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.
Inner West London
Concerns raised1
Inadequate communication between healthcare, psychological, psychiatric and prison staff
This report raised 14 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.
Cambridgeshire and Peterborough
Concerns raised1
Failure to communicate less obvious suicide and self-harm risk factors
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Leicester City and South Leicestershire
Concerns raised1
Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised2
Failure to inform Healthcare staff when prisoners arrive with an ACCT history
Failure to supply Prisoner Escort Records to Healthcare staff at reception
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.4
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.
Action
Remind prison and healthcare staff to check the PER every time and escalate unavailable records through a Datix incident report.
Stated by Practice Plus Group Hospitals LimitedStated completedThe respondent said that this action was complete 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.
County Durham and Darlington
Concerns raised1
Failure of GEOAmey, prison and healthcare procedures to inter-operate safely
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.4
Action
Require reception staff to verbally hand over self-harm warnings and relevant court-return information to First Night Centre and healthcare staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 December 2015.
Action
Hold monthly meetings between prison operations and the escort contractor to communicate procedural changes.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2015.
Action
Hold monthly prison operational and clinical governance meetings to discuss issues between prison and healthcare services.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2015.
Action
Engage with other agencies to develop and share best-practice procedures and documentation.
Stated by GeoAmey PECS LimitedStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Unable to address individual staff and local HMP Durham issues because it no longer provides healthcare there.
Stated by Care UK LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Ministry of Justice has final responsibility for policy, procedures and documentation.
Stated by GeoAmey PECS LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The contractor has no contract, contact or input regarding prison healthcare provision, policies or procedures.
Stated by GeoAmey PECS LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
The system is not dysfunctional; correct PER completion and document reading by prison and healthcare staff address interoperability concerns.
Stated by GeoAmey PECS LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure of prison, health and DART workers to share drug issue information adequately
This report raised 11 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
Hold monthly drug-strategy meetings, require B-Wing officers to attend, and require detox and recovery staff to confirm they have read the minutes.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 25 November 2015.
Action
Discuss drug-misuse trends in monthly drug-strategy and security meetings and identify and implement risk-reduction actions.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 25 November 2015.
Worcestershire
Concerns raised1
Failure to disseminate relevant medical risk information to staff involved in prisoner care
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 reception procedures and establish recorded communication between reception staff and escort providers.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Hewell Prison and HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 18 September 2015.
Manchester City
Concerns raised1
Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
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.
Mid Kent and Medway
Concerns raised1
Failure to flag medication non-compliance for clinical and custodial action
This report raised 27 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
Record medication refusal, non-attendance, diversion or failed ingestion and notify relevant healthcare and custodial staff.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
Action
Share medication non-compliance concerns through cross-agency handovers, electronic tasks, prison communication records, and relevant safeguarding processes.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
Portsmouth and South East Hampshire
Concerns raised1
Failure to consistently record and flag key healthcare events between daytime and night-time 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing professional guidance requires accurate clinical records and sharing relevant information with colleagues, addressing handover and communication concerns.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
