Recurring concern

Failure to reliably apply PSI 64/2011 mental-health risk guidance

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First reported 12 Aug 2016•Latest report 1 Aug 2024

Definition

What this concern includes

Includes failures in the PSI 64/2011 mental-health risk-guidance process, including omissions or inadequacies in identifying relevant risk factors, failure to update or disseminate its annexes and guidance, and failure of responsible staff to read, understand or apply the guidance in assessing and managing mental-health risk.

Not included

Excludes generic mental-health training, awareness or risk-assessment deficiencies that are not explicitly tied to PSI 64/2011.
Excludes failures involving other Prison Service Instructions unless the assertion directly concerns PSI 64/2011 or its dedicated mental-health risk guidance.
Excludes downstream care, communication or safeguarding failures where PSI 64/2011 guidance was reliably understood and applied.
Excludes generic failures to recognise unusual behaviour or other mental-health risk factors when no PSI 64/2011 connection is identified.

Reports: 3
Individual concerns: 3
Date range: 2016–2024
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service3

Ministry of Justice2

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.

1 Aug2024
West London
Concerns raised1
1. Failure to recognise the birth of a child as a specific mental-health risk factor
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.
AI-generated summary

Matthew Paul Braben · 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

Matthew Paul Braben died by asphyxia at HMP Wormwood Scrubs on 16 August 2021 after being found in his cell with his neck, wrists and ankles tied. The report identified concerns including failures to identify and respond to suicide risk, inadequate communication and record-keeping, failures relating to ACCT processes, and the impact of prisoners being held in their cells for up to 23 hours a day.

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 recognise the birth of a child as a specific mental-health risk factor
Wider context from the report
“1. The birth of a child is not recognised as a specific risk factor in PSI 64/2011 which means that staff may under-estimate its significance on mental health. ”
Source location
Matthew Paul Braben · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Nov2019
Avon
Concerns raised1
1. Failure to reflect remand prisoners’ higher risk of self-harm or suicide in national safer-custody guidance
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 2
1. Action
  Disseminated guidance identifying remand status as a suicide and self-harm risk factor.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Replace the existing safer-custody instruction with a policy framework and update risk and trigger lists using evidence on remand-status risks.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Shaun William Dewey · 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

Shaun William Dewey, a remand prisoner, was found hanging in his cell at HMP Bristol and died on 13 April 2018 after suspending himself from a ligature tied to the bed frame. The inquest identified anxiety, depression, separation from family, uncoordinated supervision, erratic medication use, and insufficient application of prison, healthcare and mental health systems as contributory factors. Concerns included whether remand prisoners’ higher risk of self-harm or suicide should be reflected in staff training, prisoner care, ACCT documentation and national guidance.

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 reflect remand prisoners’ higher risk of self-harm or suicide in national safer-custody guidance
Wider context from the report
“My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be: • considered by those designing the training for staff; • a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams. • a risk highlighted on the ACCT document or • reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)” ”
Source location
Shaun William Dewey · 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
Disseminated guidance identifying remand status as a suicide and self-harm risk factor.

Verbatim wording from the response
“As you rightly point out, whilst Prison Service Instruction (PSI) 64/2011 ‘Safer Custody’ contains lists of identified risks and triggers for suicide and self-harm that include factors that are relevant to many remand prisoners (such as early days in custody), it does not mention remand status itself. However, we frequently supplement the list in the PSI with additional information for staff, and this has included references to the increased risk posed by remand prisoners. For instance, the April 2014 Prison and Probation Ombudsman learning bulletin, from which you have quoted in your report, was disseminated widely within prisons, and more recent guidance issued by our prison safety team and made available to staff on the HMPPS intranet includes remand status as a risk factor for suicide. Training based on this more recent guidance has also been provided to staff in a number of prisons.”

Source location
2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Page 1 · response
Published 28 December 2019
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
Replace the existing safer-custody instruction with a policy framework and update risk and trigger lists using evidence on remand-status risks.

Verbatim wording from the response
“During 2020 we will be replacing PSI 64/2011 with a policy framework on prison safety, and as part of this process the lists of risks and triggers will be reviewed and updated. We will ensure that the evidence about the risks posed by remand status, which you have drawn to my attention, is used to inform that work. The new policy framework will include a new version of the Assessment, Care in Custody and Teamwork (ACCT) process designed to make the system easier to operate and improve the quality of care offered to prisoners. The new version of the form and associated guidance were piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal”

Source location
2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Page 1 · response
Published 28 December 2019
Open published response
12 Aug2016
Isle of Wight
Concerns raised1
1. Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stephen St Clair · 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

Stephen St Clair, a prisoner at HMP Isle of Wight, was found in his cell on 4 November 2013 with a severe cut to his throat and was pronounced dead at 05.55 hours. The report describes concerns about signs of paranoia and possible psychosis not being recognised as suicide or self-harm risk, and about the absence of corresponding wording in the Prison Service suicide risk guidance, which may have contributed to an ACCT not being opened.

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 descriptions of symptoms of undiagnosed mental illness in suicide risk guidance
Wider context from the report
“1. The Prison Service Instruction (“PSI”) 64/2011 (Management of prisoners at risk of harm to self, to others and from others (Safer Custody)) addresses the “Risk Factors for Suicide”. There are various subheadings, including “Clinical History” where the following point is made: “Mental illness diagnosis (e.g. depression, bipolar disorder, schizophrenia)” but there is no description of the possible symptoms which might be displayed by those who may be suffering from as yet undiagnosed conditions. ”
Source location
Stephen St Clair · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to recognise the birth of a child as a specific mental-health risk factor

Concerns raised1

Failure to reflect remand prisoners’ higher risk of self-harm or suicide in national safer-custody guidance

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

Concerns raised1

Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance

Actions described in response 2