HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service, in collaboration with the Association of Ambulance Chief Executives, reviews and amends the design of the medical emergency response card, to better support staff in identifying emergency situations and providing the situational information required by ambulance service call handlers. In scenarios where direct communication between staff at the scene and the ambulance service emergency centre call handlers is not possible, this will ensure that the control room receives and can provide sufficient information to the call handlers to triage the situation.
HM Prison and Probation Service is grateful for this feedback on the medical emergency response cards that we provide for our staff.
In partnership with the Association of Ambulance Chief Executives we have reviewed the design of the medical emergency response cards. We will now arrange for revised cards to be printed and distributed.
We will do this alongside the introduction of new guidance for control room staff which will equip them to ask staff at the scene for the information that they require to respond to the triage questions that are asked by ambulance service call handlers. This will be supported by the provision of revised posters for control rooms to provide a visual reminder of the triage questions. We will introduce a regular audit check to ensure that these posters remain visible to control room staff.
We will also be exploring whether and how we can include an assessment of the effectiveness of the response to medical emergencies in future safety audits.
We recently issued a new training video on ‘Responding to emergency situations’ designed to help staff to understand what they need to do in a medical emergency, including when they find a prisoner who has ligatured. The video shows a member of staff calling a code blue and following up by giving the control room relevant information about the condition of the prisoner and explains that this information is required so that ambulance control can arrange the appropriate response. The video has been viewed over 2,000 times on the HMPPS intranet and is also available on the ‘My Learning’ platform which can be accessed by staff from partner organisations and contracted prisons.
Actions planned to deliver safety recommendation:
- Review design of medical emergency response cards. By: Completed.
- Print and distribute revised cards. By: 31 March 2025.
- Issue guidance to control room staff. By: 31 January 2025.
- Print and distribute revised posters. By 31 March 2025.
- Introduce audit check on control room posters. By: 31 March 2025.
- Explore the inclusion of the response to medical emergencies in future safety audits. By: 31 March 2025.
Response received on 3 December 2024.
HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service enhances the existing training delivered to prison officers, to increase their ability to identify medical emergencies that require 999 calls to be made by prisons, thereby reducing the number of calls and diverted ambulances and easing the burden on the emergency care system. The training should be delivered on a recurrent basis.
HM Prison and Probation Service is committed to equipping staff to respond appropriately when they encounter a medical emergency.
All new Foundation Prison Officers are now required to complete Emergency First Aid at Work as part of the Foundation Course.
We recently issued a new training video on ‘Responding to emergency situations’ designed to help staff to understand what they need to do in a medical emergency, including when they find a prisoner who has ligatured. The video has been viewed over 2,000 times on the HMPPS intranet and is also available on the ‘My Learning’ platform which can be accessed by staff from partner organisations and contracted prisons.
We have worked with St John Ambulance to produce five training films for staff who are first on scene. These are available on the ‘My Learning’ platform, which can also be accessed by staff from partner organisations and contracted prisons.
The films have been sent to Governors and Directors who have been informed that it would be advantageous for all Prison Officers and other front line staff to view them and for them to be used to supplement annual refresher training for emergency first aiders.
We are committed to updating the films to include the same content as the redesigned medical emergency response cards, which identifies to staff the information they will need to share with the control room about the condition of the prisoner.
Actions planned to deliver safety recommendation:
- Launch first on scene training films. By: Completed.
- Update the films to include the content from the redesigned medical emergency response cards. By: 31 March 2025.
Response received on 3 December 2024.
HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service reviews and implements changes to current communication methods between staff at the scene of an incident and the ambulance service call centre. This is to ensure that situational information about the patient is passed directly from the scene to the call handlers, meaning faster and more accurate triage and categorisation of the emergency response.
HM Prison and Probation Service is very aware of the communication challenge presented by medical emergencies in prisons, where mobile phones are not available to facilitate direct contact between staff at the scene and ambulance control.
