First reported 30 Oct 2013•Latest report 9 Feb 2026
Definition
What this concern includes
Includes failures of the prison reception or first-night reception process, including dedicated training, role guidance, template use and transfer or availability of information, where the failure can impair safe reception of prisoners.
Not included
Excludes generic staff training deficiencies not tied to prison reception or first-night reception.
Excludes failures in later custody processes that do not concern reception or initial induction.
Excludes unrelated deficiencies in prison documentation, case management or healthcare unless they directly impair the reception process.
Reports
24
Distinct published reports
Individual concerns
38
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
54
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 Service11
Care UK7
Ministry of Justice7
NHS England5
Pentonville Prison4
GeoAmey PECS Limited2
Herefordshire and Worcestershire Health and Care NHS Trust2
Office of the Chief Coroner2
Winchester Prison2
Belmarsh Prison1
Central and North West London NHS Foundation Trust1
Chelmsford Prison1
Department of Health and Social Care1
Durham Prison1
Family's solicitors1
Executive agency11
Prison or young offender institution11
Multi-service care provider8
Ministerial department7
Executive non-departmental public body5
NHS trust3
Coronial office2
Prison operator2
Private limited company2
Sub-organisation2
Independent healthcare provider1
Justice inspectorate1
Non-ministerial department1
Police force1
Type not available1
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 North London
Concerns raised2
Inefficiency and slowness of the prison reception process
Failure to retain documentation accompanying prisoners during 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 reception procedures and implement necessary improvements identified through the review.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Action
Conduct regular early-days exercises to test reception and induction processes and identify further improvements.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Use a digital induction passport to consolidate, store and share key risk information during reception.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Provide digital Person Escort Records for PECS movements and enable authorised professionals to update them before arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Qualified medical professionals and Liaison and Diversion services are responsible for creating, maintaining and transferring healthcare and associated risk information.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
PECS suppliers are not contractually responsible for physically transferring hard-copy medical or risk documentation between courts and prisons.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Failure to search clinicians’ records from previous prison stays during Reception Health Screens or mental health needs reviews
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
Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
Action
Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
Nottinghamshire
Concerns raised1
Lack of arrangements for welfare checks when the First Night Interview cannot take place
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.1
Action
Update the induction policy to require late-arrivals forms when normal induction cannot be facilitated.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 28 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing published Expectations cover the identified prison safety issues, which inspectors will consider during inspections and follow up as appropriate.
Stated by His Majesty’s Inspectorate of PrisonsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
County Durham and Darlington
Concerns raised1
Failure to ask about family history of sudden cardiac death during reception health screening
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
Refresh the secondary health screening template to add a specific prompt about family history of sudden cardiac death.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No specific read code for sudden death syndrome is provided because there is no evidence supporting screening for the condition.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Dorset
Concerns raised1
Failure to identify prisoners’ health information during large-cohort reception
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.5
Action
Maintain prison-specific SystmOne templates and prescribing modules adapted for secure healthcare settings.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 October 2021.
Action
Provide reception healthcare staff access to digital person escort records before arrivals to identify risks and support correct reception processes.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 October 2021.
Action
Review and update healthcare reception and secondary-screening templates, then apply lessons learned across the male estate.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 22 October 2021.
Action
Transfer prisoners in smaller numbers as pandemic-related exceptional delivery measures are withdrawn.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 22 October 2021.
Action
Adopt GP2GP to enable electronic transfer of patient records into HJIS when patients enter the detained estate.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The bespoke prison SystmOne module, templates and integrated summary care record are considered adequate existing adaptations for accessing and highlighting relevant patient information.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Healthcare matters in the prison estate are commissioned by NHS England and Improvement, which has already provided a response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to interview transferred prisoners and provide distraction materials on reception
This report raised 19 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.
Oxfordshire
Concerns raised3
Failure of the pre-arrival process to ensure receipt of high-risk self-harm or suicide information
Lack of guidance for reducing observations of newly arrived prisoners from constant watch
Failure to ensure that reception staff have access to all available prisoner information
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.11
Action
Implement a reception communication process using direct telephone alerts, secure email, acknowledgement and routine inbox checks for incoming patient risk information.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Provide NHS email accounts to all reception staff, including agency staff, to securely access incoming risk information.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Remind escort contractors to alert reception staff when constant supervision preceded a prisoner’s arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Remind reception staff to share and record risk information on prisoner passports, and audit passport recording and use.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 15 August 2019.
Action
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Birmingham and Solihull
Concerns raised1
Failure to review information about prisoners entering the prison
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.
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.
Preston and West Lancashire
Concerns raised2
Lack of formal training in reception duties
Lack of written material informing reception officers of their duties
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.
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Includes failures of the prison reception or first-night reception process, including dedicated training, role guidance, template use and transfer or availability of information, where the failure can impair safe reception of prisoners.
