Recurring concern
Unreliable safety risk assessments for prisoners
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Request correctionFirst reported 11 Mar 2014•Latest report 15 Dec 2025
What this concern includes
Includes failures in prisoner safety-risk assessment processes, including incomplete or omitted assessments, reliance on a prisoner's presentation or interview instead of relevant collateral information, failure to consider known risk factors, and assessment practices that depart from appropriate prisoner-safety standards.
Not included
- Excludes mental-health-specific risk assessments where mental health risk assessment is the more specific supported concern.
- Excludes named systems or pathways such as ACCT, multidisciplinary high-risk-prisoner reviews or custody observation where those systems provide the more specific boundary.
- Excludes generic prison staffing, training, documentation or communication deficiencies unless they directly make a prisoner safety-risk assessment unreliable.
- Excludes non-prison risk assessments and assessments concerning only physical equipment, premises or public-road hazards.
- Reports
- 10
- Individual concerns
- 10
- Date range
- 2014–2025
- Stated actions
- 11
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of assessment of Spice-related risks in cell-sharing decisions
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 concernsEach 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
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Action
Require prisons to quality-assure CSRA assessments and cell allocations through sampling, escalation, rechecks, and management oversight.
Stated by HM Prison and Probation Service -
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 Service -
Action
Strengthen First Night Centre assessments to identify and promptly share current risks for people entering custody.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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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 Service
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Concerns raised1
Failure to assess risk on reception and after transfer
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to undertake risk assessments of prisoners before sentencing
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to conduct risk assessments for individual prisoners
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Review SystmOne use with partner agencies and develop a multi-agency protocol for risk communication and medicines optimisation.
Stated by Central and North West London NHS Foundation Trust -
Action
Use a daily Open ACCT Log and morning briefing to identify open ACCTs, arrange assessments and ensure mental-health attendance at reviews.
Stated by Central and North West London NHS Foundation Trust
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Concerns raised1
Failure to undertake assessments in the way recommended for prisoner safety
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to assess drug use during prison triage
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.
Stated by Care UK
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Concerns raised1
Over-reliance on prisoners’ accounts instead of previous recorded risk factors
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 concernsEach 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
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Action
Implement a robust clinical-information process with documented responsibilities, follow-up, escalation and senior risk-system scrutiny for obtaining prisoners’ clinical notes.
Stated by Leicestershire Partnership NHS Trust -
Action
Implement the Safer Prisons recording procedure and train reception and healthcare staff to document risk information and decisions in O-Nomis and SystmOne.
Stated by Glen Parva Young Offender Institution -
Action
Remind staff to open an ACCT whenever information indicates suicide or self-harm risk, even when the prisoner does not appear at risk.
Stated by Glen Parva Young Offender Institution
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Action
Remind case managers to consider comprehensive dynamic and static risk information during individual case reviews.
Stated by Glen Parva Young Offender Institution
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Concerns raised1
Failure to use trigger-date information to prompt risk reassessment for prisoners outside the ACCT process
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of dynamic assessments to account for the need for prisoner restraint
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 concernsEach 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
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Action
Apply an individual, audit-compliant escort risk assessment to determine restraint use, including reassessment following medical advice.
Stated by HM Prison and Probation Service -
Action
Provide escort and duty managers with emergency-escort advice and guidance, and review restraint decisions at operational meetings.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing individual escort risk assessments, guidance and operational reviews are considered sufficient to determine whether prisoners require restraints.
Stated by HM Prison and Probation Service
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Concerns raised1
Reliance on prisoner interview instead of balanced assessment of all known 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026