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22 September 2006
To provide further advice about reducing the incidence of deaths and self
harm amongst Approved Premises residents. IMPLEMENTATION DATE:
2 October 2006
For Probation Areas and Voluntary Management Committees: September 2008

• To note the practice advice contained in this Circular and, in TO:

particular, the requirement to update and submit revised local Chairs of Probation Boards
strategies for reducing deaths and self harm by 31 December 2006 Chief Officers of Probation
• To nominate, by 13 October, Approved Premises Managers to be Secretaries of Probation Boards
involved in discussing and, if required, piloting new arrangements for
‘in possession’ medication. CC:
Board Treasurers
SUMMARY Regional Managers

The attached practice guidance draws on lessons learnt from reports AUTHORISED BY:
produced by the Prisons and Probation Ombudsman (PPO) as a result of John Scott,
their investigations into deaths of Approved Premises residents. A number of Head of Public Protection and
common themes, such as the importance of effective information sharing Licensed Release Unit
across NOMS and with partner agencies, emerge from the reports, which are
set out in detail below. The PPO’s reports on the deaths of individual ATTACHED:
residents also highlight instances of good practice in the care of residents Annex A – Statistical information
prior to their deaths, and some of these are also highlighted in the Circular. In about deaths of residents
addition, this Circular advises of the setting up of a working group to examine Annex B – Prison Service
issues surrounding the control of medication in Approved Premises. Instruction on Cell Sharing
Annex C – List of Voluntary
Organisation Contacts

PC40/2004, PC15/2006

CONTACT FOR ENQUIRIES or 020 7217 8226


National Probation Directorate

Abell House, John Islip Street, London, SW1P 4LH

1. This Circular provides further guidance on policy and practice issues arising from a number of recommendations
contained in reports from the Prisons and Probation Ombudsman (PPO) into deaths of residents in Approved
Premises. The published reports are available on the PPO’s website Annex A to this circular
provides statistical data about deaths of Approved Premises residents over the past eight years.

2. Some of the recommendations require further work at a national level across NOMS. Work is ongoing to address
issues of common interest such as improving access to healthcare and developing information sharing protocols
with prisons, healthcare providers and specialist interventions agencies. Equally, many of the reports highlight
areas for improvement which can be implemented locally to contribute to reducing the incidence of deaths of
Approved Premises’ residents, as well as improving the effectiveness of their overall supervision and risk
management. These themes are set out below, with specific action points for probation areas and voluntary
management committees (VMCs), although the term probation areas is used throughout to include action
required by VMCs. PPO reports often also contain examples of good practice in relation to managing residents’
suicide and self-harm risk, and these too are highlighted below.


A: Review and Updating Of Local Strategies

3. Probation Circular 40/2004 required all probation areas to have in place a local strategy for reducing sudden
deaths and self-harm. These should now be reviewed and updated in the light of the guidance contained in this
circular. Revised strategies should be in place by 31st December 2006, and a copy submitted electronically to

B: Risk Assessments

Access to OASys and Other Risk Assessments

4. A key theme running through PPO and HMIP reports into the management of individual cases has been about
access to comprehensive information about offenders. This is vital both to effective management of risk of harm
to the public and management of risks of suicide and self-harm. In line with the requirements in Probation
Circular 15/2006 (Annex A- 8.9), which deals with access to OASys by providers and all other parties involved in
delivering parts of the order/licence, offender managers and other referrers should ensure that OASys
assessments include risk of self harm assessments and are included with all referrals. Information should, where
possible, also be sought from any assessments based on previous contacts with the criminal justice system, e.g.
previous OASys, records of previous supervision or records held on the Police National Computer such as
information from Prisoner Escort Forms (PER).

5. Probation Circular 37/2005 (S4) sets out clearly the requirements of referring officers in terms of providing
OASys. Care should be taken to ensure that information from OASys or other sources about risk of suicide and
self-harm is fully addressed in supervision and risk management plans. This is also covered in detail in Section 4
of PC37/05 which elaborates on what referring officers should provide by way of supervision and risk
management plans. Approved Premises are required to produce an Approved Premises supervision plan,
derived from the Offender Manager’s plan, which describes in detail what work will be done in the Approved
Premises and by whom. It should, of course, be noted that whilst there may be several interventions plans, the
Offender Manager’s sentence plan is the main plan.

