Recurring concern

Failure of the CSRA policy to protect prisoners from relevant safety risks

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First reported 16 Jan 2024•Latest report 15 Dec 2025

Definition

What this concern includes

Includes failures of the named CSRA policy or its dedicated implementation and oversight controls, including inadequate policy scope, staff understanding, operational application, training, monitoring or audit where these undermine protection of prisoners.

Not included

Excludes generic policy, training, audit or implementation deficiencies not explicitly tied to the CSRA policy.
Excludes prisoner healthcare or medical-condition management failures where the CSRA policy is not identified as the deficient control.
Excludes unrelated custody observation, safeguarding, suicide-prevention or risk-assessment systems unless the assertion specifically concerns the CSRA policy.
Excludes the underlying prisoner safety risk when no CSRA policy failure is identified.

Reports: 2
Individual concerns: 4
Date range: 2024–2025
Stated actions: 10

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.

Belmarsh Prison1

HM Prison and Probation Service1

Ministry of Justice1

Practice Plus Group1

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.

15 Dec2025
Inner South London
Concerns raised3
1. Lack of staff training and operational understanding of the CSRA policy
2. Failure to monitor CSRA policy implementation
3. 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 10
1. 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 planned
2. Action
  Redesign CSRA training materials to explain how staff must treat NOMIS racism alerts.
  Stated by HM Prison and Probation ServiceStated in progress
3. 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 planned
1. 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 progress
2. 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 planned
3. Action
  Embed CSRA quality assurance within HMP Belmarsh internal audit processes and conduct regular compliance reviews.
  Stated by HM Prison and Probation ServiceStated completed
4. 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 planned
5. Action
  Continue independent Performance, Assurance and Risk Group audits of the CSRA process.
  Stated by HM Prison and Probation ServiceStated in progress
6. 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 planned
7. Action
  Strengthen First Night Centre assessments to identify and promptly share current risks for people entering custody.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 1
1. 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 concern
AI-generated summary

Sundeep Ghuman · 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

Sundeep Ghuman was a prisoner at HMP Belmarsh who was placed in a triple cell with a prisoner known to have racist and violent behaviour. On 18 February 2020, that prisoner violently assaulted Mr Ghuman with a table leg, and Mr Ghuman died in hospital on 19 February 2020 from a head injury. The principal concerns included failures in the CSRA process and training, inadequate treatment of racism alerts and other risk information, insufficient consideration of risks when allocating cellmates, and wider concerns about violence and drug use at HMP Belmarsh.

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
Lack of staff training and operational understanding of the CSRA policy
Wider context from the report
“In addition, the lack of understanding of the policy by all staff (including senior management) at HMP Belmarsh appears to reflect a systemic failing of training and operational understanding, and a disconnect between those responsible for creating and maintaining the policy and those taking operational decisions within prisons. The fact that the comprehensive misunderstanding of the policy by HMP Belmarsh over a period of many years was entirely unknown to those responsible for the policy, even in circumstances where HMP Belmarsh operated its own system (complete with bespoke “S1” stickers) and not picked up by any audit or monitoring procedure also indicates a failure in policy implementation. ”
Source location
Sundeep Ghuman · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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 monitor CSRA policy implementation
Wider context from the report
“In addition, the lack of understanding of the policy by all staff (including senior management) at HMP Belmarsh appears to reflect a systemic failing of training and operational understanding, and a disconnect between those responsible for creating and maintaining the policy and those taking operational decisions within prisons. The fact that the comprehensive misunderstanding of the policy by HMP Belmarsh over a period of many years was entirely unknown to those responsible for the policy, even in circumstances where HMP Belmarsh operated its own system (complete with bespoke “S1” stickers) and not picked up by any audit or monitoring procedure also indicates a failure in policy implementation. ”
Source location
Sundeep Ghuman · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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 consider risks beyond the minimum CSRA when allocating prisoners to share a cell
Wider context from the report
“The evidence of staff at HMP Belmarsh (including from the Head of Security and Intelligence) was by contrast to the effect that moving into a cell are simply a daily occurrence and that as long as a CSRA says the individuals concerned can share then they can be moved in, and that no further consideration is necessary or appropriate. Consistently with this, the evidence of officers was that when arranging a cell move they would not look at the NOMIS notes of a prisoner, or other records, but solely at the CSRA to check that they were not High Risk (or “S1”). ”
Source location
Sundeep Ghuman · Prevention of Future Deaths report
Page 5 · 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
Require prisons to quality-assure CSRA assessments and cell allocations through sampling, escalation, rechecks, and management oversight.

