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.
Mid Kent and Medway
Concerns raised1
Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011
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.
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.5
Action
Share relevant medication and safety-risk information during weekly Safety Intervention Meetings.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 August 2024.
Action
Introduce a Practice Development Nurse role to support healthcare-team training, guidance and policy compliance.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 August 2024.
Action
Deliver PSI 64/2011 and relevant policy guidance through teaching, read-and-sign procedures, handovers and supervision, with training records retained.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 August 2024.
Action
Review, update and disseminate healthcare policies to staff using the latest versions.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Embed a process with the healthcare provider for sharing relevant information about prisoners with in-possession medication, including discussion at weekly safety intervention meetings.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
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 are assigned to Oxleas NHS Foundation Trust because they relate to healthcare rather than prison responsibilities.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Sussex
Concerns raised1
Inadequate communication about prisoners’ health conditions
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
Implement Regional Multi Professional Complex Case Clinic escalation for the most complex patients.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Work with NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Sussex
Concerns raised1
Absence of a protocol or policy for healthcare-prison communication when monitoring sick prisoners on the wing at night
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.1
Action
Implement an agreed system clarifying prison welfare checks, healthcare clinical observations, required check levels and clinically appropriate inpatient transfers.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.
Hampshire, Portsmouth and Southampton
Concerns raised1
Incomplete information sharing between healthcare and prison security staff
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Operational staff cannot access healthcare records because medical confidentiality prevents direct access to SystmOne.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing multidisciplinary meetings, briefing sheets and observation books are considered sufficient to share necessary prisoner safety information.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Dorset
Concerns raised1
Absence of a local operating policy on the use of force between prison and healthcare services
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.4
Action
Implement a memorandum of understanding governing healthcare attendance at, and planned participation in, use-of-force interventions.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Write to prison healthcare providers requiring agreed local procedures covering healthcare roles during restraint and monitoring, recording and response to vital signs during and after incidents.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 25 October 2022.
Action
Request assurance from regional commissioning directors that the required local procedures have been implemented and evidenced by April 2023.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 25 October 2022.
Action
Produce a memorandum of understanding defining healthcare roles during planned and unplanned use-of-force incidents and required post-incident actions.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing policies and the local memorandum of understanding address healthcare roles during planned and unplanned use of force incidents.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Oxfordshire
Concerns raised1
Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly
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.7
Action
Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Work with Care UK, Pharmacy and Safer Custody on medication reviews and stop checks under the ACCT procedure.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
Action
Review in-possession medication risk assessments after specified incidents, changed circumstances, ACCT openings, or other identified safety concerns.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Conduct random medication spot checks and review or remove in-possession status when discrepancies or patient-safety concerns arise.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Issue guidance requiring ACCT case managers to discuss in-possession medication routinely and complete risk assessments with healthcare input.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Distribute a safety briefing on in-possession medication risks and required action during fabric checks or cell searches to all staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Include stockpiled medication and temporary removal considerations in future local ACCT case-manager training.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing monthly audits, policy reviews and spot checks are considered sufficient to manage in-possession medication risks.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Safer Custody Governor is taking forward responsibility for including medication-risk awareness in case manager training.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Lack of medication information sharing with discipline staff
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to communicate elevated NPS-related risk to Healthcare and prison officers
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
Notify staff that healthcare determines when additional checks are needed and must communicate this to prison discipline staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Action
Issue a notice reminding Forward Trust drug workers how to share information with prison and healthcare staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Action
Give every Forward Trust member access to SystmOne to enter and access information.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 10 May 2019.
Lancashire
Concerns raised1
Failure to routinely share prisoner self-harm and well-being information with reception healthcare staff
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
Provide reception staff with PSI 07/2015, require them to read and comply with it, and monitor completion through performance records.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Routinely pass PER forms to the reception nurse and require documentation in SystemOne that each form was received and considered.
Stated by North Cheshire and Mersey NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Explore incorporating a PER-form receipt check into the existing reception health-screen template.
Stated by North Cheshire and Mersey NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CNomis is not managed by healthcare, and reception nurses are not routinely granted access to it.
Stated by North Cheshire and Mersey NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Inner North London
Concerns raised1
Failure to share relevant healthcare information on prisoners’ ACCT records
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.1
Action
Embed procedures for identifying and sharing relevant prisoner risks and triggers with prison staff, supported by senior-management audits.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 12 February 2018.
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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.