Access to Prison Service and Court Escort Information on Risk of Suicide and Self Harm

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6. Several PPO reports made comment and recommendations concerning the availability of information from
prisons (both public and contracted) and court escort contractors about risks identified during the custodial period.
Approved Premises managers should endeavour to obtain from the Prison Service, contracted prisons and court
escort services full information on risk of self-harm and suicide. Where managers are unsure who to contact to
obtain information from prisons, they should in the first instance approach the Resettlement Manager or the
Suicide Prevention Co-ordinator. Once C-NOMIS has been implemented across prisons and probation it will
become the usual means of communicating risk of self harm information between HMPS, Offender Managers and
Approved Premises staff.

We have had the following advice from the Prison Service:

“Legal advice to prisons is that they have a legal duty to inform other relevant agencies of the self-harm or suicide risk
that a prisoner/trainee presents. That duty comes from the ordinary law of negligence, and can be paraphrased as the
duty of care to take reasonable steps to avoid reasonably foreseeable risks. The duty also comes from Article 2 of the
ECHR, the duty to protect the life of those in the State's custody, which includes information sharing.

All prisons will have moved from using the F2052SH (care of at-risk prisoners system) to the new Assessment, Care in
Custody and Teamwork (ACCT) system by 31 March 2007; three quarters will have done so by 30 September 2006. It is
mandatory for prisons using ACCT to provide partner agencies with information about prisoners who are at risk and are
due for discharge. In the meantime those prisons still using the F2052SH system have been reminded that it is good
practice for them to also do this.

Prisons using ACCT are instructed that if an at-risk prisoner is to be under the supervision of the Probation Service upon
discharge, a photocopy of the final Case Review, CAREMAP, front cover and inside front cover of the ACCT Plan must
be provided to their Offender Manager or Approved Premises manager in accordance with local protocols. Ideally this
should be provided at least 48 hours before discharge. This is in addition to any requirements in respect of updating Risk
of Harm information on OASys.

Similarly, where an at-risk prisoner released at court is to be under the supervision of the Probation Service upon
discharge, depending on the type of risk warning form open, either a photocopy of the Suicide/Self-Harm Warning Form,
or a photocopy of the final Case Review, CAREMAP, front cover and inside front cover of the ACCT Plan must be
provided to their Offender Manager or Approved Premises manager in accordance with local arrangements agreed
between escort contractors and the local Probation Service”.

7. Approved Premises managers should note that if closure of an at-risk prisoner’s ACCT Plan is because s/he is
being discharged from custody to the supervision of Probation, the prisoner’s ACCT Case Manager must involve
Probation staff in at least the final prison based Case Review. Prison staff have also been informed that it is good
practice to involve Probation staff as early as possible in updating the ACCT CAREMAP to promote effective
planned support into the community, and to develop local protocols with Probation in respect of this. Prisons are
instructed to ensure there are local arrangements in place to ensure that where an at-risk prisoner is to be
discharged from custody, the relevant external Offender Manager and/or Approved Premises manager is invited
to participate (preferably by attending in person) in the final Case Review and in updating the CAREMAP to
reflect the care required in the community. Approved Premises managers should, wherever possible, respond
positively to any such requests for involvement in the care planning of prisoners being released to their care.

8. Approved Premises in the North West probation region are in the process of introducing a modified version of
ACCT as their preferred suicide and self-harm management framework. The NPD is considering how the learning
from that initiative might best inform practice development across the estate.

Threat Assessments

PC35/2006 – Preventing Deaths of Approved Premises Residents


9. A concern was raised by the PPO about the proper identification of potential threats to the safety of prospective
residents. Approved Premises managers should ensure that referral forms ask for information about potential
threats to prospective residents. Threat assessment should cover potential risks to individual residents from
within the Approved Premises or the wider population, and be updated periodically once an offender is in

Risk Assessment Prior to Allocation to Shared Rooms and Care Of Vulnerable Residents

10. In some circumstances, shared rooms can be useful in helping to reduce the risks of self-harm or suicide; equally
sharing a room may potentially increase risk. Managers should therefore assess whether allocation to a shared
room has the potential to be a protective factor or to increase risk. In addition managers, before allocating
residents to shared rooms, for whatever reason, should undertake a risk assessment to identify any potential
risks to the residents’ safety. For potential residents held in custody, information should be sought from prisons
about any risk factors identified by cell sharing risk assessments. In due course this will flagged up on C-NOMIS,
but in the interim, Approved Premises should amend their referral forms to ensure that this information is
requested. A copy of the current Prison Service Instruction is attached at Annex B. Approved Premises will wish
to consider adopting similar criteria as part of their own risk assessment procedures. Approved Premises owe a
duty of care to all residents, many of whom may be vulnerable for a range of different reasons. Additional welfare
checks should be put in place at night to safeguard vulnerable individuals, including those with special health or
mobility needs.

