First reported 11 Mar 2014•Latest report 15 Dec 2025
Definition
What this concern includes
Includes failures of controls dedicated to cell-sharing decisions, including risk assessment, consideration of relevant prisoner information, allocation decisions and prompt communication of changes in cell-sharing risk or status.
Not included
Excludes generic prison communication failures not specifically concerning cell-sharing decisions.
Excludes general prisoner allocation or placement issues that do not involve cell-sharing risk.
Excludes unrelated hazards or failures in other prison safety systems, even if they could affect cell-sharing safety.
Reports
8
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
16
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.
Ministry of Justice3
Pentonville Prison3
Belmarsh Prison1
Cardiff Prison1
HM Inspectorate of Prisons1
Home Office1
Office of the Chief Coroner1
Practice Plus Group1
St George's Hospital1
Wandsworth Prison1
Prison or young offender institution6
Ministerial department4
Coronial office1
Healthcare site1
Independent healthcare provider1
Justice inspectorate1
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 South London
Concerns raised3
Lack of assessment of Spice-related risks in cell-sharing decisions
Lack of structured staff training on treatment of active racism alerts during cell-sharing assessments
Failure to consider risks beyond the minimum CSRA when allocating prisoners to share a cell
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.11
Action
Require prisons to quality-assure CSRA assessments and cell allocations through sampling, escalation, rechecks, and management oversight.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Incorporate CSRA checks into LTHSE safety assurance visits, including sample reviews, escalation, rechecks, and targeted support for assurance gaps.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Strengthen First Night Centre assessments to identify and promptly share current risks for people entering custody.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
Action
Withdraw the S1 system, review affected prisoners, and designate prisoners with racist markers as high-risk sharers at HMP Belmarsh.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
Action
Update CSRA policy and electronic records to distinguish general and specific high-risk sharing restrictions and clearly record affected people or groups.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Prohibit local CSRA terminology and clarify that any elevated risk requires a high-risk designation in the new policy framework.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Redesign CSRA training materials to explain how staff must treat NOMIS racism alerts.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2025.
Action
Provide new CSRA training through trained prison staff able to reinforce the content with colleagues during policy-framework rollout.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Complete mandated CSRA training for HMP Belmarsh managers and require all staff to complete CSRA e-learning, with completion monitored.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2025.
Action
Deliver a CSRA upskilling session for Heads of Safety across LTHSE prisons, emphasizing cautious, safest-option decisions.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Embed CSRA quality assurance within HMP Belmarsh internal audit processes and conduct regular compliance reviews.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Available evidence indicates secondary exposure to psychoactive substances is highly unlikely to cause adverse effects or currently pose a risk to cellmates.
Stated by HM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Drug misuse alone does not warrant changing a prisoner’s CSRA because not all drug users become more violent.
Stated by HM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised1
Failure to communicate changes in cell sharing risk promptly to prisoners
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.2
Action
Complete and reissue the CSRA policy, clarifying that prisoners must be informed promptly of changes to their CSRA status.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 28 January 2025.
Action
Amend the local safety strategy to require written notification when prisoners’ CSRA levels change following review.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete 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.
Inner North London
Concerns raised1
Careless completion of cell sharing risk assessments
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.2
Action
Provide specialised reception-process training, induction explanation, shadowing and periodic refresher training for nurses completing cell-sharing risk assessments.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
Action
Implement the Early Days quality-assurance process, including passport checks, multidisciplinary review, task tracking and completion sign-off before patients leave the system.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing reception training, Early Days checks, clinical reviews and monitoring are considered sufficient to prevent inaccurate cell-sharing risk assessments.
Stated by Practice Plus GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner West London
Concerns raised1
Inappropriate cell allocation for vulnerable prisoners
This report raised 14 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.
Inner North London
Concerns raised1
Failure to consider potential dangers in cell-sharing decisions
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.
Liverpool and the Wirral
Concerns raised1
Lack of policy or guidance requiring consideration of the ACCT care plan during mandatory ACCT review when a CSRA indicates single-cell placement for the protection of others
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 Prison Service Instruction 64/2011 on the ACCT process.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 January 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ACCT policy requires review teams to address cell-sharing risks, provide alternative support, and revisit decisions at further reviews.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised3
Failure to ensure reliable communication of healthcare cell-sharing instructions to prison officers
Lack of staff knowledge and shared understanding of cell sharing risk assessment requirements
Failure to complete and retain cell sharing risk assessments
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.
Cardiff & the Vale of Glamorgan
Concerns raised1
Insufficient efforts to find a suitable shared-cell prisoner for a first night prisoner with identified risk factors
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.
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Includes failures of controls dedicated to cell-sharing decisions, including risk assessment, consideration of relevant prisoner information, allocation decisions and prompt communication of changes in cell-sharing risk or status.
