First reported 6 Jan 2014•Latest report 7 Apr 2026
Definition
What this concern includes
Includes failures of the custody observation process in any custody setting, including determining the required level, communicating or handing over observation requirements, implementing the level, and maintaining it during transfer, where the failure could leave a detained person insufficiently observed.
Not included
Excludes hospital or community observation failures that are not explicitly connected to custody.
Excludes generic staffing, documentation, training, or handover deficiencies unless they directly make custody observation requirements unreliable.
Excludes unrelated medical-information transfer failures that do not concern observation requirements.
Reports
8
Distinct published reports
Individual concerns
13
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
22
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 Service3
South Yorkshire Police2
Care UK1
Department of Health and Social Care1
G4S1
GeoAmey PECS Limited1
Greater Manchester Police1
Lewisham and Greenwich NHS Trust1
Medacs Healthcare Limited1
Midlands Partnership University NHS Foundation Trust1
Ministry of Justice1
National Police Chiefs’ Council1
Nestor Primecare Services Limited1
North Staffordshire Combined Healthcare NHS Trust1
Practice Plus Group1
Police force4
Executive agency3
Independent healthcare provider2
Ministerial department2
NHS trust2
Prison or young offender institution2
Multi-service care provider1
National policing body1
Prison operator1
Private limited company1
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 South London
Concerns raised1
Unavailability of larger disabled cells adapted for constant watch
This report raised 8 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.
Nottinghamshire
Concerns raised1
Failure to consult a supervising officer on ACCT observation levels
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for delivering suicide and self-harm risk management and the ACCT process at HMP Ranby sits with the Head of Safety.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised2
Lack of audit trail for signed constant observation forms and sergeant briefings
Lack of timely controlled handover of constant observation forms
This report raised 7 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 compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
Stated by South Yorkshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 4 April 2024.
Action
Consult the Performance and Governance team about activating body-worn video during constant observations.
Stated by South Yorkshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 4 April 2024.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to ensure correct levels of observation up to constant watch
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.2
Action
Consider constant supervision when ligature material has been removed.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Action
Remind Case Co-Ordinators to record reasons when a discussed constant watch is deemed inappropriate.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
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.
Stoke-on-Trent and North Staffordshire
Concerns raised3
Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Insufficient training emphasis on correct observation levels
Failure to specify detainee observation levels precisely
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.8
Action
Issue guidance requiring medical practitioners to provide custody sergeants with verbal consultation updates.
Stated by Staffordshire PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2015.
Action
Review Force Policy to incorporate the verbal medical consultation update requirement.
Stated by Staffordshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2015.
Action
Review Detention and Custody Authorised Professional Practice to consider guidance on medical practitioner–custody sergeant consultation, observation levels and detailed medical records.
Stated by College of Policing and DCC Nick EphgraveStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2015.
Action
Consider further training to supplement and enhance observation-level guidance.
Stated by Staffordshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2015.
Action
Provide mandatory custody-officer training on setting observation levels during induction, aligned with current custody guidance.
Stated by G4S Care And Justice Services (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 15 April 2015.
Action
Maintain training standards that emphasise selecting correct detainee observation levels and direct users to Authorised Professional Practice.
Stated by College of Policing and DCC Nick EphgraveStated completedThe respondent said that this action was complete when they made their response on 15 April 2015.
Action
Instruct custody officers and medical practitioners to record agreed observation levels and avoid non-specific continuation phrases.
Stated by Staffordshire PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2015.
Action
Add advice to Detention and Custody Authorised Professional Practice requiring doctors and custody sergeants to specify observation levels precisely.
Stated by College of Policing and DCC Nick EphgraveStated plannedThe respondent said that this action was planned when they made their response on 15 April 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing training standards already emphasise the importance of correct observation levels and refer to applicable guidance.
Stated by College of Policing and DCC Nick EphgraveExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Western)
Concerns raised2
Failure to record changes to detainee observation levels
Failure to implement and record required detainee observation levels
This report raised 27 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
Remind custody staff to record all decisions about detainee checks in custody records.
Stated by South Yorkshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 23 March 2015.
Action
Implement digital custody records requiring electronic recording of checks, observations, assessments and associated audit times.
Stated by South Yorkshire PoliceStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Thirty-minute checks were unnecessary at Bridge Street because the detainee was never placed in a cell and remained under constant supervision.
Stated by South Yorkshire PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised2
Lack of understanding of required custody observation levels and rationale
Failure to transfer and replicate medical observation information during GEO AMEY custody
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
Amend MEDACS observation-level dropdown menus to improve clarity.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 January 2014.
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Includes failures of the custody observation process in any custody setting, including determining the required level, communicating or handing over observation requirements, implementing the level, and maintaining it during transfer, where the failure could leave a detained person insufficiently observed.