Induction Interviews – Prevention of Drug Overdoses

11. One of the main causes of deaths amongst Approved Premises residents is a drug overdose, often due to
reduced tolerance after release from prison. Where this topic is not already covered at the induction interview,
Approved Premises should ensure that advice and guidance is given to all residents on reduced drug tolerance
following release from custody. It is good practice for this to be included in a leaflet for residents, which could
include contact details for drugs advice agencies.

C: Access to and Recording of Information and Communications with Offender Managers and Partner Agencies

Access to Local Strategies and Other Policy Documents

12. The PPO has specifically drawn attention to instances where members of staff of Approved Premises were
unfamiliar with local policies and practices on sudden death and self-harm. Approved Premises Managers must
ensure that all staff are made aware of the local strategy for reducing sudden deaths and self harm and other
relevant guidance, including the Approved Premises Handbook on induction, and that this is reinforced at regular
intervals thereafter.

Recording of Referrals

13. Attention was drawn to an instance where, because of a lack of clarity in communicating a decision on a referral,
staff at an Approved Premises were unprepared for the arrival of a new resident. In the light of this, Approved
Premises Managers should ensure that the outcome of all referrals is communicated in writing (letter, fax, or e
mail) to referrers.

Recording of Significant Events & Drawing Them to the Attention of Staff

14. Managers should ensure that, as required by National Standards, significant events in relation to residents are
recorded in the house record or equivalent log and drawn to the attention of all staff coming on duty. Staff should
then annote the record to indicate that they have read and noted relevant entries. The importance of clear and
contemporaneous record keeping on offenders’ case records is also highlighted in Probation Circular 15/2006
(Annex A-8.2). A review of OASys and the sentence plan should take place following a significant change in

PC35/2006 – Preventing Deaths of Approved Premises Residents


circumstances, and therefore the Offender Manger should be notified of any significant changes; ideally there
should be a three-way review as to how best to proceed.

Information Sharing Arrangements and Protocols

15. A theme which emerges from many PPO reports is the timely sharing of information between key partners such
as providers of drug treatment. In line with National Standards and Probation Circular 15/2006 (Annex A -8.10-
12), offender managers are required to ensure regular exchanges of information. Where offenders are resident in
Approved Premises, the Approved Premises should be included in information exchanges and should, in turn,
communicate all key information promptly to offender managers e.g. the results of drug tests conducted at
Approved Premises. Probation Areas should ensure they have information sharing protocols and effective
liaison arrangements in place with local prisons, healthcare providers and partner agencies such as CJIP and
other drugs providers.

D: Enforcement

16. Effective and timely enforcement action is fundamental to the work of the probation service in protecting the
public and reducing reoffending. Probation Areas should ensure that all Approved Premises follow National
Standards guidance on enforcement of orders, licences and conditions of residence imposed by courts on bailees
(General Standard 9 and Specific Standards 9.1 to 9.9). This is reinforced in Probation Circular 15/2006 (Annex
A-8.1). The Offender Manager in the community holds ultimate responsibility for enforcement. Where the
Offender Manager is not based in the Approved Premises, then any failures to comply should be communicated
to him/her on the day of the failure, or the following day in the case of evening/overnight failures, so that
appropriate action may be taken. Particular issues arising from the supervision of those on life licence will also be
addressed in a forthcoming revision to the Lifer Manual.

