First reported 21 Feb 2017•Latest report 13 Mar 2024
Definition
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.
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.
Reports
2
Distinct published reports
Individual concerns
2
A report can raise multiple concerns
Date range
2017–2024
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.
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
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.
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.
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.12
Action
Introduce resettlement-services drop-in sessions for prisoners approaching release.
Stated by G4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Roll out remote resettlement-services sessions using approved laptops.
Stated by G4SStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.
Stated by G4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Review the Prison Discharge Coordinator job description, role scope and potential additional resource requirements.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Implement an improved referral and discharge procedure through the updated standard operating protocol.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.
Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Concerns about SystmOne, cross-agency release guidance and the MAPPA discharge coordinator fall outside G4S’s power to address.
Stated by G4SOutside remitThe respondent said that this matter was outside its role or authority.
Position
G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.
Stated by G4SOutside remitThe respondent said that this matter was outside its role or authority.
Position
Other interested persons addressed by the report are better placed to consider concerns 2, 3 and 4 and determine any response.
Stated by G4SRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.
Stated by G4SRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Health Board lacks jurisdiction or power over the cross-agency actions required for release planning at sentence end.
Stated by Swansea Bay University Local Health BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
HMPPS will address cross-agency guidance for releasing high-risk prisoners with mental health difficulties at sentence end.
Stated by West Midlands PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Probation has no statutory authority to supervise prisoners released into the community at sentence expiry.
Stated by HM Prison and Probation ServiceOutside 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.
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.4
Action
Use a shared complex-case database to coordinate resettlement planning and live information sharing among the establishment and relevant support providers.
Stated by Woodhill PrisonStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.
Action
Review the complex-case database in July 2017 for fitness for purpose and assess how information sharing supports vulnerable prisoners approaching release.
Stated by Woodhill PrisonStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
Action
Share immediate complex-case resettlement concerns with relevant departments by telephone and record them in prisoner case notes to address safeguarding issues.
Stated by Woodhill PrisonStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
Action
Enable prisoners to register with a GP before release, including timely transfer of clinical information and active registration support.
Stated by Woodhill PrisonStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Community Rehabilitation Companies are responsible for resettlement services for prisoners serving 12 months or less.
Stated by Woodhill PrisonRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
