Recurring concern

Unreliable ACCT suicide and self-harm prevention processes

First to latest report 16 Sep 2013 — 29 Jun 2026

Reports that mention this concern
92
Times this concern has been raised
184
Stated actions linked to this concern
276

What this concern includes

Includes deficiencies in controls dedicated to the ACCT process, including quality assurance, observations, reviews, documentation, information sharing, staffing or training, where the failure undermines reliable ACCT risk prevention or management.

What is not included
  • Excludes generic organisational quality assurance, staffing or training failures that are not explicitly tied to ACCT.
  • Excludes unrelated prison, healthcare or mental-health processes that do not form part of ACCT.
  • Excludes outcomes, individual clinical judgments or underlying causes unless the assertion identifies a failure of an ACCT control.

Reports and published responses 92 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Johnpaul Digweed · 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

    Johnpaul Digweed died by suicide by hanging in his cell at HMP Garth between 17:06 on 12 April 2024 and 11:31 on 13 April 2024. The concerns included failures to open an ACCT process after incidents of self-harm, inadequate assurance about staff training and information-sharing, and welfare observations not being carried out in accordance with prison procedures, including when observation panels were obscured.

    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 maintain and monitor staff competence in opening an ACCT where required

    Wider context from the report

    “1. Evidence was heard that despite several staff being aware of incidents of self-harm involving a prisoner at HMP Garth an Assessment, Care in Custody Teamwork process (ACCT) was not opened. Whilst evidence was provided that staff are trained as part of their induction program and that training materials is available to staff, no assurance could be given that there was any ongoing mandatory refresher training or any system in place to monitor understanding that every member of staff is responsible for opening an ACCT where required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”

    Source location

    Johnpaul Digweed · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce daily mandatory knowledge-check sessions for operational and non-operational staff, recording attendance, completion and understanding to reinforce ACCT and welfare-check practice.

    Verbatim wording from the response

    “The prison have begun introducing daily knowledge check sessions for both operational and non-operational staff, and additional staffing resources are being secured to support the delivery of this initiative. Attendance and completion of the knowledge check sessions will be required and formally recorded, with staff providing written confirmation they have attended a session, and that the content is understood. A training log will be maintained by the prison’s Learning and Capabilities Team to monitor attendance and completion rates.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 3 September 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Secure additional staffing resources to support delivery of the daily knowledge-check sessions.

    Verbatim wording from the response

    “The prison have begun introducing daily knowledge check sessions for both operational and non-operational staff, and additional staffing resources are being secured to support the delivery of this initiative. Attendance and completion of the knowledge check sessions will be required and formally recorded, with staff providing written confirmation they have attended a session, and that the content is understood. A training log will be maintained by the prison’s Learning and Capabilities Team to monitor attendance and completion rates.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 3 September 2026

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    Alan Joseph Whelan · 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

    Alan Whelan, a serving prisoner at HMP Leeds, was moved to the Segregation Unit after starting a fire in his cell while on an open ACCT document. A required mental health assessment was not carried out within 24 hours, and he was later found hanging in his cell and died in hospital on 30 December 2024. Concerns included non-compliance with the mandatory assessment requirement and failures relating to the frequency of ACCT observations.

    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 provide a mental health assessment within 24 hours of transfer to the Segregation Unit for prisoners on an open ACCT document

    Wider context from the report

    “A mandatory requirement that a prisoner on an open ACCT document should have a mental health assessment within 24 hours of being transferred to the Segregation Unit was not complied with. Alan took steps that caused his death after that 24-hour window had closed. There was scant acknowledgement of this breach of a standing instruction from the witnesses who gave evidence to the inquest. The possibility that not carrying out such an assessment made no difference to the outcome is obvious. But that possibility neither explains nor excuses the failure to comply with the instruction, especially where it is unclear whether that failure was inadvertent or deliberate, and if deliberate, with what justification. ”

    Source location

    Alan Joseph Whelan · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the national mental health policy to require 24-hour mental health assessments for relevant ACCT prisoners placed in segregation.