E: Safety and First Aid

First Aid

17. Both PPO reports and correspondence from coroners following inquests have highlighted the importance of staff
having appropriate and up to date first aid skills. Probation areas should refer to the Health and Safety Risk
Assessment “Approved Premises Management Guidance” which has been circulated to Areas and is also
available on EPIC. This states that “all supervisory staff must be trained, as a minimum, in basic first aid”.
Details of the different levels of training are available in the training guidance “Approved Premises - Working
Safely”, also available on EPIC. In addition, Probation Areas/VMCs should ensure that staff considering whether
to commence cardiopulmonary resuscitation (CPR) should follow advice given in their training, and that where
mouth guards and other resuscitation aids are issued they are of the type with non-return valves and are carried
on the person of staff at all times. Probation Areas may also wish to seek advice from their local Primary Care
Trusts (PCTs) about technical issues such as first aid techniques and equipment to be provided on site.

Retention of CCTV Records

18. Preservation of records is vital to the conduct of PPO investigations as well as for use in other investigations that
could lead to enforcement action or criminal proceedings against residents. Approved Premises managers must
ensure that CCTV records relevant to incidents are retained, and made immediately available to investigating
officers. CCTV and other records should be retained until after any inquest.

Carrying of Personal Alarms, Radios and Mobile Phones

19. Summoning assistance immediately on discovery of an incident may be critical to avoiding fatalities. Approved
Premises managers should ensure that staff carry personal alarms and other safety equipment such as radios at

PC35/2006 – Preventing Deaths of Approved Premises Residents


all times. Mobile phones should be made available and carried by staff patrolling the premises so that they can
summon assistance from the emergency services immediately in the event of an incident.

Monitoring Residents and Wellbeing Checks

20. Probation Circular 35/2004 requires residents’ movements in and out of premises to be controlled and recorded;
where appropriate this information should be communicated to the Offender Manager. It is vital for public
protection and risk management reasons that managers and staff on duty know which residents are on the
premises at any given time. In addition, as part of delivering the duty of care to residents, staff should ensure that
residents’ whereabouts can be established whilst they are on site, particularly after curfew and at weekends.
Approved Premises should, for example, ensure that checks are undertaken of residents’ rooms if they are not
present at mealtimes.

Car Numbers

21. Approved Premises managers should ensure that the registration numbers of residents’ vehicles are recorded to
assist in the identification of residents absent from the Premises.

F: Medication

Recording & Storage

22. In some PPO reports, attention is drawn to poor recording practices that have made it difficult to establish
whether residents have been issued with the correct dosage of medications at the required intervals. Approved
Premises managers must ensure that accurate records are kept of all medication made available to residents,
including medication issued to new residents on leaving prison, and should undertake regular audits of both stock
and the standards of record keeping.

Risk Assessment Prior to the Issue of More Than One Day’s Medication

23. The PPO has highlighted an instance where a resident was able to take an overdose through stockpiling
medication. Approved Premises managers should ensure that a risk assessment is undertaken prior to the issue
of significant quantities of medication, e.g. to residents going on home leave or moving out of the Approved
Premises, so as to avoid potential overdoses or sale of medication. Risk assessments should also include
consideration of whether room mates or others who associate with at-risk residents may represent an additional
risk factor, e.g. of sharing/illicit sale of medication.

Review of ‘In Possession’ Medication

24. Practice in the Prison Service is to allow prisoners to retain their own medication, subject to risk assessment, and
there are some views that this should be extended to Approved Premises. The implications of such a change
would be far reaching and will need further consideration and consultation before any change is implemented. A
working group is being set up involving colleagues from NOMS, the Department of Health and the PPO.
Probation Areas and VMCs are invited to submit nominations for managers/practitioners who would be willing to
participate in discussions on the proposals and, if required, to assist in piloting any new arrangements in their
Approved Premises. Nominations should be submitted electronically to by Friday 13 October 2006.

G: Good Practice Examples

The following are examples of good practice which probation areas and VMCs may wish to consider adopting.

PC35/2006 – Preventing Deaths of Approved Premises Residents


Attendance at Funerals

25. Subject to the views of the family and where practical, probation areas should consider sending a representative
to attend the funeral of former residents.


26. Premises may wish to consider the planting of a tree or shrub or installing another form of memorial in the
grounds to commemorate deceased former residents.