Verbatim wording from the response
“Another improvement in the new framework will be to require all prisons to put in place a quality assurance process. This will involve checking samples of initial assessments to see that all available evidence has been taken into account, and that the results are based on that evidence. It will also cover how CSRA is used in practice, to check whether prisoners’ cell allocations match their risk level. In addition, independent audits of the CSRA process by our Performance, Assurance and Risk Group will continue.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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
Redesign CSRA training materials to explain how staff must treat NOMIS racism alerts.

Verbatim wording from the response
“You suggested that training could be improved to strengthen operational understanding. Alongside the new policy framework we are redesigning the CSRA training materials and these will address how NOMIS alerts for racism should be treated by staff. When implementing the framework, we plan to give prisons enough time to ensure a core group of staff will receive the new training and be able to reinforce its content with colleagues before they are required to comply with it.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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
Provide new CSRA training through trained prison staff able to reinforce the content with colleagues during policy-framework rollout.

Verbatim wording from the response
“You suggested that training could be improved to strengthen operational understanding. Alongside the new policy framework we are redesigning the CSRA training materials and these will address how NOMIS alerts for racism should be treated by staff. When implementing the framework, we plan to give prisons enough time to ensure a core group of staff will receive the new training and be able to reinforce its content with colleagues before they are required to comply with it.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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
Complete mandated CSRA training for HMP Belmarsh managers and require all staff to complete CSRA e-learning, with completion monitored.

Verbatim wording from the response
“In the meantime, all managers at HMP Belmarsh are currently completing the mandated CSRA training as part of scheduled training days. In addition, all staff are required to undertake the CSRA e-learning package to support improvements in assessment quality. Completion of these training requirements is being monitored by the Head of Business Assurance, who holds overall responsibility for the establishment’s training programme.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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 a CSRA upskilling session for Heads of Safety across LTHSE prisons, emphasizing cautious, safest-option decisions.

Verbatim wording from the response
“The Long-Term and High Security Estate (LTHSE) Safety Team will also deliver a CSRA upskilling session at a future Heads of Safety Meeting to ensure consistent, policy-compliant application of CSRAs across all LTHSE prisons. It will emphasise that a cautious approach should be taken so that decisions default to the safest option when risk is uncertain or information is incomplete.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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
Embed CSRA quality assurance within HMP Belmarsh internal audit processes and conduct regular compliance reviews.

Verbatim wording from the response
“As well as improving training, quality assurance measures have been formally embedded within HMP Belmarsh’s internal audit processes. These arrangements ensure that decisions and practice remain compliant with national policy and are subject to regular review. Additionally, the LTHSE Safety Team will incorporate CSRA checks during safety assurance visits to provide the Prison Group Directors (PGDs) with assurance that prisons are policy compliant in CSRA application. This will include reviewing a sample of 10% of CSRAs completed in the last 60 days (on reception, transfer, and following incidents) for process compliance and quality. CSRA forms will be checked to ensure there is a clear rationale for”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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
Incorporate CSRA checks into LTHSE safety assurance visits, including sample reviews, escalation, rechecks, and targeted support for assurance gaps.

Verbatim wording from the response
“As well as improving training, quality assurance measures have been formally embedded within HMP Belmarsh’s internal audit processes. These arrangements ensure that decisions and practice remain compliant with national policy and are subject to regular review. Additionally, the LTHSE Safety Team will incorporate CSRA checks during safety assurance visits to provide the Prison Group Directors (PGDs) with assurance that prisons are policy compliant in CSRA application. This will include reviewing a sample of 10% of CSRAs completed in the last 60 days (on reception, transfer, and following incidents) for process compliance and quality. CSRA forms will be checked to ensure there is a clear rationale for”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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
Continue independent Performance, Assurance and Risk Group audits of the CSRA process.