    Verbatim wording from the response

    “PPG acknowledge that its policies do not contain an explicit requirement that matches PSO1700, i.e. that:”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Communicate the PSO1700 assessment requirement to regional managers and mental health leads, requesting consistent implementation across services.

    Verbatim wording from the response

    “In the meantime, communication has been sent to PPG’s HIJ regional managers and regional mental health leads highlighting the requirement within PSO1700 and requesting that this is consistently implemented across all of our services. The role of PPG’s regional managers and regional mental health leads is to implement, communicate and embed processes and ensure compliance with the same.”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with HMPPS nationally and locally to establish communications identifying ACCT patients moved to segregation.

    Verbatim wording from the response

    “In addition, PPG will be working with HMPPS both at site level and nationally to ensure effective communications are in place between the two organisations to make sure patients who are on ACCTs and then moved to segregation are identified,”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Obtain site-level confirmation that the communication was actioned and monitor compliance regionally through the mental health steering group.

    Verbatim wording from the response

    “Further, PPG has a mental health steering group, which meets quarterly, and is attended by all regional mental health leads, the National Mental Health & Psychosocial Lead, the Lead Psychiatrist and the Lead Psychologist. On the agenda at the next meeting, due to take place in July 2026, is obtaining confirmation that the aforementioned communication has been actioned at site levels and confirmation that compliance is being monitored at a regional level.”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the Take ACCTion audit to check compliance with PSO1700 and whether required mental health assessments occurred.

    Verbatim wording from the response

    “PPG already has a process in place, within its audit schedule, to audit ACCTs, which is called Take ACCTion. It is intended that the Take ACCTion audit will be updated to include whether there has been compliance with PSO1700, to check if a mental health assessment”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete the comprehensive review of the segregation policy.

    Verbatim wording from the response

    “A comprehensive review of the segregation policy is currently underway, with publication of the revised framework scheduled for later this year. As part of this work, the Segregation Policy Framework has been aligned with the Safety Policy Framework to reduce duplication, improve clarity and strengthen consistency across related provisions, including healthcare. Under the Safety Policy Framework an ACCT case review must take place within 24 hours of a prisoner being placed in segregation conditions. Healthcare and/or mental health staff are required to attend the initial case review. In exceptional circumstances, where attendance is”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Align the Segregation Policy Framework with the Safety Policy Framework to improve clarity and consistency, including healthcare provisions.

    Verbatim wording from the response

    “A comprehensive review of the segregation policy is currently underway, with publication of the revised framework scheduled for later this year. As part of this work, the Segregation Policy Framework has been aligned with the Safety Policy Framework to reduce duplication, improve clarity and strengthen consistency across related provisions, including healthcare. Under the Safety Policy Framework an ACCT case review must take place within 24 hours of a prisoner being placed in segregation conditions. Healthcare and/or mental health staff are required to attend the initial case review. In exceptional circumstances, where attendance is”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish the revised Segregation Policy Framework.

    Verbatim wording from the response

    “A comprehensive review of the segregation policy is currently underway, with publication of the revised framework scheduled for later this year. As part of this work, the Segregation Policy Framework has been aligned with the Safety Policy Framework to reduce duplication, improve clarity and strengthen consistency across related provisions, including healthcare. Under the Safety Policy Framework an ACCT case review must take place within 24 hours of a prisoner being placed in segregation conditions. Healthcare and/or mental health staff are required to attend the initial case review. In exceptional circumstances, where attendance is”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish supporting tools and learning resources for implementing the updated Segregation Policy Framework.

    Verbatim wording from the response

    “The updated Segregation Policy Framework will be published alongside a comprehensive suite of supporting tools and learning resources designed to support effective implementation within prisons and ensure staff are aware of the expectations. In addition, HMPPS will deliver a structured programme of scheduled briefing sessions, providing staff - including healthcare professionals- with the opportunity to familiarise themselves with the revised policy, and receive guidance on its application in practice.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver scheduled briefing sessions to familiarise staff, including healthcare professionals, with the revised policy and its application.