Support and Counselling For Residents and Staff

27. Following a sudden death Probation Areas should consider providing support to residents and staff, including
making counselling available for residents in addition to their current arrangements for staff to access such
services. There are a number of organisations, both national and local, that can offer support to both residents
and staff following a sudden death. These include:
Samaritans 08547 90 90 90
CRUSE Bereavement Care 08701 671677
National Association of Bereavement Services 020 7709 2090


28. Local arrangements with NHS medical centres for comprehensive health checks for residents are an example of
good practice. Similarly, establishing good links with local Primary Care Trusts can result in the development of
more appropriate services for Approved Premises residents.

Family Liaison

29. Probation areas may wish to consider appointing a named individual at each Approved Premises as the first point
of contact with bereaved families, and should consider whether there are any training needs which should be
addressed prior to individuals taking up this role. The role could encompass giving information to families after
the initial notification of the death by the police, arranging for the family to visit the Approved Premises and
organising the return of property to the family. Areas may wish to draw on the experience available in local
prisons or voluntary organisations to assist with this. A list of voluntary organisations which may be of assistance
is attached at Annex C, and the Prison Service guidance on Family Liaison will be placed as a reference
document on EPIC.

PC35/2006 – Preventing Deaths of Approved Premises Residents

Annex A

Data on deaths of Approved Premises residents

Details on total number of deaths of residents of Approved Premises, and the

causes of death, are set out below.

YEAR Suicide Overdose Natural Accident/ Currently Total

Causes Homicide unknown
1998 3 11 3 3 0 20
1999 4 4 1 0 0 9
2000 8 13 2 1 0 24
2001 3 12 5 2 0 22
2002 3 8 8 2 0 21
2003 4 3 3 1 0 11
2004 2 8 8 2 0 20
2005* 7 6 2 0 2 17
Total 34 65 32 11 2 144

*Provisional analysis for 2005

Annex B

Prison Service Instruction 32/2005

Cell Sharing Risk Assessment

(Replaces PSI 26/2002)

PSO 2750 Violence Reduction

8 August 2005 7 August 2006


For Action Monitored by

Area Managers, Prisons, Area Managers & Director of High Security, SAU
Governors, Directors & Controllers of & Self- Audit
Contracted Prisons
For Information On authority of
All prison service staff Prison Service Management Board

Contact Point
Gill Brigden, Safer Custody Group, tel. 020 7217 2174

Other Processes Affected

PSO 0500 Reception
PSO 0550 Induction

Cell – sharing risk assessment and ongoing risk management is an integral part of the violence
reduction strategy.
There is no change to the initial cell-sharing risk assessment process on reception, new
requirements are explained in the text
Mandatory Actions are written in italics and must be acted upon.

Issued 29/7/05
Policy and Output



1. This Prison Service Instruction (PSI) replaces PSI 26/2002 on Cell-Sharing

Risk Assessment and accompanying forms which were introduced on 20
June 2002. It incorporates changes to improve the efficiency and
effectiveness of the current risk assessment and subsequent risk
minimisation process. The revised PSI, additional forms and guidance notes
will come into effect on [8th August 2005] and should be implemented as part
of each establishment’s violence reduction strategy. The first form (xf 001)
remains unchanged.

2. The risk assessment process has been evaluated by Research Development

Statistics RDS) under the direction of a working group including policy,
research and operational staff. Additionally a small working group of
Governors & other key officers has undertaken a special review, motivated by
a homicide incident.

3. The main changes to the risk assessment process are

Change Reasons for change

Includes a risk minimisation To ensure that any risks

plan & management identified are minimised and that
arrangements the document is kept ‘live’
Facility to record a risk review Recognition from case studies
triggered by circumstances that new events and
other than re-location circumstances can trigger new

A manager is designated to To provide consistent ongoing

oversee the risk management risk assessment & management
process as part of the violence relating to cell-sharing
reduction strategy.

A register of prisoners To provide a reference point for

designated high or medium risk overview of risks and an audit
must be held centrally in each trail of open and closed cases

4. The purpose of the risk assessment tool remains the same to:

• draw together information about risk

• make best use of documentary evidence;
• support staff judgement about allocation to cells and risk management;
• record additional operational precautionary measures for a prisoner
identified as a potential risk, where cell sharing is unavoidable;
• provide a record about risk of harm to others as a prisoner moves
between wings/ prisons;
• to enable early identification of racist, homophobic or violent prisoners,
to ensure that other Prison Service procedures to protect potential
victims are followed.

