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.
Liverpool and the Wirral
Concerns raised1
Failure to provide nurses with relevant prisoner escort information during first health reception screening
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
Provide reception healthcare staff with Person Escort Records, brief relevant staff, and conduct spot checks of compliance.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing information-sharing arrangements make recording receipt of documents on NOMIS unnecessary.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Central Hampshire
Concerns raised2
Failure to ensure clarity about information available during prison reception
Failure to ensure receipt and training for important medical and risk information at prison reception
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
Circulate reception-screening expectations and provide a Trust-wide reception-screening guide for staff.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 July 2019.
Action
Roll out standardised reception-screening training and competencies, restricting screening to trained and competent staff.
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 18 July 2019.
Inner North London
Concerns raised1
Failure to conduct the second reception screen
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
Maintain a register of missed Second Reception/Wellman assessments, arrange follow-up appointments through the Lead Nurse, and document patient refusals with scanned disclaimers.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 April 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Lead Nurse is responsible for arranging follow-up and completion of missed Second Reception/Wellman assessments.
Stated by Care UKRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised3
Failure to explore recorded history of depression during reception screening
Failure to apply objective clinical analysis during nurse reception screening
Ambiguity in reception screening questions for identifying increased-risk prisoners
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.3
Action
Roll out the wellbeing wheel assessment, supported by online and face-to-face training, to explore mental health, physical health and substance-misuse issues in greater depth.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2016.
Action
Replace the reception templates with an auditable, task-driven referral pathway that assigns greater accountability to the screening clinician.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 December 2016.
Action
Replace the prescriptive self-harm and suicide risk score with clinician-led exploration of presentation and relevant risk factors.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 December 2016.
Inner North London
Concerns raised4
Unavailability of the first night reception template key to the assessing GP
Failure of the assessing GP to recognise the inpatient healthcare threshold in the first night reception template
Failure to ensure staff understand the status of the first night reception template
Failure of the first night reception template to indicate that its instructions are advisory rather than mandatory
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
Roll out refresher training on the first-night reception template and its clinical guidance to all staff.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 26 July 2016.
Action
Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2016.
Central Hampshire
Concerns raised1
Failure to make the SASH document identifiable to all relevant staff during reception
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised3
Failure to inform Healthcare staff when prisoners arrive with an ACCT history
Failure to review available historical prisoner information at initial presentation
Failure to supply Prisoner Escort Records to Healthcare staff at reception
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
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 raised3
Lack of clarity about the designated recipient of SASH forms
Failure of reception procedures under foreseeable high-demand conditions
Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures
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.7
Action
Require reception staff to physically check, read, cross-reference and jointly sign prisoner documentation before escort departure, with daily staffing records and routine observation.
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
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.
Action
Require reception staff to complete minimum online training before working in prisoner reception, with completion managed through learning plans and appraisals.
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
Reissue and publish a reception-focused notice requiring documentation checks and warning of possible disciplinary action for failures.
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
Instruct nursing staff to read and review all patient documents during reception screening.
Stated by G4S Forensic & Medical Services (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 15 December 2015.
Action
Remind staff through meetings and briefings to ensure all paperwork accompanying each prisoner is transferred with them on arrival.
Stated by G4S Forensic & Medical Services (UK) LtdStated 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
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 contractor has no remit over HMP Durham staff compliance with Prison Service Instructions.
Stated by GeoAmey PECS LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing procedures and systems are considered correct and sufficient for safe custody and escort, with focused training addressing the concerns.
Stated by GeoAmey PECS LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Requesting individual operating specifications from every establishment is not feasible because of the number of sites and resulting paperwork.
Stated by GeoAmey PECS 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 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.
Worcestershire
Concerns raised1
Failure to recognise the toxic significance of medication combinations during reception screening
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
Provide whole-nursing-team training to recognise medicines requiring ECG referral.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2015.
Essex
Concerns raised1
Lack of a process for following up non-attendance at Reception Healthcare first night screening
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
Undertake a second health screen within 72 hours of arrival, checking GP-record consent and recording refusals in SystmOne.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 September 2016.
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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.
