Recurring concern

Inadequate prison reception safeguards

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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
Individual concerns: 38
Date range: 2013–2026
Stated actions: 54

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 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

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.

20 Jun2014
Suffolk
Concerns raised1
1. Failure to obtain relevant medical information for care planning during initial reception assessment
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.
AI-generated summary

Redmond Johnson · 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

Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.

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 obtain relevant medical information for care planning during initial reception assessment
Wider context from the report
“(1) If a detainee has a history of significant medical problems, healthcare professionals undertaking the initial reception assessment should request further information from the General Practitioner and, where necessary, hospital doctors normally involved in the detainee’s care to enable appropriate care planning while that detainee is in the custody of the prison service. ”
Source location
Redmond Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Dec2013
Inner South London
Concerns raised1
1. Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening
This report raised 9 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 1
1. Action
  Develop a care pathway with healthcare partners to screen for tobacco-withdrawal risks and provide appropriate support, including nicotine replacement therapy.
  Stated by HM Prison and Probation ServiceStated in progress
AI-generated summary

Adrian Johnson · 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

Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.

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 routinely screen and enquire into tobacco withdrawal during prison reception screening
Wider context from the report
“(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”
Source location
Adrian Johnson · Prevention of Future Deaths report
Page 4 · 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
Develop a care pathway with healthcare partners to screen for tobacco-withdrawal risks and provide appropriate support, including nicotine replacement therapy.

Verbatim wording from the response
“NOMS accepts that despite the above range of screening during the reception process, further consideration needs to be given to identifying prisoners for whom tobacco withdrawal may give rise to an increase in suicidal feelings or self-harm, and to develop the support given to prisoners who do not have access to tobacco, or to the amount they would normally rely on. NOMS is currently working with healthcare partners to develop a care pathway, that includes an appropriate level of screening, to ensure that when tobacco is not available, or it is available but in more limited supply than the level they are used to (because they have limited funds/access to prison shop), that the relevant healthcare provider ensures that appropriate support, including Nicotine Replacement Therapy is available.”

Source location
2013-0364-Response-by-NOMS
Page 2 · response
Published 20 December 2013
Open published response
6 Dec2013
County Durham and Darlington
Concerns raised1
1. Failure to ensure that relevant forms are seen during the reception process
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 2
1. Action
  Place a reception trolley to ensure relevant documentation is passed to healthcare staff.
  Stated by Practice Plus Group Hospitals LimitedStated completed
2. Action
  Deliver regular refresher training, including Self Harm Warning Forms within induction training for all new staff.
  Stated by Practice Plus Group Hospitals LimitedStated completed
AI-generated summary

Kirk Duboise · 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

Kirk Duboise arrived at HMP Durham with documents highlighting self-harm risks, but the documents were not seen and an ACCT was not opened. He was found dead in his cell approximately eight hours after arrival; concerns included the failure to identify the relevant forms and a delay in summoning an ambulance.

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 ensure that relevant forms are seen during the reception process
Wider context from the report
“(2) That not all relevant forms were seen by those involved in the reception process one of whose duties at such time was to properly assess the risk of self harm of the new prisoner, particularly a prisoner who had not been in custody before. ”
Source location
Kirk Duboise · Prevention of Future Deaths report
Page 1 · 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
Place a reception trolley to ensure relevant documentation is passed to healthcare staff.

Verbatim wording from the response
“In addition to the steps taken by the prison service and following the re-location of the First Night Centre, a trolley which has also been located in reception to ensure that all of the relevant documentation is passed onto healthcare.”

Source location
2013-0329-Response-by-Care-UK
Page 3 · response
Published 22 February 2014
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
Deliver regular refresher training, including Self Harm Warning Forms within induction training for all new staff.

Verbatim wording from the response
“In addition further refresher training is regularly undertaken and particular focus is given regarding the Self Harm Warning Forms which is considered as part of the induction training for all new staff.”

Source location
2013-0329-Response-by-Care-UK
Page 3 · response
Published 22 February 2014
Open published response
30 Oct2013
Liverpool
Concerns raised1
1. Failure to identify domestic abuse risk factors during prison reception and risk assessment
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.
AI-generated summary

Damion Anthony Andre Martin · 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

Damion Anthony Andre Martin was remanded to HMP Liverpool on 6 December 2011 and was found hanging in the toilet area of his cell on 11 December 2011; attempts to resuscitate him were unsuccessful. The report raised concerns about the identification of domestic-abuse-related suicide risk during reception, basic life-support refresher training, the restricted view into the toilet area, and whether a prison officer completed a roll-check visit.

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 identify domestic abuse risk factors during prison reception and risk assessment
Wider context from the report
“During the initial prison reception and risk assessment, the domestic nature of Mr Martin’s alleged charges of Common Assault and Witness Intimidation against his girl friend were not identified, notwithstanding it was considered to be a known suicidal risk factor. ”
Source location
Damion Anthony Andre Martin · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to obtain relevant medical information for care planning during initial reception assessment

Concerns raised1

Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening

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

Concerns raised1

Failure to ensure that relevant forms are seen during the reception process

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

Failure to identify domestic abuse risk factors during prison reception and risk assessment

Actions described in response 1

Actions described in response 2