Risk of suicide and self-harm in newly arrived prisoners
His Majesty's Prison and Probation Service received 3 coroners' reports about this hazard between 14 Dec 2015 and 13 Sept 2017.
They came from 2 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.”
Original on judiciary.uk ↗ His Majesty's Prison and Probation Service responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre.”
Stated timescale: January 2016
“The reviews will evaluate existing procedures which relate to all aspects of safer custody including suicide prevention and self-harm management and violence reduction. The reviews will look to explore the following issues; = Early days in custody - Transfer from court/ reception timings, reception interview and assessment, first night interview and induction package, healthcare screening and mental health referrals; = Assessment, Care in Custody and Teamwork - compliance and delivery, quality”
Stated timescale: January 2016
- 10 months laterClosely relatedConfidence 0.90 · higha different coroner
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
Original on judiciary.uk ↗ Repeated from the earlier report:staffrisksuicideselfharm
His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗
“NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the endjof April 2017.”
Stated timescale: endjof April 2017
- 11 months laterClosely relatedConfidence 0.90 · high
“He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death.”
Original on judiciary.uk ↗ Repeated from the earlier report:ACCTsuicide
His Majesty's Prison and Probation Service responded.Response (PDF) ↗
- All reports to His Majesty's Prison and Probation Service
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2016Roy Hoey10 months after Daniel Byrne · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern the identification and response to suicide/self‑harm risk at prisoner reception.
Daniel Byrne · 14 Dec 2015
“staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.”
Original on judiciary.uk ↗ Roy Hoey · 13 Oct 2016
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre.”
2016 → 2017Sam Molyneux11 months after Roy Hoey · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern the identification of suicide or self‑harm risk and the need to place a prisoner on an ACCT plan. The earlier report focuses on admission staff duties, while the later report highlights missed opportunities to act on expressed threats.
Roy Hoey · 13 Oct 2016
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
Original on judiciary.uk ↗ Sam Molyneux · 13 Sept 2017
“He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the endjof April 2017.”
Stated action · timescale: January 2016
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre.”
Stated action · timescale: January 2016
“The reviews will evaluate existing procedures which relate to all aspects of safer custody including suicide prevention and self-harm management and violence reduction. The reviews will look to explore the following issues; = Early days in custody - Transfer from court/ reception timings, reception interview and assessment, first night interview and induction package, healthcare screening and mental health referrals; = Assessment, Care in Custody and Teamwork - compliance and delivery, quality”
Stated action · timescale: endjof April 2017
“NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the endjof April 2017.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to His Majesty's Prison and Probation Service at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2016 | 0.71 | 0.18 | Closely related · 0.90 | different |
| 2016 → 2017 | 0.70 | 0.25 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for His Majesty's Prison and Probation Service
- Obscured observation panels hinder monitoring3 reports · 2024–2026
- Lack of basic first aid training and CPR among prison officers12 reports · 2015–2026
- Inadequate ACCT training leading to incomplete documentation16 reports · 2014–2026
- Lack of certified safer cells outside segregation unit4 reports · 2023–2025
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.