Recurring concern

Unreliable recording of safety-critical prisoner behaviour and welfare information

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First reported 17 Oct 2014•Latest report 6 Oct 2017

Definition

What this concern includes

Includes failures to record, update or preserve significant prisoner behaviour, presentation, mood, welfare changes and related events in prison-wing or comparable custody records when the information is needed by staff for risk assessment, supervision, handover or protective action.

Not included

  • Excludes failures to review or act on accurately recorded prisoner information when the recording process itself was reliable.
  • Excludes formal prisoner risk-assessment and risk-management decision records where the concern is the assessment or decision record rather than recording underlying behavioural or welfare information.
  • Excludes generic prison communication or information-sharing failures where no deficiency in recording safety-critical prisoner behaviour, presentation, mood or events is identified.
  • Excludes routine administrative movement, walk-book or attendance records unless they contain safety-critical behavioural, presentation or welfare information.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2017

First to latest report issue date

Stated actions
0

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.

Highpoint Prison1
HM Prison and Probation Service1
Leeds Community Healthcare NHS Trust1
Office of the Chief Coroner1

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. Suffolk

    AI-generated summary

    LEVI CRONIN · 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

    Levi Cronin, a serving prisoner at HMP Highpoint, was found hanging in a shower and later confirmed deceased at West Suffolk Hospital. The inquest recorded a conclusion of suicide and identified concerns about insufficient recording and information-sharing, inadequate staffing, and inadequate support and supervision within the mental health department and prison staff.

    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

    Inadequate recording on prison wings of potentially significant events or observed changes in mood or behaviour

    Wider context from the report

    “- The importance of ensuring that there is adequate and appropriate recording on prison wings of potentially significant event or observed changes in a person’s mood or behaviour that could, if all were taken together, assist staff in their very difficult task of making risk assessments in the complex and challenging environment of a busy prison. ”

    Source location

    LEVI CRONIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Yorkshire Eastern

    AI-generated summary

    William Thomas Anderson · 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

    William Thomas Anderson died in his cell at HMP Wealstun on 19 September 2010 after taking prescription medication belonging to others and drinking hooch, having appeared intoxicated or under the influence of alcohol or drugs the previous afternoon. The concerns included insufficient vigilance around inmate gatherings involving drugs and alcohol, incomplete staff training and recording of observations, failure to use an emergency code, and delay in summoning paramedic assistance.

    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 record relevant inmate behaviour and presentation information in the Wing Observation Book

    Wider context from the report

    “(3) The Deceased’s behaviour and presentation on the 18th September 2010 was not recorded by any member of Wing staff in the C Wing Observation Book. Evidence was adduced in the course of the Inquest as to the importance of recording all relevant information in the said Observation Book, thereby apprising all members of Wing staff on all shifts of all material facts and matters. In the circumstances, all relevant information in relation to, for example, an inmate’s behaviour and general presentation should be brought to the attention of all Wing staff and should be done so via an appropriate entry/entries in the Wing Observation Book. All Wing staff (Wing Managers, Prison Officers and Operational Support Grades) should be made aware of the importance of such, and should ensure information is recorded accordingly; ”

    Source location

    William Thomas Anderson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026