
Action
Establish forums for prison and healthcare staff to share knowledge about prisoners of concern.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Nottinghamshire
Concerns raised2
Use of inaccessible email channels for risk pertinent information
Failure to identify and share risk pertinent information between prison and healthcare 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 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.20
Action
Review estate-wide email practices to ensure risk information reaches available healthcare staff.
Stated by Serco UK & EuropeStated plannedThe respondent said that this action was planned when they made their response on 13 February 2025.
Action
Audit and quality-review documentation of risk information in wing observation books.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2025.
Action
Maintain generic healthcare email inboxes with daily administrative monitoring for non-urgent prison queries.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Disseminate healthcare mailbox addresses and radio call signs to prison wings and staff.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Develop collaborative information-sharing arrangements between the prison and healthcare provider and reinforce use of designated information systems.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Introduce and operate a digital Reception Screening Risk Assessment tool across Sodexo prisons to identify arrival risks and generate alerts for staff review.
Stated by SodexoStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Remind staff across Sodexo prisons to record concerns in NOMIS and wing observation books.
Stated by SodexoStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Implement the Information Sharing Position Statement to guide health-information sharing and consent decisions across the criminal justice system.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Complete nationally delivered training for staff using the new prison reception-screening template.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Amend the reception supervision proforma to record clinical staff access to digital Person Escort Records.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2025.
Action
Attend weekly Safety Interventions Meetings through Mental Health Team representation and quality-check attendance and information sharing.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Complete CSIP training for healthcare staff to support risk-information sharing.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Deliver healthcare training to prison officers through the prison staff induction programme, expanding from emergency response to mental-health awareness.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Continue providing healthcare staff training on clinical risk, self-harm and suicide.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Scope systems for sharing risk information with prison colleagues on residential wings.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Review ACCT attendance and contributions through the safer-custody process to assure quality.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2025.
Action
Share ACCT safety plans with patients and prison colleagues, with identified escalation routes, and audit this practice.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2025.
Action
Introduce risk-sharing measures, including a triggers database and improved shift handovers, first-night processes and induction.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Refresh the Safety Intervention Meeting to improve multidisciplinary information-sharing and strategic support for prisoners at risk.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Work with NHS England to devise revised guidance on information-sharing in prison reception areas, including healthcare access to digital Person Escort Records.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Urgent information sharing involving safety risks should follow local safeguarding processes rather than the routine information-sharing statement.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Custodial staff cannot access healthcare records because of medical confidentiality, so they rely on healthcare staff to communicate risk information.
Stated by Serco UK & EuropeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Resource constraints mean staff cannot always fully review PNOMIS records or previous ACCTs, although higher-risk cases are prioritised.
Stated by Serco UK & EuropeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Access to the digital Person Escort Record cannot be audited, preventing direct monitoring of whether staff access risk information.
Stated by Nottinghamshire Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Mid Kent and Medway
Concerns raised1
Lack of national guidance or policy on returning prisoners to custodial settings when prison healthcare concerns have not been considered by the consultant
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.1
Action
Ask officials to consider whether hospital discharge guidance should explicitly require consideration of care-provider concerns before discharge to custodial settings.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 8 October 2024.
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Includes failures of the dedicated prison custody–healthcare interface, including incompatible or poorly understood procedures, unclear responsibilities, inadequate appreciation of each function's limitations, and failures to share safety-relevant information needed for coordinated prisoner care.