We have considered including the facilitation of direct communication to ambulance control amongst the requirements for our reprocurement of prison radios. However, our reprocurement is initially focused on support for the existing hardware and infrastructure, and is unlikely to deliver new radios to prisons until 2029, so this is not an option that could facilitate improvements in the short or medium term. Moreover the project team has not been able to identify a suitable system that would facilitate direct communication with ambulance control, and it has therefore been decided that this will not be within the scope of the project.
We will conduct a review to consider how to improve communication between the incident scene and ambulance control within the confines of the current policy and technology. The review will include workshops involving operational staff and partners, including the Association of Ambulance Chief Executives.
Actions planned to deliver safety recommendation:
- Consider prison radios as an option for direct communication to ambulance control. By: Completed.
- Arrange workshops involving operational staff and partners. By: 31 March 2025.
- Complete review of communications between incident scene and ambulance control. By: 30 June 2025.
Response received on 3 December 2024.
Association of Ambulance Chief Executives
HSSIB recommends that the Association of Ambulance Chief Executives, in collaboration with HM Prison and Probation Service, sets up formal communication routes, at both national and regional levels, between prison and ambulance services to escalate concerns, review risks and improve systems for emergency care response and ensure continuous improvement of the service.
Since receiving the HSSIB report, representatives from the Association of Ambulance Chief Executives (AACE) have worked in close co-operation with counterparts in His Majesty’s Prisons and Probation Service (HMPPS) to agree actions to address all four of the safety recommendations outlined in the report.
Specifically in relation to this action assigned to us we have agreed through our National Directors of Operations Group (NDOG) that ambulance service Operations Directors (or Chief Operating Officers) will be the lead point of contact for regional communications with prisons. We have agreed with HMPPS that Prison Group Directors (PGDs) are the appropriate regional counterpart and we will be mapping prison regions onto ambulance regions and establishing connections between Operations Directors and PGDs.
At a national level we will formalise the existing relationships between HMPPS and AACE to offer a national channel for regional colleagues to escalate issues and conversely for national issues to be cascaded to regional teams.
We expect that these arrangements will build on existing local relationships that may exist between individual prisons and individual ambulance services and that the overlaying of regional and national channels will strengthen those relationships and encourage greater consistency.
We will document these arrangements in a brief, simple partnership agreement and cascade to colleagues in the prisons and ambulance environment in order to improve communications at all levels
Actions planned to deliver safety recommendation:
- Agree regional and national points of contact for ambulance services. By: November 2024. Other dependencies identified: Corresponding agreement of HMPPS points of contact. Additional comments: Complete.
- Agree regional and national points of contact for HMPPS. By: November 2024. Other dependencies identified: Internal approval required.
- Develop simple partnership agreement. By: January 2025. Other dependencies identified: Internal approval required from AACE and HMPPS.
- Cascade partnership agreement. By: February 2025.
Response received on 27 November 2024.
HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released from court. This will reduce variation and ensure better continuity of care for patients when being transferred or on their release.
HM Prison and Probation Service (HMPPS) is grateful for this feedback on the Prison Service Order 3050 Continuity of Healthcare for Prisoners.
We are working with health partners, including NHS England (NHSE), The Welsh Government, OHID, Association of Directors of Adult Social Services (ADASS) and the Association of Ambulance Chief Executives (AACE) to improve access to health and social care services for people who encounter and move through the criminal justice system. This includes at court, in the community, in custody and returning to the community.
A multi-agency Continuity of Care Steering Group has been considering the changes necessary to PSO3050 and agreement reached to extend the remit of the current policy to include people under probation supervision and pre and post custody transitions. The Steering Group oversaw 10 workshops between October 2023 and April 2024 involving a range of internal and external stakeholders. The policy will include an agreed definition for Continuity of Care for those in touch with HMPPS services, mandatory actions, as well as supporting guidance and a chapter specific to continuity of care for women.
The policy will cover requirements in relation to transition points from court, community, custody and back to the community, including unplanned releases, including via court appearances. It will strengthen existing guidance in relation to information sharing between prison and healthcare services at transition points, including transfer between prisons and on release. Additionally, the policy will reference the partnership working required to support NHS pre and post release services and reinforce the expectation that prison and healthcare staff follow required pre-release processes designed to support Continuity of Care.