5. The cell sharing risk assessment system does not:

• replace staff judgement
• provide an actuarial risk score
• rule out cell sharing by prisoners who pose a risk.
Policy and Output

6. The first form (xf 001) must be completed as part of the Reception procedure
before the first night in custody. It should be reviewed by the Induction Board.

7. Evidence of risk should be recorded clearly, so that officers referring to the

form will be sure about the risks present and be able to plan on the basis of
that risk.

8. The Prisoner Escort Record (PER), warrant, probation reports, OASys and
previous convictions must be consulted, if available, when the cell-sharing
risk assessment form is being completed.

9. Where available and in compliance with PSO 0905, the Police National
Computer Link, must be used to access pre-conviction data as soon as
possible. If staff are on duty and trained to access the PNC for previous
convictions, arrangements must be made to provide pre-conviction data to
reception/induction staff on the first night.

10. A prisoner with a history of violence in custody (situational violence) presents

a heightened risk. Particular attention should be paid to section 2 of form xf
001 (initial risk assessment) if the prisoner is known to the service. In
compiling any subsequent risk minimisation plan and/or reviewing the risk
assessment, a prisoner who has exhibited over reactive behaviour in
response to perceived threats or who is known to have armed themselves
with a weapon whilst in custody should be managed with extreme care.

11. In prisons with a first night centre, the form may be completed there as long
as documentary evidence is used and information from health care staff is

12. Typically, reception officers and health-care staff should handle the
assessment process with allocation decisions taken by the reception
manager. More sensitive decisions about cell allocations (for example, if a
prisoner represents risk to self and others) should be referred to a more
senior manager. Where a prisoner is identified as being at risk of self-
harm or suicide, an F2052SH or an ACCT plan must be opened. (If the
prisoner is newly arrived at reception, local protocols may allow for any risk-
to-self information to be passed to the reception healthcare screener for them
to decide if an F2052SH or an ACCT plan should be opened).

13. In the case of a transferred prisoner, the sending prison must ensure an up-
to-date (i.e. reflecting the current circumstances if different to when the
assessment was completed) cell sharing risk assessment form, and any risk
management plans, accompany the prisoner to the receiving prison as part of
the transfer documentation. These must be read before location decisions are
made in receiving closed prisons where there is the option of other than
single cell occupancy.

14. Prisons without shared accommodation must complete a risk assessment

form on every prisoner by the end of the Induction process. This will allow
them to make informed decisions about the management/control of prisoners
who exhibit potentially violent, racist, or homophobic behaviour.
15. A risk minimisation plan must be in place to manage any high or medium risks
identified. This must be agreed within 7 days and signed by the duty
governor. This plan will form the core of the prisoner’s history sheet and a
copy should be kept on the wing file. These plans must be consulted when
relocating prisoners. They can be cancelled, confirmed or revised at any
subsequent review.

16. Particularly sensitive judgements are needed if a prisoner is seen to be at

risk of harming him/ herself as well as others. The incidence of self-harm
and suicide is significantly higher than murder. Cell sharing can be an
important element of the support provided for an at-risk prisoner, and
placement in a single cell could increase risk. Where an at-risk prisoner is to
be placed in a single cell the ACCT CAREMAP (or F2052SH support plan)
should take this into account, in respect of frequency of conversations and
observations (level of supervision), additional support for the prisoner, and
location, e.g. use of a safer cell.

17. Where cell sharing may be a medical recommendation, such as having

someone to call for help for in case of illness, the prisoner must still be
managed according to the identified risks (to self or others). If there are
difficulties then these should be resolved through a multi-disciplinary case

18. Full account needs to be taken of the implications for the cell mate of such a
locating decision, and that beyond the everyday responsibility all individuals
hold towards each other, the care of their cell mate is not their responsibility;
this remains the responsibility of management and staff.


19. Cell sharing risk assessment can aid identification and management of
prisoners who show signs of racism, or other forms of bigotry or
discriminatory behaviour. But it is not an appropriate way of managing
prisoners who press for scarce single cell accommodation. Sharing with
someone from a non-targeted group can be considered.

20. Racist, or other discriminatory attitudes may be visible (e.g. tattoos), but
should be evidenced by monitoring behaviour. It must be made clear to any
prisoner who appears to pose a threat to any group of prisoners that racist or
harassing behaviour is in breach of Prison Rules, and will be treated as a
serious disciplinary offence (using the racially aggravated offences where
evidence is available.)