    Verbatim wording from the response

    “The updated Segregation Policy Framework will be published alongside a comprehensive suite of supporting tools and learning resources designed to support effective implementation within prisons and ensure staff are aware of the expectations. In addition, HMPPS will deliver a structured programme of scheduled briefing sessions, providing staff - including healthcare professionals- with the opportunity to familiarise themselves with the revised policy, and receive guidance on its application in practice.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The PS1700 requirement is an HMPPS policy outside PPG’s control, so PPG limits its response to healthcare matters.

    Verbatim wording from the response

    “Practice Plus Group (“PPG”) would like to clarify that the document PS1700, referred to in the Regulation 28 report dated 7 May 2026, is a HMPPS policy and is not under the control of PPG.”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Practice Plus Group is responsible for responding separately to concerns about mental health assessment requirements for prisoners in segregation under ACCT.

    Verbatim wording from the response

    “Following evidence heard at the inquest you raised a concern regarding the requirements for mental health assessments for prisoners held in segregation unit whilst being managed under ACCT procedures. I understand that Practice Plus Group will be responding to this matter separately.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 July 2026

    Open published response

  3. Inner North London

    AI-generated summary

    Rickie Wai Kee POON · 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

    Rickie Poon, a dismissed police officer detained under the Mental Health Act and later remanded in custody at HMP Pentonville, was found hanging in his cell one month after arriving at the prison. The jury found failures in the prison’s ACCT process contributed to his death, including inadequate management, accountability, training, implementation of actions and the early closure of the ACCT; concerns were also raised about inappropriate CPR after he had died.

    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

    Premature closure of ACCT processes

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    ACCT reviews lacking structure and consistency

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inappropriate reduction of ACCT observations

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 complete handovers between ACCT staff

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Expired ACCT training

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 of supervising officers to acquaint themselves with case notes or history when completing ACCT reviews

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inaccurate ACCT sign-offs

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 ACCT record keeping

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Automatically enrol newly promoted Senior Officers in national ACCT Case Review training.

    Verbatim wording from the response

    “Further to this work, all ACCT Case Coordinators have now completed refresher training delivered by the London Group Safety Team, which included one to one sessions, and have also received additional upskilling from the National Safety Support Team. All newly promoted Senior Officers are automatically enrolled onto the national Case Review training to ensure that those undertaking this important role receive timely training.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 10 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate a structured ACCT quality-assurance framework covering opening checks, targeted case-review sampling, ongoing review assurance and final documentation compliance checks.

    Verbatim wording from the response

    “The establishment has implemented a structured and robust ACCT Quality Assurance (QA) framework, designed to provide oversight across the full lifecycle of an ACCT, developed in line with national guidance and local risk appetite. The QA framework comprises four linked checks, providing end-to-end assurance, directly addressing the concerns you raise.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 10 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver continuous suicide and self-harm prevention training through the reintroduced Pentonville Speed School.

    Verbatim wording from the response

    “You will be aware that ACCT is the key tool by which staff manage and support those at risk of suicide or self-harm in custody. All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes the ACCT process. A continuous learning approach is taken, and locally, HMP Pentonville has re-introduced the “Pentonville Speed School”, which is an initiative that”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete refresher and additional upskilling for all ACCT Case Coordinators.

    Verbatim wording from the response

    “Further to this work, all ACCT Case Coordinators have now completed refresher training delivered by the London Group Safety Team, which included one to one sessions, and have also received additional upskilling from the National Safety Support Team. All newly promoted Senior Officers are automatically enrolled onto the national Case Review training to ensure that those undertaking this important role receive timely training.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 10 April 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.

    Verbatim wording from the response

    “We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisation.”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 10 April 2026

    Open published response

  4. Kent and Medway

    AI-generated summary

    Thomas Daniel RUGGIERO · 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

    Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing and died later that day following attempts at treatment and resuscitation. The principal concern was that healthcare or mental health team attendance at ACCT reviews was not consistently secured, creating an ongoing risk for vulnerable prisoners relying on those processes as a safety-net and protective factor.

