Recurring concern

Inadequate prison reception safeguards

First to latest report 30 Oct 2013 — 9 Feb 2026

Reports that mention this concern
24
Times this concern has been raised
38
Stated actions linked to this concern
54

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.

What is 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 and published responses 24 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Suffolk

    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

  2. Inner South London

    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

  3. County Durham and Darlington

    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

  4. Liverpool

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026