Recurring concern

Failure to conduct multidisciplinary risk assessments for high-risk prisoners

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First reported 16 Sep 2013•Latest report 20 Apr 2020

Definition

What this concern includes

Includes failures of multidisciplinary risk-assessment or review processes for high-risk prisoners where relevant healthcare, mental-health, self-harm, custodial or placement information is not brought together before or during a consequential custody decision, including RSU deselection and comparable high-risk prisoner reviews.

Not included

  • Excludes failures confined solely to the general ACCT process when no wider multidisciplinary risk-assessment or review condition is identified.
  • Excludes generic prisoner risk-assessment failures that do not involve a multidisciplinary assessment or review for a high-risk prisoner.
  • Excludes routine prison transfers, placement decisions or segregation decisions where no high-risk or multidisciplinary risk-assessment deficiency is asserted.
  • Excludes generic staffing, communication, training or record-keeping deficiencies unless they directly prevent the required multidisciplinary risk assessment or review.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2013–2020

First to latest report issue date

Stated actions
2

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.

Bristol Prison1
Herefordshire and Worcestershire Health and Care NHS Trust1
Hewell Prison1
HM Prison and Probation Service1

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.

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Andrew Patrick Jones · 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

    Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.

    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 conduct multidisciplinary risk assessment before RSU deselection

    Wider context from the report

    “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera; d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer; e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death; g. Inconsistent medication regimes without explanation; h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred; i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place; j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Worcestershire

    AI-generated summary

    Reggie Johns · 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

    Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.

    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 hold required multidisciplinary review meetings

    Wider context from the report

    “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status. (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare. This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review. Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed. (3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view. Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel. Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents. ”

    Source location

    Reggie Johns · Prevention of Future Deaths report
    Page 3 · 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

    Review Prison Service Instruction 64/2011 to identify and address areas of non-compliance at HMP Hewell.

    Verbatim wording from the response

    “I can also confirm that following the inquest into Mr Johns’ death ████████ and ████████ Prison Governor, HMP Hewell have reviewed Prison Service Instruction 64/2011 (updated) – in order to identify any areas of non-compliance and to address these.”

    Source location

    2013-0202-Response-by-Worcestershire-Health-Care-NHS
    Page 2 · response
    Published 16 September 2013

    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

    Issue Operational Orders requiring ACCT reviews to be multidisciplinary and obtain views from all appropriate departments.

    Verbatim wording from the response

    “Since Mr Johns' death, the enclosed Operational Orders have been issued entitled ‘Chairing ACCT Reviews’ and ‘ACCT Reviews’ which provide guidance for selecting appropriate ACCT case managers, and confirm that it is the case manager's responsibility to ensure that each review is multi-disciplinary with views from all appropriate departments being taken into consideration.”

    Source location

    2013-0202-Response-by-NOMS
    Page 2 · response
    Published 16 September 2013

    Open published response
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Data last updated 7 September 2026