    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 secure attendance of the mental health team at required ACCT reviews

    Wider context from the report

    “(1) There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews. In this case, there were numerous instances that this was not met. While I heard evidence of some improvement, it was accepted that there were ongoing issues with securing the attendance of the mental health team (where required) at ACCT reviews. I was insufficiently reassured that the matter has been addressed and I consider that there is ongoing risk to particularly vulnerable prisoners for whom the ACCT processes should act as a safety-net and protective factor. ”

    Source location

    Thomas Daniel RUGGIERO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise mental-health staffing rotas to provide skilled practitioners during peak ACCT review periods.

    Verbatim wording from the response

    “In December 2024, a review of the mental health staffing model at HMP Swaleside was undertaken to strengthen the service's capacity to consistently attend and contribute to ACCT reviews. This review identified gaps in aligning staff availability with periods of higher ACCT demand. In response, revised rota arrangements were introduced, ensuring that appropriately skilled mental health practitioners are available during peak activity times, particularly during core ACCT review periods. This adjustment has improved responsiveness, reduced delays in attendance, and supported more consistent multidisciplinary input into risk management planning.”

    Source location

    Response from Oxleas NHS FT
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Run a daily multidisciplinary safety huddle to review ACCT patients, prioritise reviews, escalate risks, allocate actions and share information.

    Verbatim wording from the response

    “In January 2025, a structured daily safety huddle was introduced at HMP Swaleside, providing a formal mechanism for real-time oversight and coordination of high-risk patients. The huddle is held each morning and is attended by key members of the multidisciplinary team, including mental health, primary care, substance misuse, and operational leads where required. During the huddle, the team reviews all patients subject to ACCT, as well as any other individuals identified as presenting an elevated or emerging risk. The daily huddle includes:”

    Source location

    Response from Oxleas NHS FT
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Circulate and embed the Kent ACCT Standard Operating Procedure through local induction and mandatory training, including exceptional non-attendance requirements.

    Verbatim wording from the response

    “In June 2025 the Kent ACCT Standard Operating Procedure was circulated and sets out clear guidance to all healthcare staff to reinforce expectations regarding attendance at ACCT reviews. This includes clarification of when mental health team involvement is required and the actions that must be taken if attendance cannot be achieved. The Standard Operating Procedure reiterates that a telephone or written contribution must be provided in exceptional circumstances when healthcare staff cannot attend. This updated guidance has been embedded within local induction processes and incorporated into mandatory training to support consistent understanding and application.”

    Source location

    Response from Oxleas NHS FT
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce an escalation and contingency process for missed healthcare attendance, including senior notification, alternative staffing, documentation and risk mitigation.

    Verbatim wording from the response

    “A formalised escalation and contingency process has been introduced to address occasions where healthcare attendance cannot be secured. This requires immediate notification to senior clinical leads, consideration of alternative appropriately qualified staff where feasible, and clear documentation of the rationale for non-attendance, alongside any mitigating actions taken to manage risk.”

    Source location

    Response from Oxleas NHS FT
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen forward planning for high-risk ACCT cases and monitor healthcare representation through daily operational meetings.

    Verbatim wording from the response

    “Multi-disciplinary working between healthcare and prison staff has been further strengthened through improved communication arrangements, particularly in relation to the scheduling of ACCT reviews. A daily tracker is circulated each evening by the prison safety team, clearly identifying individuals due for ACCT review the following day, which is then reinforced and actioned through the daily huddles. Any discrepancies are promptly identified and escalated to ensure timely resolution. Enhanced forward planning is now in place for high-risk individuals, and mental health representation at case reviews is actively monitored and supported through daily operational meetings.”

    Source location

    Response from Oxleas NHS FT
    Page 3 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit healthcare attendance at ACCT reviews and oversee compliance through clinical governance, PSIRF, risk-register and executive assurance arrangements.