Verbatim wording from the response
“Another improvement in the new framework will be to require all prisons to put in place a quality assurance process. This will involve checking samples of initial assessments to see that all available evidence has been taken into account, and that the results are based on that evidence. It will also cover how CSRA is used in practice, to check whether prisoners’ cell allocations match their risk level. In addition, independent audits of the CSRA process by our Performance, Assurance and Risk Group will continue.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 18 December 2025
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
Update CSRA policy and electronic records to distinguish general and specific high-risk sharing restrictions and clearly record affected people or groups.

Verbatim wording from the response
“HMPPS is currently updating the CSRA policy, which will be issued as a policy framework that will supersede PSI 20/2015. There are two improvements that we intend to make which address the concerns you have raised. First, the forms in the current PSI contain only two options, ‘high risk’ and ‘standard risk’. Where a prisoner is high risk but cannot share with anyone (as “M” was), the details of those at risk will be set out separately and then entered into the”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 18 December 2025
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
Strengthen First Night Centre assessments to identify and promptly share current risks for people entering custody.

Verbatim wording from the response
“First Night Centre processes have also been strengthened and a robust assessment procedure is now in place for all individuals entering custody, whether via court or transfer. These assessments ensure that information is current and accurate, that any risks to others are clearly identified, and that critical information is promptly shared with all relevant stakeholders. The First Night Centre now works closely with the local Safety team, which further improves the flow of information and early risk identification.”

Source location
Response from HM Prison & Probation Service
Page 5 · response
Published 18 December 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Drug misuse alone does not warrant changing a prisoner’s CSRA because not all drug users become more violent.

Verbatim wording from the response
“Drug misuse is not, of itself, a reason to change a prisoner’s CSRA. Not all individuals who use drugs become more violent, and staff are instructed to remain alert to any behavioural changes that may indicate an increased risk of violence or harm to others, regardless of the underlying cause. The forthcoming policy framework will reinforce this message and will emphasise the importance of acting quickly when a prisoner is seen to be more violent, including making them temporarily high risk while the situation is reviewed.”

Source location
Response from HM Prison & Probation Service
Page 4 · response
Published 18 December 2025
Open published response
16 Jan2024
East Sussex
Concerns raised1
1. Failure of the CSRA policy to protect prisoners with relevant medical conditions
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.
Respondent positions 1
1. Position
  PPG decides whether prisoners with epilepsy require standard or inpatient placement; HMPPS facilitates any required move.
  Stated by HM Prison and Probation ServiceRedirects responsibility
AI-generated summary

Trevor Alan MONERVILLE · 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

Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.

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 of the CSRA policy to protect prisoners with relevant medical conditions
Wider context from the report
“a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition. Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements. ”
Source location
Trevor Alan MONERVILLE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
PPG decides whether prisoners with epilepsy require standard or inpatient placement; HMPPS facilitates any required move.

Verbatim wording from the response
“As was heard at the inquest, the creation of a seizure care plan and seizure diary, a clinical matter, falls within the responsibility of the healthcare provider at HMP Lewes, Practice Plus Group (PPG). It is within PPG’s remit to decide which prisoners are fit to be managed on a standard wing and, where a health condition such as epilepsy is identified, whether the severity of this means they should be located on the inpatient wing. HMPPS will facilitate a move to the inpatient unit where this is required.”

Source location
Response from HM Prison and Probation Service
Page 1 · response
Published 19 January 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Lack of staff training and operational understanding of the CSRA policy

Failure to monitor CSRA policy implementation

Failure to consider risks beyond the minimum CSRA when allocating prisoners to share a cell

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.10

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of the CSRA policy to protect prisoners with relevant medical conditions

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 10

Respondent positions 1

Respondent positions 1