The detailed findings in the report will further inform the development of the revised Continuity of Care policy.
Actions planned to deliver safety recommendation:
- Establish a Steering Group to review PSO3050 identifying updated practices and instructions to include those on probation and update to a Policy Framework. By when: completed. Organisational lead: HMPPS Health & Social Care Team. Resources in place: Identified leads in place.
- Draft new policy framework considering Steering Group advice, instruction and direction. By when: April 2025. Organisational lead: HMPPS Health & Social Care Team. Resources in place: Identified leads in place.
- Consult draft with internal and external partners and stakeholders. By when: August 2025. Organisational lead: HMPPS Health & Social Care Team. Resources in place: Identified leads in place.
- Submit policy to HMPPS governance gateway. By when: November 2025. Organisational lead: HMPPS Health & Social Care Team. Resources in place: Identified leads in place.
- Publish and promote policy framework. By when: March 2026. Organisational lead: HMPPS Health & Social Care Team. Resources in place: Identified leads in place.
Response received on 21 February 2025.
HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood of patients refusing to attend healthcare appointments, while balancing appointment availability, thus improving the continuity and equality of care.
A comprehensive review of escort provision, including longer term hospital admissions is currently being jointly undertaken between HMPPS and NHSE (and Wales). A priority of the review is to improve prisoner / patient access to health services, considering demand and understanding how this is influenced by factors such as age or gender. This work will also consider how to optimise appointment times, factoring in prison regimes, the timings of clinics, and the geographical proximity of health facilities.
Separate work is underway to improve standardisation of resource allocation across the estate across a range of service areas including escort provision, in the longer term this work will support greater consistency of provision. The review recognises the need to reduce demand through improved access to (and uptake of) telephone and video consultations, and telemedicine services, drawing on best practice from across the health sector and beyond.
Actions planned to deliver safety recommendation:
- Model actual demand for outpatient escorts. By when: February 2026. Organisational lead: Head of Workforce Modelling. Resources in place to deliver actions: Joint working arrangements between HMPPS and NHSE, with identified leads from each department. Other dependencies identified: Access to anonymised patient data. Qualitative research and analysis. Other data sets.
- Improve access to (and uptake of) telemedicine. By when: February 2026. Organisational lead: Head of Workforce Modelling. Resources in place to deliver actions: Joint working arrangements between HMPPS and NHSE, with identified leads from each department. Other dependencies identified: Qualitative research and analysis. Secondary Care engagement.
- Preventative action (recommendations). By when: February 2026. Organisational lead: Head of Workforce Modelling. Resources in place to deliver actions: Joint working arrangements between HMPPS and NHSE, including the Health & Wellbeing team. Other dependencies identified: Qualitative research and analysis. Sufficient evidence supporting ‘what works’ to consider whether the need for medical appointments might be reduced, through tackling the root causes of poor health and the use of Social Prescribing.
- Escorts - Workforce Delivery Model. By when: April 2026. Organisational lead: Workforce Delivery Project Senior Lead. Resources in place to deliver actions: Limited project team. Other dependencies identified: Assurance and testing of all WDMs, including affordability.
Response received on 21 February 2025.
NHS England
HSSIB recommends that NHS England, via regional commissioning teams, works with HM Prison and Probation Service to identify barriers to using telemedicine for outpatient appointments, and then implements local solutions to promote and enhance the capability and usability of telemedicine. This aims to reduce the burden on prisons of providing escorts and the likelihood of patients not attending appointments.
NHS England is committed to continuing to identify opportunities to create equal and improved access and reduce barriers to telemedicine adoption for all patients.
A great deal of work has been undertaken to identify the barriers to using telemedicine for outpatient appointments within the Secure and Detained Estate (SDE). This includes engagement with NHS providers and prison senior managers led by the NHS England South East regional team and the subsequent development of guidance to address implementation challenges. NHS England will continue to build on this work and remain engaged with His Majesty’s Prison and Probation Service (HMPPS) to further scale and spread adoption and good practice.
NHS England will update all existing implementation materials for using telemedicine in the SDE, these have already been developed and trialled in the NHS England South East region.
