Unsafe discharge planning for vulnerable prisoners
First to latest report 21 Feb 2017 — 13 Mar 2024
Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
16
What this concern includes
Includes failures in the end-to-end planning and coordination of discharge for vulnerable prisoners, including assessment from admission, accommodation, primary-care registration, mental-health and substance-misuse support, multi-agency planning, information transfer, responsibility allocation and confirmation that required aftercare is arranged.
What is not included
Excludes ordinary prisoner release or discharge where no vulnerability, complex care need or safety-related discharge-planning deficiency is identified.
Excludes failures limited to post-release healthcare continuity after discharge planning and handover were adequate.
Excludes generic prison staffing, training or communication deficiencies unless they directly impair vulnerable-prisoner discharge planning.
Excludes general hospital or community discharge processes without a prisoner-discharge context.
Excludes the separate concern about high-risk-offender release arrangements when the assertion concerns public-protection release controls rather than vulnerable prisoners’ discharge needs and aftercare.
Trends
Reports over time
Reports mentioning this concern, 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.
Birmingham and Solihull Mental Health NHS Foundation Trust1
Central and North West London NHS Foundation Trust1
G4S1
HM Prison and Probation Service1
Oxford Health NHS Foundation Trust1
Swansea Bay University Local Health Board1
West Midlands Police1
Woodhill Prison1
NHS trust2
Executive agency1
Local health board1
Police force1
Prison operator1
Prison or young offender institution1
Reports and published responses 2 reports
See individual reports that have raised this concern, and the actions taken in response
Birmingham and Solihull
Concerns raised1
Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust
G4S
HM Prison and Probation Service
Swansea Bay University Local Health Board
West Midlands Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
G4S
Introduce resettlement-services drop-in sessions for prisoners approaching release.
G4S
Roll out remote resettlement-services sessions using approved laptops.
G4S
Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.
Birmingham and Solihull Mental Health NHS Foundation Trust
Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.
Birmingham and Solihull Mental Health NHS Foundation Trust
Review the Prison Discharge Coordinator job description, role scope and potential additional resource requirements.
Birmingham and Solihull Mental Health NHS Foundation Trust
Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.
Birmingham and Solihull Mental Health NHS Foundation Trust
Implement an improved referral and discharge procedure through the updated standard operating protocol.
Swansea Bay University Local Health Board
Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.
Swansea Bay University Local Health Board
Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.
West Midlands Police
Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.
HM Prison and Probation Service
Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.
HM Prison and Probation Service
Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
G4S
Concerns about SystmOne, cross-agency release guidance and the MAPPA discharge coordinator fall outside G4S’s power to address.
Outside remitThe respondent said that this matter was outside its role or authority.
G4S
G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.
Outside remitThe respondent said that this matter was outside its role or authority.
G4S
Other interested persons addressed by the report are better placed to consider concerns 2, 3 and 4 and determine any response.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
G4S
HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Swansea Bay University Local Health Board
The Health Board lacks jurisdiction or power over the cross-agency actions required for release planning at sentence end.
Outside remitThe respondent said that this matter was outside its role or authority.
West Midlands Police
HMPPS will address cross-agency guidance for releasing high-risk prisoners with mental health difficulties at sentence end.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
HM Prison and Probation Service
Probation has no statutory authority to supervise prisoners released into the community at sentence expiry.
Outside remitThe respondent said that this matter was outside its role or authority.
Buckinghamshire
Concerns raised1
Failure to adequately assess and manage discharge needs of vulnerable prisoners
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Woodhill Prison
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Woodhill Prison
Use a shared complex-case database to coordinate resettlement planning and live information sharing among the establishment and relevant support providers.
Woodhill Prison
Review the complex-case database in July 2017 for fitness for purpose and assess how information sharing supports vulnerable prisoners approaching release.
Woodhill Prison
Share immediate complex-case resettlement concerns with relevant departments by telephone and record them in prisoner case notes to address safeguarding issues.
Woodhill Prison
Enable prisoners to register with a GP before release, including timely transfer of clinical information and active registration support.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Woodhill Prison
Community Rehabilitation Companies are responsible for resettlement services for prisoners serving 12 months or less.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.