First reported 6 Jan 2014•Latest report 9 Feb 2026
Definition
What this concern includes
Includes failures of controls dedicated to the prisoner transfer process, including pre-transfer risk assessment, transfer handover and information sharing, receiving-prison checks, and continuity of essential prisoner support.
Not included
Excludes generic staffing, training, documentation or communication deficiencies unless they are specifically tied to the safety of a prisoner transfer.
Excludes failures concerning prisoner supervision or care that are unrelated to a transfer.
Excludes general deficiencies in prison healthcare or custody operations without a transfer-specific connection.
Reports
26
Distinct published reports
Individual concerns
43
A report can raise multiple concerns
Date range
2014–2026
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 Service11
Ministry of Justice11
NHS England7
Department of Health and Social Care5
Greater Manchester Police2
Oxleas NHS Foundation Trust2
Practice Plus Group2
Serco Group plc2
Bedford Prison1
Belmarsh Prison1
Cardiff Prison1
Cardiff & Vale University LHB1
College of Policing1
Cookham Wood Prison1
G4S1
Ministerial department14
Executive agency11
Prison or young offender institution11
Executive non-departmental public body7
NHS trust5
Police force3
Prison operator3
Independent healthcare provider2
Private limited company2
Type not available2
Local health board1
London borough council1
National policing body1
Non-ministerial department1
Sub-organisation1
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.
Inner North London
Concerns raised1
Failure to retain documentation accompanying prisoners during reception
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.3
Action
Use a digital induction passport to consolidate, store and share key risk information during reception.
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
Review reception procedures and implement necessary improvements identified through the review.
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 digital Person Escort Records for PECS movements and enable authorised professionals to update them before arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 12 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Qualified medical professionals and Liaison and Diversion services are responsible for creating, maintaining and transferring healthcare and associated risk information.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
PECS suppliers are not contractually responsible for physically transferring hard-copy medical or risk documentation between courts and prisons.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East Riding and Hull
Concerns raised1
Failure to ensure continuity of psycho-social drug misuse support during prisoner transfers
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
Use nationally agreed clinical templates, including Court, Release and Transfer Out screening, to standardise information sharing and healthcare delivery.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
Action
Audit continuity of care for relevant transfers between HMP Hull and HMP Humber.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
Action
Complete a second audit against the same continuity-of-care parameters in January 2026.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing transfer pathway was considered sufficient because it was followed correctly and referrals were opened for all transferred service users.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised1
Lack of a formal prison-to-prison transfer management system
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Mid Kent and Medway
Concerns raised1
Lack of national guidance or policy on returning prisoners to custodial settings when prison healthcare concerns have not been considered by the consultant
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.1
Action
Ask officials to consider whether hospital discharge guidance should explicitly require consideration of care-provider concerns before discharge to custodial settings.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 8 October 2024.
Dorset
Concerns raised7
Lack of guidance on transferring prisoners under healthcare-team care between establishments
Lack of national guidance for management and operational staff on pre-transfer prisoner handover
Lack of consultation with receiving-prison healthcare teams about care capability
Lack of national guidance for healthcare handover to receiving prisons
Delays in transferring prisoners requiring mental health hospital admission
Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care
Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
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.
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.8
Action
Work with NHS England and His Majesty’s Prison and Probation Service to respond to concerns about delays transferring mentally unwell prisoners to hospital.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Review the response to the thematic review and monitor progress in addressing delays transferring mentally unwell prisoners to hospital.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Action
Introduce the Mental Health Bill during the current Parliamentary session.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Action
Respond directly to concerns identified in the thematic review of delays transferring mentally unwell prisoners.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Use a clinical template to record and monitor referrals, assessments and transfers under sections 47 and 48 of the Mental Health Act.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Action
Gather transfer-timeliness data and work with commissioners to improve the quality and completeness of existing data collection.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Review mental health pathway processes, communication and information sharing, then develop a proposed pathway and programme plan addressing identified gaps and priorities.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Raise prisoner-movement communication issues with the Ministry of Justice and explore confidentially sharing relevant movement information to support timely message redirection.
Stated by Unilink Software LimitedStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
HMPPS should respond to the absence of a national prison healthcare directory and related prisoner-transfer guidance.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England leads the response to delays transferring mentally unwell prisoners to hospital, with the Department reviewing progress.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Without access to prisoner movement information, the service could not redirect the message or notify the sender of the transfer.
Stated by Unilink Software LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
South Wales Central
Concerns raised2
Failure to provide agency staff with sufficient information for informed reception support
Failure to accompany transfers with Caswell Clinic staff
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East Sussex
Concerns raised1
Inadequate understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment
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.
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
Actively review the emergency-escort policy.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 20 March 2024.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to ensure transfer for psychiatric treatment where required
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.1
Action
Discuss reviewing the standard operating procedure for referring and transferring prisoners to establishments with hospital wings.
Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
Northamptonshire
Concerns raised1
Failure to assess fitness to transfer
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.1
Action
Undertake and record a fitness-to-transfer assessment for every patient before transfer to an establishment or court.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 1 November 2023.
Manchester South
Concerns raised1
Failure to require body worn video during prisoner escorts nationally
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
Revise and publish NPCC body-worn video guidance requiring recording during prisoner transport and addressing coverage, access and retention of journey footage.
Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2023.
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Includes failures of controls dedicated to the prisoner transfer process, including pre-transfer risk assessment, transfer handover and information sharing, receiving-prison checks, and continuity of essential prisoner support.