We will also ensure this includes clear guidance on best practice when transferring responsibility for patients from the SDE between NHS trusts, to ensure the receiving trust can take required action immediately. The guidance will make clear to healthcare teams that a patient’s position on the waiting list should not be affected. It will also make clear that this transfer of care should be communicated to the patient in an accessible format.
NHS England has produced a detailed remote consultation toolkit to support remote consultation implementation and improvement. The toolkit will be updated to include specific actions for using remote consultations in the SDE.
The use of telemedicine in the SDE is more suitable for some specialties and pathways, NHS England’s Outpatients Technology Enabled Improvement team will work with national clinical leads and analytics teams to identify the areas in which telemedicine would be most appropriate and impactful. This will be reflected in our updated guidance and resources. Once the guidance and the toolkit have been updated, national communications will be shared to ensure NHS trusts are aware of and have access to the resources. The resources will also be shared directly with Health and Justice regional commissioners for onward sharing with all relevant stakeholders, including healthcare providers in the SDE and NHS acute and community providers.
NHS England’s Health and Justice team, including regional commissioners will lead work and engage other national and regional colleagues to continue to support local NHS providers to improve their relationships with local SDE healthcare teams. Encouraging them to establish formal arrangements to improve remote appointment bookings and other key processes. This will include the creation of local directories of services, so NHS trusts can understand the capabilities, staffing and suitable timings to schedule remote appointments for patients in the SDE they are responsible for.
Actions planned to deliver safety recommendation:
- Update the existing implementation guidance. This will include:
Standard Operating Procedure (SOP)
Implementation checklist
Implementation flowchart
HMP Healthcare chaperone on the day processes flowchart
Prison activity data - Metrics script
Patient information leaflet and consent form
Patient questionnaire.
We will ensure documents are updated with key information such as guidance on the transfer of care when patients are moving between trusts, by January 2026.
2. Work with national clinical leaders and analytic teams to identify the specialties and pathways that are most suitable for telemedicine in the SDE and reflect this in relevant national resources, by January 2026.
3. Share all updated guidance with regional Health and Justice commissioners to circulate with SDE healthcare provider leads, by January 2026.
4. Share national communications to promote updated resources and showcase existing good practice, by April 2026.
5. Support formal arrangements between the SDE and their local hospitals, creating local directories of services, by April 2026.
6. Provide learning and advice to trusts about best practice about the transfer of care for patients moving between trust locations, to prevent waiting times from being negatively impacted, by April 2026.
Response received on 24 July 2025.
Department of Health and Social Care |
NHS England
HSSIB recommends that NHS England/Department of Health and Social Care ensures that the General Medical Services registration process, for patients in prison, is designed using informed consent principles, providing patients sufficient time, advice and support to understand what registration means for them. This is to ensure patients are making informed decisions about their healthcare provision, therefore improving patient safety.
We agree with this recommendation. NHS England and DHSC recognise the importance of supporting patients in prison to make fully informed choices about their healthcare registration. Following a review of current policy options and operational dependencies, we propose the following actions and indicative timeframes.
Actions planned to deliver safety recommendation:
- Initial scoping review completed, with engagement of healthcare providers, clinicians, and patient representatives to understand current challenges, by Mid 2026. Resources in place: Existing policy and commissioning teams including NECS and support from prison healthcare providers. Other dependencies identified: Coordination with DHSC, HMPPS, and digital registration systems. Additional comments: This review will inform future policy development and operational changes.
- Updated guidance issued, supported by the development of staff training resources on informed consent, by late 2026/27. Resources in place: Policy and clinical teams. NECS and collaboration with DHSC and HMPPS. Other dependencies identified: Dependent on completion of scoping review and stakeholder input. Additional comments: Guidance will reflect best practice and legal standards.
- Evaluation of implementation and patient feedback to ensure consistency across the estate, by 2028. Resources in place: Policy and commissioning teams. Other dependencies identified: Requires integration with future policy cycles and operational planning. Additional comments: Findings will inform future updates to guidance and training.
Our long-term aspiration is to establish a fully consistent, patient- centered registration process in every prison, ensuring that informed consent is embedded as a principle of care.
