Recurring concern

Ineffective prison suicide and self-harm prevention systems

First to latest report 2 Dec 2013 — 13 May 2026

Reports that mention this concern
52
Times this concern has been raised
86
Stated actions linked to this concern
166

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.

What is 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 and published responses 52 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Oxfordshire

    AI-generated summary

    Marcin Jack STOGA · 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

    Marcin Stoga had been held on remand at HMP Bullingdon since November 2012 and was found hanging in his cell on 24 April 2013, the day after attending court. Concerns included information about a previous overdose not being available during his initial assessment, and prisoners with mental health difficulties or a medium/high risk of self-harm not being routinely assessed after returning from court. The inquest jury confirmed suicide and identified missed opportunities to support him that were systemic in nature.

    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 to provide thorough post-court assessments for prisoners at elevated self-harm or suicide risk

    Wider context from the report

    “(2) A second concern, which is to some degree related to the first, is the fact that prisoners (particularly those with mental health difficulties or who are otherwise at a medium/high risk of self-harm) are not routinely assessed on return from court hearings. Mr Stoga attended court on 7 December 2012 and again on 11 February 2013 and 23 April 2013, the day before his death. There were no such assessments. On this last occasion it is believed that Mr Stoga was charged with assaulting his partner. I understand from evidence and information at Inquest that there has been a review (and that this issue also formed part of the PPO Recommendations) and that persons returning from court will be seen by the Duty Reception Nurse to ascertain any change in circumstances. What is not clear is if this is anything other than a cursory assessment. It appears that a more thorough assessment is likely to be required for those prisoners who have a history of mental health issues and are believed to be at a medium/high risk of self-harm or suicide. It appears there may be a need for some written guidance for staff or perhaps a protocol. ”

    Source location

    Marcin Jack STOGA · Prevention of Future Deaths report
    Page 1 · 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

    Implement and routinely use a reception checklist to acknowledge risk information and support self-harm and suicide risk assessment after court returns.

    Verbatim wording from the response

    “In your Regulation 28 report, you expressed your concern that on Mr Stoga’s arrival at HMP Bullingdon, the Prisoner Escort Record (PER) was not shared with prison officers or healthcare staff who initially interviewed and assessed Mr Stoga. The PER is the key document for ensuring that information about the risks posed to and by prisoners on external movement from prisons or transferred within the criminal justice system is available to those responsible for their custody. I am aware that you invited submissions on your draft Regulation 28 report to which the Treasury Solicitor responded on 18 July confirming that since the inquest into the death of Mr Stoga, the Deputy Governor had put in place a checklist to assist in the assessment of risk of self-harm and suicide.”

    Source location

    2014-0576-Response-by-NOMS
    Page 1 · response
    Published 21 July 2014

    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

    Trial revised national and local Prisoner Escort Records in the South Central Area, incorporating suicide and self-harm alerts and prominent red-flag risk information pages.

    Verbatim wording from the response

    “You will, I am sure be interested to know that a Pilot Regional PER forum has met twice in the second part of this year at HMP Winchester attended by a wide range of key stakeholders and operational practitioners. The forums remit is to consider and develop improvements to the PER whilst addressing the recommendations from the HMIP Thematic Review and related ones from the Independent Police Complaints Commission and HM Coroners in response to deaths in custody. Whilst the Regional forum reports to a National Steering Group there has been much progress and it is intended to trial two revised PER’s in the South Central Area in early 2015. The first is a “National” PER document for use by court escorts and for inter prison transfers and a “Local” PER for use in hospital and Police escorts.”

    Source location

    2014-0576-Response-by-NOMS
    Page 1 · response
    Published 21 July 2014

    Open published response

  2. Manchester City

    AI-generated summary

    Michael James Meyler · 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

    Michael James Meyler died in hospital on 1 January 2011 after being found hanging by the neck in his prison cell on 28 December 2010 and sustaining a hypoxic brain injury. The principal concerns were that information about his recent self-harm and suicide risk was not adequately circulated, read, or attached to his ACCT plan, limiting the ability of prison staff and healthcare personnel to make informed decisions about his welfare.

    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 to circulate Risk of Self-Harm / Suicide information promptly to relevant prison functions

    Wider context from the report

    “1. I am concerned that if a Risk of Self-Harm / Suicide document enters the prison after the prisoner has undergone first Reception Screening, that the information in this document is not adequately circulated to all those who would need to know about it within the prison system. Whilst I am now told that the information is made the subject of an Intelligence or Information Report, which is disseminated (after being “sanitised”) to the Head of Healthcare, the Deputy Head of Healthcare and the Head of Safer Custody, it unclear to me why it is not sent as a priority to Healthcare in the first instance as the information contained within it must be passed on without delay. ”

    Source location

    Michael James Meyler · Prevention of Future Deaths report
    Page 5 · 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 ensure that Risk of Self-Harm / Suicide information is read and considered by Senior Wing Officers after prisoner moves

    Wider context from the report

    “2. Furthermore, I am concerned that the information in the Risk of Self-Harm / Suicide document is not brought to the attention to the Senior Officers on Wings which the prisoner may move to at a later stage during their incarceration. I believe that a copy of the Risk of Self-Harm / Suicide document is contained in the prisoner’s physical (buff) folder, which goes with them from Wing to Wing, however there needs to be a safeguard to ensure that this information is read and considered at each stage of the prisoner’s term of imprisonment. ”

    Source location

    Michael James Meyler · Prevention of Future Deaths report
    Page 5 · 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 attach existing Risk of Self-Harm / Suicide documents to ACCT documents

    Wider context from the report

    “3. I am concerned that if an ACCT document is opened for any reason that if there should be a Risk of Self-Harm / Suicide document in existence for the prisoner, that it MUST be attached to the ACCT document. In this case the ACCT document was opened principally as an “instrument of support” where it was believed that the prisoner’s primary issues involved contact with his family and his children in particular. It was not known by those who opened the ACCT document and who conducted the various ACCT reviews that he had a history of self-harm which involved both taking an overdose and cutting his wrists on several occasions in the immediate months before he was committed to prison as a consequence of his distress over a long-term relationship breaking down. Furthermore, in the light of the information contained in the Risk of Self-Harm / Suicide document which came to their attention after the death of the deceased, all the Prison Officers involved indicated that they would have referred the deceased on for a Mental Health Inreach Assessment had they known of the details of his previous history. All the Prison Officers concerned felt that they had not been able to make “informed decisions” regarding the welfare of the prisoner concerned as they were not in possession of all the facts at the relevant times. ”

    Source location

    Michael James Meyler · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026