    Verbatim wording from the response

    “Healthcare attendance at ACCT reviews is now subject to routine audit, with results reviewed through local clinical governance forums and within the Trust's Patient Safety Incident Response Framework (PSIRF) oversight structures. This is overseen by the head of healthcare and compliance is actively monitored, with any identified gaps followed up through targeted action plans. This area has also been incorporated into the Trust's risk register, with appropriate executive oversight in place.”

    Source location

    Response from Oxleas NHS FT
    Page 3 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Disseminate learning across offender healthcare through reflective practice sessions reinforcing healthcare input in ACCT processes.

    Verbatim wording from the response

    “Finally, learning from this case has been disseminated across the Offender healthcare directorate. Reflective practice sessions have been undertaken with clinical teams to reinforce the importance of healthcare input within ACCT processes. Ongoing monitoring arrangements are in place to ensure that these improvements are embedded and sustained overtime.”

    Source location

    Response from Oxleas NHS FT
    Page 3 · response
    Published 26 March 2026

    Open published response

  5. Kent and Medway

    AI-generated summary

    Thomas Daniel RUGGIERO · 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

    Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report identifies concerns about the emergency cell bell system, incomplete ACCT documentation, confusion over calling a “code blue”, and staffing, experience and communication at the prison, with risks to future prisoners remaining.

    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 complete ACCT care plan documentation

    Wider context from the report

    “(2) ACCT documentation and staff approach to this In Mr Ruggiero's case some ACCT documentation (his Care Plan) had not been completed. The jury found that this, "led to missed opportunities for all staff to understand Mr Ruggiero's triggers and other vital information in order to care for him" under the ACCT. I heard evidence that there are now additional systems in place in terms of an 'ACCT reassurance process'. However, during the course of the inquest two supervising prison officers gave evidence to the effect that they had the opportunity to complete Mr Ruggiero's care plan, should have done so, but still did not do it. On further exploration in the evidence, there appeared to be a view that some staff still did not see the value in the completion of such documentation. While there have been some steps taken that are aimed at reducing the risk, I am not sufficiently reassured that sufficient action has been taken. In my opinion, the attitude of some staff towards the value of such documentation remains a real and valid concern that continues place particularly vulnerable prisoners at risk. ”

    Source location

    Thomas Daniel RUGGIERO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide rolling weekly refresher training on the ACCT process to operational staff.

    Verbatim wording from the response

    “Your second concern relates to the completion and quality of ACCT documentation, particularly the ACCT Care Plan. I can confirm that the prison is providing rolling weekly refresher training on the ACCT process to operational staff. Additionally, to support staff in the comprehensive completion of ACCT documentation, two Safety Flowerwalkers have been introduced. As well as supporting staff in the completion of ACCT documents, the Safety Support Workers will identify areas of additional upskilling and training needs, feeding their findings back to the establishment Safety Team.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use two Safety Flowerwalkers to support ACCT documentation and identify staff upskilling and training needs for the Safety Team.

    Verbatim wording from the response

    “Your second concern relates to the completion and quality of ACCT documentation, particularly the ACCT Care Plan. I can confirm that the prison is providing rolling weekly refresher training on the ACCT process to operational staff. Additionally, to support staff in the comprehensive completion of ACCT documentation, two Safety Flowerwalkers have been introduced. As well as supporting staff in the completion of ACCT documents, the Safety Support Workers will identify areas of additional upskilling and training needs, feeding their findings back to the establishment Safety Team.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce scenario-based learning within local ACCT refresher training.

    Verbatim wording from the response

    “HMP Swaleside also plan to introduce scenario-based learning within the ongoing local ACCT refresher training with the aim of reinforcing the importance of the ACCT process, and to improve the overall quality of ACCT record keeping. Furthermore, ongoing partnership working with Oxleas NHS Foundation Trust will strengthen multidisciplinary care and planning for prisoners with complex needs.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue partnership working with Oxleas NHS Foundation Trust to strengthen multidisciplinary care and planning for prisoners with complex needs.