Response received on 20 October 2025.
Department of Health and Social Care |
NHS England
HSSIB recommends that NHS England/Department of Health and Social Care, working with healthcare service providers and their healthcare teams at prisons which hold remand prisoners, reviews and amends the process for GMS registration of patients on remand.
This is to ensure a consistent approach to GMS registration across the prison estate, which acknowledges the potential negative impact short-term changes in care provision may have on the continuity of care for patients who have been remanded in custody.
We agree with this recommendation. We recognise the unique challenges associated with the remand population, where frequent transfers and shorter stays often disrupt continuity of care. We recognise the need for a consistent and patient-centred approach to registration for remand prisoners.
Actions planned to deliver safety recommendation:
- Conduct targeted review of GMS registration processes for remand populations in collaboration with healthcare providers and patient representatives, by early 2026. Resources in place: Policy and commissioning teams. Legal team Input from remand-holding establishments. Other dependencies identified: Coordination with DHSC, HMPPS, and prison healthcare teams. Additional comments: Review will focus on unique needs and challenges of remand populations.
- Explore the best way to enable functionality that would provide access to the full Electronic Patient Record through technical changes or access to other digital products, by 2026/27. Resources in place: GPIT programme teams; collaboration with digital teams and prison healthcare providers. Other dependencies identified: Dependent on digital infrastructure, interoperability standards, and stakeholder engagement HMPPS – sentencing review. Additional comments: Aims to improve continuity of care and reduce administrative burden for short-term prisoners.
- Undertake a consultation process with professional bodies, prison healthcare teams, and patient representatives to explore the Scottish model of mandatory registration after six months, by end 2026. Resources in place: Policy and commissioning teams. Legal oversight support from DHSC and external stakeholders. Other dependencies identified: Regulatory implications; technical enablers; alignment with existing NHS registration frameworks. Additional comments: Primary Care team to assist with coordination and stakeholder engagement.
- Continue development of a digital pathway for pre-release registration to support continuity of care post-release, by end 2026. Resources in place: Online Registration Team, NHS England (Primary Care to assist). Other dependencies identified: Digital development teams; collaboration with prison healthcare and commissioning teams. Additional comments: Integration with prison release planning systems and NHS registration platforms.
- Consider the technical requirements and possibilities for temporary care information following release to be held in the National Data Repository, by end 2026. Resources in place: Digital architecture and data governance teams; support from Primary Care. Other dependencies identified: Dependent on national data strategy, IG compliance, and system capabilities. Additional comments: Exploration will inform future data integration and continuity of care improvements.
The long-term ambition is to reduce disruption to patient care and ensure that GMS registration processes for remand prisoners are consistent, equitable, and support seamless continuity of treatment.
Response received on 20 October 2025.
HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service ensures that the development of the Digital Prison Services system includes interoperability with healthcare IT systems. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing of staff, patients and other prisoners, is available at the point of need.
HM Prison and Probation Service (HMPPS) is grateful for this feedback on the Healthcare provision in prisons: data sharing and IT report.
Thank you for the recommendation regarding the integration of healthcare information systems with the Digital Prison Services system. We fully recognise the importance of ensuring that relevant information, where appropriate and lawful, is available at the point of need to support the safety and wellbeing of those in custody.
HMPPS has already developed and deployed the External Integration Application Programming Interface (API), a strategic digital service that enables secure, real-time data sharing with third parties to access prison data. This aligns with our standard practice of de-coupled integration, where each organisation retains responsibility for its own systems and data flows. The ongoing development of this platform is being designed with interoperability in mind and could, in future, support two-way data exchange, subject to appropriate governance and safeguards. A bid for funding in the current spending review to continue development of the API was made. However, allocation decisions are yet to be confirmed.
To fully realise the benefits of integration with NHS systems, NHSE will need to develop and maintain the necessary infrastructure to support integration. Further development of the HMPPS API may also be required to support specific integration needs, which would be subject to SR funding allocations. This approach ensures that both partners contribute to a sustainable and secure integration model.