Impact and resource assessment


21. The principles of risk assessment remain unchanged. Guidance is

incorporated into the additional forms.

22. Reception and Health care staff will need to be familiar with the revised form.
All staff will need to be familiar with the principles and procedures of risk

Mandatory Action
23. PSI 26/2002 must be replaced by this PSI and the changes reflected in local
policies and procedures.

24. Governors of all closed prisons and YOIs and directors of contracted prisons
must satisfy themselves that staff are aware of this Instruction. They must
also be satisfied that;

• the cell sharing risk assessment form is being used and completed
• risk minimisation plans are agreed for those prisoners who present a
significant or increased risk, and a review schedule agreed
• a manager is designated to oversee the risk management process as
part of the violence reduction strategy.
• a register of prisoners designated as high or medium risk must be held
centrally in each establishment to provide an audit trail of open and
closed cases. These will be monitored by the area manager on their
regular visits.

25. Regular reviews will be required for those prisoners initially rated as high or
medium risk, and whose rating was then confirmed at the Induction Board.
This should initially be after one month, then at least three monthly intervals.
The review form must be used for ongoing assessment. Where other risk
management processes offer the potential to manage this process, ( OASys,
MAPPA) these can be used. The focus of cell-sharing risk assessment must
be maintained e.g personal safety of cellmate.

26. The review form must also be used for re-assessment of any prisoner if there
is a significant event that triggers concern. There will be some prisoners who
have a completed OASys prepared by the Probation Service. The OASys
document, particularly the sections dealing with self harm and harm to others,
must be consulted at the time of any subsequent review carried out on
prisoners identified as at risk of harming a cellmate or others. Circumstances
that may trigger a review are for local judgement. Here are some examples;
repeated or escalated threats of violence, particularly towards cellmates;
discharge from segregation following violent or threatening behaviour;
unexpected conviction or harsh sentence.

Advice and information

27. Queries about the cell sharing risk assessment form should be made to Safer
Custody Group (Gill Brigden) on 020 7217 2174, or

Ordering of forms

28. Prisons that require additional supplies of form xf 001 should submit orders to
Corby Customer Liaison Team on 01536 274674.

29. The forms xf 001 can also be obtained from the intranet.
30 Templates for a Risk Minimisation Plan and for the Cell Sharing Risk
Assessment Review form are only available on the intranet on the Violence
Reduction Toolkit, and under forms. There will be no printed version

31 The use of Form xf 002 will cease. The cell sharing risk assessment review
form replaces it.


Peter Atherton
Deputy Director General.

Prisoner name Date of review Current risk rating

Low / Medium / High

Reason for review

Scheduled Revised assessment *see below

* Circumstances that may trigger a review of the initial assessment are for local judgement;
here are some examples;
Repeated or escalated threats of violence, particularly towards cellmates;
Discharge from segregation following violent or threatening behaviour;
Unexpected conviction or harsh sentence.
Evidence of arming with weapon
Assessment information
Has there been any new information to link the prisoner with violent

Yes No Brief details Based on the

information the
Has the prisoner displayed any homophobic or racist behaviour? risk of harming a
cell-mate is high
Brief details
Yes No

Has the prisoner displayed any anti-social behaviour, bullying, threats,

damage to property, aggression, hate-motivated behaviour, assaults?
Brief details
Yes No
Based on the
Is there a reason to suspect that the prisoner is abusing drugs/ alcohol information the
Brief details risk of harming a
Yes No cell-mate is
Does the prisoner have a history of self-harm?
Brief details
Yes No

Does the security department have any information that may affect the
risk assessment – eg evidence of weapon?
Brief details Based on the
Yes No
information the
Does the Health Care Team have any information that may affect the risk of harming a
risk assessment? cell-mate is low
Brief details
Yes No

Personal/ Wing Officer………………………………

Duty Manager/ Duty Governor Comment

Signature …………………………………….……. date………………

Outcome of review

The last plan is cancelled and normal location recommended

The plan dated ………………………still stands

A New Risk Minimisation Plan must be agreed within 7days

Copy to history sheet and wing file

copy to history
sheet & wing file


Date: Prisoner name number Significant / Increased


Details of those contributing to plan

Name Designation


Unit Manager
How does the prisoner feel about the situation?
Ask open questions; e.g. ‘Can you tell me what you think this is about?’ Explore the source of
the risk/ prejudice, what the prisoner thinks would trigger violence /how the prisoner thinks
he/she can learn to cope with his/her risky behaviour