    Verbatim wording from the response

    “HMP Swaleside also plan to introduce scenario-based learning within the ongoing local ACCT refresher training with the aim of reinforcing the importance of the ACCT process, and to improve the overall quality of ACCT record keeping. Furthermore, ongoing partnership working with Oxleas NHS Foundation Trust will strengthen multidisciplinary care and planning for prisoners with complex needs.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Carry out monthly local ACCT quality audits, disseminate learning through staff briefings and meetings, and apply accountability measures where standards are unmet.

    Verbatim wording from the response

    “Monthly ACCT quality audits are now being carried out locally. Learning identified as part of this audit is disseminated through formal staff briefings and monthly meetings. Where standards are not being met individual accountability measures, including performance management action, will continue to be applied.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed the national ACCT quality-assurance process at HMP Swaleside and review all open ACCTs daily.

    Verbatim wording from the response

    “The national ACCT Quality Assurance (QA) process has been firmly embedded at HMP Swaleside, and all open ACCTs are reviewed daily by a Supervising Officer in line with HMPPS national QA guidelines.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

  6. Inner West London

    AI-generated summary

    Rajwinder Singh · 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

    Rajwinder Singh was imprisoned after being sentenced at Southwark Crown Court and was identified as at risk of self-harm and suicide. He was transferred to St George’s Hospital after failures including unanswered cell bells and inadequate observations, and died there on 25th June 2026. The principal concerns included inadequate risk assessment and record keeping, failures in observations and handovers, and insufficient mandatory ACCT training for prison and agency healthcare 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

    Lack of training in the principles of risk formulation during ACCT induction

    Wider context from the report

    “(3) When Prison Officers and/or Healthcare staff are given ACCT induction training at HMP Wandsworth, there is no training in the principles of risk formulation ”

    Source location

    Rajwinder Singh · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of mandatory ACCT refresher training for prison officers

    Wider context from the report

    “(1) There is no mandatory ACCT refresher training for prison officer at HMP Wandsworth; ”

    Source location

    Rajwinder Singh · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commission training modules examining self-harm and suicide risk formulation beyond the ACCT process.

    Verbatim wording from the response

    “Oxleas NHS Foundation Trust have recognised that the principles of risk formulation is vital when managing the ACCT process at HMP Wandsworth. We have commissioned a series of training modules to specifically focus on a deeper examination of the risk of self-harm and suicide in the prison population, beyond the ACCT process. Healthcare staff and prison officer colleagues have been invited to attend this non mandatory training.”

    Source location

    Response from Oxleas NHS
    Page 2 · response
    Published 23 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Facilitate a two-day Mindworks module developing risk-practice and risk-assessment skills for managing self-harm and suicide risk.

    Verbatim wording from the response

    “A further two-day module will be facilitated by Mindworks on March 5th and 6th and will use a variety of media including a full day of working with an actor to explore the skills required and the detailed practice of risk practice and risk assessment in the management of this vital area. It is planned that this training will form part of our future core training for all staff.”

    Source location

    Response from Oxleas NHS
    Page 2 · response
    Published 23 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Make risk-formulation training part of future core training for all staff.

    Verbatim wording from the response

    “A further two-day module will be facilitated by Mindworks on March 5th and 6th and will use a variety of media including a full day of working with an actor to explore the skills required and the detailed practice of risk practice and risk assessment in the management of this vital area. It is planned that this training will form part of our future core training for all staff.”

    Source location

    Response from Oxleas NHS
    Page 2 · response
    Published 23 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Appoint three dedicated safety floorwalker officers to oversee ACCT processes, coach assessors and deliver targeted refresher training.

    Verbatim wording from the response

    “Whilst HMPPS does not mandate how staff awareness and confidence in delivering ACCT should be maintained, HMP Wandsworth has appointed three dedicated safety floorwalker officers to strengthen oversight of ACCT processes and enhance support for individuals at risk of self-harm or suicide. Their role includes providing direct coaching to ACCT assessors and delivering targeted refresher training to staff to build confidence in key aspects of the process, including identifying risks, triggers and protective factors.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 23 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Extend ACCT process coaching and refresher training to non-operational colleagues, including healthcare staff.

