First reported 2 Dec 2013•Latest report 13 May 2026
Definition
What this concern includes
Includes failures of an explicitly prison-based suicide and self-harm prevention system or strategy, including dedicated ACCT, risk-assessment, monitoring, information-sharing, learning and response controls.
Not included
Do not include suicide or self-harm outcomes without evidence of an ineffective prison prevention system or dedicated control.
Excludes generic staffing, training, communication or documentation deficiencies unless the report directly ties them to prison suicide and self-harm prevention.
Excludes suicide and self-harm concerns outside prison settings.
Excludes isolated emergency-response failures that are not presented as part of prison suicide and self-harm prevention arrangements.
Reports
52
Distinct published reports
Individual concerns
86
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
166
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.
HM Prison and Probation Service23
Ministry of Justice12
NHS England6
HM Prison Service5
Care UK4
Hewell Prison3
HM Inspectorate of Prisons3
Pentonville Prison3
Central and North West London NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Leicestershire Partnership NHS Trust2
Long Lartin Prison2
Oxleas NHS Foundation Trust2
Practice Plus Group2
Sodexo2
Prison or young offender institution28
Executive agency23
Ministerial department14
NHS trust13
Executive non-departmental public body6
Multi-service care provider5
Sub-organisation5
Prison operator4
Justice inspectorate3
Community interest company2
Independent healthcare provider2
Private limited company2
Advisory non-departmental public body1
Healthcare site1
Local health board1
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.
Cumbria
Concerns raised1
Incentive for prisoners in crisis to underreport self-harm intent
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 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
Premature closure of ACCT processes
This report raised 11 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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
Stated by Practice Plus GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment
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 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.6
Action
Conducted a quality assurance visit verifying ACCT training arrangements and temporary staff completion at HMP Wandsworth.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Requested regional commissioning teams to confirm timely access to required joint training, including ACCT, for prison healthcare staff.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Obtained assurance from London prison healthcare providers that temporary staff had access to ACCT training arrangements.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Obtained further assurance from London prison health providers that systems ensure all staff access required training, including ACCT.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Require temporary healthcare staff to complete ACCT training before deployment and record attendance.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Extend ACCT process coaching and refresher training to non-operational colleagues, including healthcare staff.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing processes are considered sufficient to ensure temporary prison healthcare staff access required ACCT training.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Oxleas is responsible for commenting on ACCT training offered to staff during induction.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to provide suicide and self-harm risk management training to prison officers
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
Reintroduce the Pentonville Speed School and deliver self-harm and suicide-prevention training to officers.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Action
Provide ACCT case-review training to all band 4 staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Worcestershire
Concerns raised1
Failure to record and implement support actions in ACCT care plans
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.
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.7
Action
Implement the Prison Safety Policy Framework requiring ACCT teams to identify, review and record support actions and care-plan decisions.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Introduce and complete four local ACCT quality-assurance checks covering opening, reviews, complex-case oversight and closure.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Monitor and upload ACCT assurance findings, sharing them for follow-up through case management and monthly Safety Meetings.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Implement a single ACCT case-management allocation system assigning open cases to trained Supervising Officers or Custodial Managers.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Schedule ACCT reviews around allocated coordinators’ duties and use a buddy system to maintain continuity and prevent over-allocation.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Action
Book refresher training for staff who misunderstood care-plan requirements when prisoners missed reviews.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Action
Provide one-to-one ACCT coaching to 21 Case Coordinators with support from Safety Leads.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Essex
Concerns raised1
Inadequate national prison officer training for suicide risk assessment
This report raised 13 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
Review the risks, triggers and protective factors module in collaboration with Prison Learning Design and Delivery.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Deliver interim risk-identification upskilling sessions across the reception estate.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 20 January 2026.
Action
Review Reception Officer training to strengthen early-custody risk-identification and support for vulnerable individuals.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Complete the revised Reception Officer training once Prison Learning Design and Delivery capacity allows.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 20 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Revised Reception Officer training will be completed once Prison Learning Design and Delivery capacity allows.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Lancashire and Blackburn with Darwen
Concerns raised2
Lack of ACCT training and awareness of ACCT responsibilities among prison officers
Failure to open an Assessment, Care in Custody Teamwork process after a serious incident of self-harm
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 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.3
Action
Provide all new entry officers with suicide and self-harm prevention training covering ACCT and changes in risks, triggers and protective factors.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Maintain an accessible online Safety Learning Reference Library, including ACCT guidance, templates and training materials, and promote it to HMP Garth staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Issue HMP Garth staff instructions reiterating when and how to open ACCTs, who should open them, and how to complete ACCT records.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ACCT training, induction and accessible guidance are considered sufficient to address concerns about staff suicide and self-harm prevention training.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Inability to navigate System One records to find previous incidents of self-harm in prison
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 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.5
Action
Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
Action
Require agency staff to confirm in writing that they understand how to navigate SystmOne clinical records and record confirmations.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
Bedfordshire and Luton
Concerns raised1
Failure to report serious self-harm incidents and trigger further assessment
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.
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
Investigate serious incidents, document findings, and action and monitor resulting recommendations.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
Action
Remind staff and provide additional training and support on escalating incidents and conducting ACCT reviews when risk increases.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
Kent and Medway
Concerns raised1
Failure to provide bedding materials resistant to being ripped into ligatures
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.
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
Conduct a cell design review to assess alternative materials meeting fire-safety and anti-ligature requirements for bedding.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
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Includes failures of an explicitly prison-based suicide and self-harm prevention system or strategy, including dedicated ACCT, risk-assessment, monitoring, information-sharing, learning and response controls.