We are committed to working with NHSE to deliver digital interoperability. While the technical, governance and financial implications of interoperability are being explored we are working with NHSE and their providers to maximise the benefits of the DPS system roll out, for example we are supporting establishments to exploit the functionality for healthcare appointment booking and attendance monitoring to drive improvements in prisoner attendance at healthcare activities.
We remain committed to improving interoperability and welcome continued collaboration to ensure shared goals around safety and wellbeing are met.
Actions planned to carry out safety recommendation:
- Facilitate initial engagement with health partners, by Q4 2025. Resources in place: Limited internal capacity. Other dependencies identified: Dependent on funding and delivery capacity. Additional comments: HMPPS is committed to ongoing discussions with NHSE to explore integration possibilities and mutual capabilities.
- Initiate discovery work for two-way data sharing, by Q1 2026. Resources in place: Limited internal capacity. Other dependencies identified: Early scoping only; dependent on funding and delivery capacity. Additional comments: Explore technical and governance requirements to allow data exchange between the systems (NHSE and HMPPS).
- Explore alternative approaches to data sharing, Q2 2026. Resources in place: Limited internal capacity. Other dependencies identified: Dependent on HMPPS delivery capacity and NHSE integration Infrastructure. Additional comments: Enable access to relevant existing data to support safety and wellbeing, within legal and governance frameworks.
Response received on 22 October 2025.
Department of Health and Social Care |
NHS England
HSSIB recommends that NHS England/Department of Health and Social Care includes within its healthcare IT procurement system specification the need to support interoperability between the operational prison IT systems and any future prison healthcare IT system. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing of staff, patients and other prisoners, is available at the point of need
We agree with this recommendation. Work to embed interoperability requirements has already been completed and is included within the healthcare IT procurement roadmap.
Actions planned to deliver safety recommendation:
- Work in partnership with HMPPS to align priorities for interoperability with the Digital Prison System, by end 2026. Resources in place: Joint working groups; digital strategy and infrastructure teams from NHS England and HMPPS. Other dependencies identified: Dependent on HMPPS digital roadmap and NHS system capabilities. Additional comments: Alignment will support seamless data sharing and continuity of care.
- Engage suppliers (if new supplier procured) and design system specifications that reflect interoperability requirements as standard, by end 2026. Resources in place: Procurement and digital architecture teams; supplier engagement processes. Other dependencies identified: Dependent on procurement outcomes and alignment with NHS and HMPPS digital strategies. Additional comments: Specification will embed interoperability as a core requirement to support continuity of care.
- Incorporate interoperability as a contractual requirement in any future system procurement, by end 2026. Resources in place: Procurement frameworks; legal and technical advisory support. Other dependencies identified: Dependent on procurement timelines and supplier engagement outcomes. Additional comments: Will ensure interoperability is embedded from the outset to support continuity of care and data sharing.
- Deliver a modern, integrated digital system across the detained estate. Resources in place: National digital infrastructure programmes; collaboration with HMPPS and NHS stakeholders. Other dependencies identified: Dependent on funding, procurement, and interoperability alignment. Additional comments: System will support continuity of care, data sharing, and patient safety across the estate.
The long-term aspiration is to reduce duplication, improve data quality, and strengthen both operational and clinical decision-making through modern, connected digital systems.
Response received on 20 October 2026.
HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service, in collaboration with the Department of Health and Social Care, formalises arrangements for alerting healthcare commissioners and providers to changes in prison populations likely to impact on healthcare provision requirements. This is to ensure that healthcare commissioners and providers can plan for changes to healthcare services that are necessary to meet the changing needs of the prison population.
Department of Health and Social Care
HSSIB recommends that the Department of Health and Social Care works with local authorities to redesign how the health and social care needs of prisons’ populations are assessed. This is to ensure that appropriate services are commissioned to meet the needs of people in prison and prevent possible delays in care.
HM Prison and Probation Service
HSSIB recommends that HM Prison and Probation Service reviews and amends its information gathering processes for accommodation requirements for wheelchair users and people with mobility issues, to identify and mitigate risks for people whose accommodation does not meet their needs. This is to enable and support the effective identification of appropriate prison accommodation for these groups.