Elements of Risk Minimisation Plan

Consideration may be given to the following: alcohol and drugs, mental illness/ distress, fears,
self-care, medication, social needs, custodial/legal problems, occupation, sentence plan, co-
Specific Need Action Required
Timing of review
e.g 1 month, 3months

NB Events would trigger review sooner E.g. adjudications, violent

behaviour, security information, anti-bullying logs,
conviction/change of status

Duty Manager/Duty Governor

Comments of Duty Manager/Duty Governor:

Signature: Date
Annex C

Provides information, support, guidance and legal advice to families
bereaved by death in custody on inquest procedures and basic rights in
coroners’ courts. Can also put families in touch with each other.
Comprehensive information booklet available. Helpline hours: 10.00 –
18.00, Monday – Friday.

Tel: 0207 263 1111

Address: INQUEST, 89-93 Fonthill Road, London, N4 3JH

Offering emotional support for people who are experiencing feelings of
distress or despair. Local branches can be visited or telephoned. See
local directory.

Helpline hours: 24 hours, Monday - Sunday.

National Helpline: 08457 90 90 90 (local rate)

Or write to: Samaritans at PO Box 90 90, Stirling, FK8 2SA uk


Provides support services for people who have been bereaved. The
Helpline offers listening support and practical advice related to
bereavement. Local (rate) numbers offering individual and group
Helpline hours: 09.30 – 17.00 Monday - Friday.

Tel: 0870 167 1677 (national rate)

Office: Cruse House, 126 Sheen Road, Richmond, Surrey,



Helpline and support services run by a self-help group for people
bereaved by suicide. The Helpline provides listening support and will put
people in touch with their nearest local group. There are monthly
meetings in various locations.
Helpline hours: 09.00 – 21.00 everyday.

National Helpline: 0870 2413 337 (national rate)

Welsh -phone: 01792 774646

Address: SOBS Centre 88, Saner Street,Hull, HU3 2TR

Bereavement support for children and their families.

National Helpline: 0845 20 30 205 (local rate)

Address: The Clara Burgess Centre, Gloucestershire

Royal Hospital, Great Western Road,
Gloucester, GL1 3NN


A Helpline and support service run by bereaved parents offering support
to parents and their immediate families after the death of a
child/children of any age and from any cause. Local contacts and support
meetings offered.
Helpline hours: 10.00 – 16.00 and 18.30 – 22.30 everyday.

National Helpline: 0117 953 9639 (national rate)

Address: 53 North Street, Bristol, BS3 1EN
Helpline and support for young people aged 12 – 18 following a
Helpline hours: 09.00 – 17.00 Monday – Friday.

Telephone Helpline: 0808 808 1766 (free phone)

Office: Cruse House, 126 Sheen Road, Richmond,

Surrey, TW9 1UR

Provides support to anyone bereaved by suicide.

Telephone Helpline: 01252 661002 (national rate)

Address: 139 Reading Road, Farnborough, Hampshire,

GU14 6NZ


One to one support offered.

Telephone Helpline: 01772 760662.




Offers counselling and support to individuals and families affected by

Post Traumatic Stress or Post Traumatic Stress Disorder.

Helpline 01788 560800

A dedicated counselling service to members of the Asian community.

Telephone: 020 8567 5616

Address: Asian Family Counselling Service 76 Church Road Hanwell London
W7 8LB


Emotional help and support to bereaved members of the Jewish
community throughout the UK.

Telephone: 020 8349 0839 or 020 8343 8989

Address; The Jewish Bereavement Counselling Service PO Box 6748
London N3 3BX


A help line for gay men and women who have been bereaved and family,
friends, colleagues and carers.

Telephone: 020 8455 8894

Address: Lesbian and gay Bereavement Project Vaughan M Williams
Centre Colindale Hospital London NW9 5GH



For information on counselling services in your area.

Telephone: 01788 550899

Address: The British Association for Counselling and Psychotherapy 1
Regent Place Rugby Warwickshire CV21 2PJ (Enclose SAE)