First reported 30 Oct 2013•Latest report 29 Jun 2026
Definition
What this concern includes
Includes failures of prison staff supervision, staff-prisoner engagement, welfare checks, observation or equivalent monitoring where these controls are intended to identify or respond to risks to prisoners, including failures arising during or after handover between custodial settings.
Not included
Excludes illicit drug supply reduction and other substance-control strategies unless the assertion specifically concerns supervision or monitoring of prisoners.
Excludes generic staffing, accommodation or regime deficiencies that are not directly tied to inadequate prisoner supervision or monitoring.
Excludes healthcare assessment, treatment and clinical observation concerns unless the assertion concerns custodial supervision or monitoring rather than clinical care.
Excludes failures of information sharing, reception processing or documentation where the primary unsafe condition is information transfer or administrative processing rather than supervision or monitoring.
Reports
34
Distinct published reports
Individual concerns
49
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
62
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 Service12
Ministry of Justice10
NHS England3
Bedford Prison2
Care UK2
Dorset Healthcare University NHS Foundation Trust2
HM Inspectorate of Prisons2
Home Office2
Swaleside Prison2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Birmingham Community Healthcare NHS Foundation Trust1
Birmingham Prison1
Cardiff Prison1
Central and North West London NHS Foundation Trust1
David Ake & Co1
Prison or young offender institution21
Executive agency12
Ministerial department12
NHS trust9
Executive non-departmental public body3
Justice inspectorate2
Multi-service care provider2
Company1
Company limited by guarantee1
Independent healthcare provider1
Ombudsman1
Sub-organisation1
Type not available1
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.
County Durham and Darlington
Concerns raised2
Failure to complete SACU hourly prisoner checks consistently
Lack of real-time detection of incomplete SACU prisoner checks
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.3
Action
Provide an additional officer and administration staff member to support SACU operations.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Provide a “Know Your Job” sheet for staff temporarily assigned to SACU, setting out required duties.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 September 2021.
Action
Oversee daily and weekly SACU management checks and report recurring issues to the Head of Residence for action.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing staffing, supervision and assurance arrangements are considered sufficient to deliver SACU regimes and required hourly checks safely.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
A real-time system for confirming checks cannot be implemented because the required resources would be significant and prohibitive.
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 raised1
Failure to conduct welfare checks during first morning cell unlocks
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.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to detect unlawful segregation and deprivation of basic amenities
This report raised 19 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.
Oxfordshire
Concerns raised1
Lack of guidance for reducing observations of newly arrived prisoners from constant watch
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.7
Action
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 15 August 2019.
Action
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Action
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019.
Shropshire, Telford and Wrekin
Concerns raised1
Lack of policy or guidance for additional checks of prisoners with repeated NPS use
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.2
Action
Launch an updated drug strategy at the establishment.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Action
Notify staff that healthcare determines when additional checks are needed and must communicate this to prison discipline staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Healthcare staff determine when additional checks of prisoners at risk from repeated psychoactive substance use are necessary.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Exeter and Greater Devon
Concerns raised2
Reliance on continuous CCTV monitoring to detect prisoner self-harm
Intermittent night welfare checks and ACCT observations
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.2
Action
Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
HMPPS owns and operates the ACCT process; healthcare staff contribute risk information but do not oversee or monitor it.
Stated by Care UKRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cambridgeshire and Peterborough
Concerns raised1
Lack of meaningful pastoral interaction with a dedicated custodial officer
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Leicester City and South Leicestershire
Concerns raised3
Failure to maintain visual observation when the observation panel is blocked
Delays in responding when a prisoner is unobserved
Failure to complete scheduled observations
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.3
Action
Revise and disseminate the contingency plan, train staff to intervene quickly when observation panels are blocked, and permit individual staff to open cells during immediate danger.
Stated by National Offender Management Service Equality, Rights and Decency GroupStated completedThe respondent said that this action was complete when they made their response on 11 July 2016.
Action
Introduce the Safer Custody toolkit with guidance on ACCT procedures, emergency response, and communication with hard-to-engage prisoners.
Stated by National Offender Management Service Equality, Rights and Decency GroupStated plannedThe respondent said that this action was planned when they made their response on 11 July 2016.
Action
Implement unpredictable ACCT observations, remind staff of requirements, and monitor compliance through management checks and document quality assurance.
Stated by National Offender Management Service Equality, Rights and Decency GroupStated completedThe respondent said that this action was complete when they made their response on 11 July 2016.
Birmingham and Solihull
Concerns raised2
Failure to monitor prisoners overnight
Inadequate overnight security officer capacity for B wing
This report raised 10 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
No additional night staff are planned because current deployment exceeds contractual requirements and provides access to senior and clinical staff.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Exeter and Greater Devon
Concerns raised1
Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme
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.2
Action
Review patients on drug treatment programmes jointly with prison staff, agree observation arrangements, and share caseload information.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 July 2015.
Action
Introduce a robust system for monitoring patients arriving at HMP Exeter who require night welfare checks.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 July 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The action plan addressed identified care issues, with ongoing compliance audit and executive review providing sufficient assurance.
Stated by Dorset Healthcare University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NOMS at HMP Exeter is responsible for training and auditing operation of the ACCT document system.
Stated by Dorset Healthcare University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of prison staff supervision, staff-prisoner engagement, welfare checks, observation or equivalent monitoring where these controls are intended to identify or respond to risks to prisoners, including failures arising during or after handover between custodial settings.
