Recurring concern
Unreliable prison staff communication during safety-critical situations
Pin
Get email alerts
Request correctionFirst reported 16 May 2019•Latest report 23 Mar 2026
What this concern includes
Includes failures in prison-based communication arrangements for conveying the severity, scope, changing circumstances and required response to safety-critical situations between prison staff and relevant healthcare or custodial functions, including communication that should trigger enhanced observations, healthcare notification or other protective action.
Not included
- Excludes the narrower existing concern concerning sharing safety-critical risk information within prisons when the assertion is specifically about transfer of a defined risk record or risk-information field rather than broader communication of a safety-critical situation.
- Excludes generic prison staffing, training, documentation or leadership deficiencies unless they directly cause unreliable communication during a safety-critical situation.
- Excludes prison-to-probation, prison-to-community, court-to-prison and other external information-transfer processes unless the assertion concerns the same internal prison safety-communication control.
- Excludes clinical assessment or treatment failures after relevant prison staff communication has operated reliably.
- Reports
- 5
- Individual concerns
- 5
- Date range
- 2019–2026
- Stated actions
- 8
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
-
Concerns raised1
Failure of prison staff communication to relay the severity and complete scope of situations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
Embed practical emergency-response simulations, including Code Blue scenarios, within local training and mentoring arrangements.
Stated by HM Prison and Probation Service -
Action
Continue joint emergency-response exercises with healthcare staff to strengthen shared understanding and multidisciplinary response.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to establish a communication strategy during critical medical emergencies in custodial settings
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Inadequate communication about prisoners’ health conditions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
Implement Regional Multi Professional Complex Case Clinic escalation for the most complex patients.
Stated by Practice Plus Group Health And Rehabilitation Services Limited -
Action
Work with NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.
Stated by Practice Plus Group Health And Rehabilitation Services Limited
-
Position
Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Stated by HM Prison and Probation Service
-
Concerns raised1
Breakdown in communication among junior prison 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 concernsEach 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
Share the escort-review findings with healthcare staff to improve communication and clarify urgency during hospital escorts.
Stated by HM Prison and Probation Service
-
Concerns raised1
Inadequate advance notification and information sharing for ACCT reviews
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 concernsEach 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
Develop escalation procedures with Care UK and the prison for occasions when healthcare cannot attend an ACCT review.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Embed the new ACCT case-management process, including dedicated case managers, review booking oversight and daily healthcare attendance allocation.
Stated by HM Prison and Probation Service
Data last updated 7 September 2026