    Verbatim wording from the response

    “Whilst HMPPS does not mandate how staff awareness and confidence in delivering ACCT should be maintained, HMP Wandsworth has appointed three dedicated safety floorwalker officers to strengthen oversight of ACCT processes and enhance support for individuals at risk of self-harm or suicide. Their role includes providing direct coaching to ACCT assessors and delivering targeted refresher training to staff to build confidence in key aspects of the process, including identifying risks, triggers and protective factors.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 23 February 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    HMPPS does not mandate how staff awareness and confidence in delivering ACCT should be maintained.

    Verbatim wording from the response

    “Whilst HMPPS does not mandate how staff awareness and confidence in delivering ACCT should be maintained, HMP Wandsworth has appointed three dedicated safety floorwalker officers to strengthen oversight of ACCT processes and enhance support for individuals at risk of self-harm or suicide. Their role includes providing direct coaching to ACCT assessors and delivering targeted refresher training to staff to build confidence in key aspects of the process, including identifying risks, triggers and protective factors.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 23 February 2026

    Open published response

  7. Worcestershire

    AI-generated summary

    Emmett Peter MORRISON · 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

    Emmett Peter Morrison, a serving prisoner at HMP Long Lartin, was found suspended by a ligature in his cell on 13 October 2024 and died from his injuries at hospital on 16 October 2024. The report raised concerns about the continued influx of illicit drugs into the prison and failures to record support actions in ACCT care plans and arrange a further ACCT review sooner.

    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 and implement support actions in ACCT care plans

    Wider context from the report

    “2) Failures in ACCT process Emmett was a prisoner with a considerable history of substance misuse and self-harm while in custody. Of the eight ACCT reviews which were conducted after Emmett's ACCT document was re-opened on 10.9.24, not one resulted in any support actions being entered onto the ACCT care plan. The ACCT care plan is a key part of the ACCT process, which requires those taking part in ACCT case reviews to set in train actions designed to reduce the prisoner’s risk of suicide or self-harm. As the guidance then in force made plain, it is a mandatory part of the ACCT process. The reasons given by staff who took part in these ACCT reviews for not having done this included: (i) being sure that they had talked about it, but had not noted anything down; (ii) thinking that, if EM didn’t attend an ACCT review, they couldn’t put any actions in place because that could only be done with his agreement; and (iii) they were so weighed down by the number of ACCT reviews which they had to carry out and the rest of their workload, that they simply had no time to complete this part of the review. Most worryingly, two of those witnesses who cited a heavy workload and pressures of work for Care Plans not being completed, made clear that not only this was commonplace at the time of these events but also that it is still an issue. Despite hearing evidence that measures have been put in place to train officers conducting ACCT reviews, and to conduct Quality Assurance checks on open ACCT documents, I was left with the clear impression that ACCT Care Plans are still being overlooked. I also note that as long ago as 2021 this court heard an inquest into the death of a prisoner at the same prison in 2018, following which I wrote a Prevention of Future Deaths report to the then Governing Governor of the prison, indicating my concern that ACCT Case Reviews for that prisoner had, on several occasions, failed to review or add actions to the ACCT Care Plan. It is therefore a concern that, 6 years on from that prisoner's death, the same issue arose in Emmett's case. As long as that remains the case, the lives of those vulnerable prisoners whom the ACCT process is designed to protect will continue to be put at risk. ”

    Source location

    Emmett Peter MORRISON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the Prison Safety Policy Framework requiring ACCT teams to identify, review and record support actions and care-plan decisions.

    Verbatim wording from the response

    “Regarding your concern about the ACCT process, the Prison Safety Policy Framework which was implemented on 1 January 2025, and superseded PSI 64/2011, requires that an ACCT case review team must set and review support actions to mitigate the risks identified. The ACCT Case Co-ordinator is expected to record the areas of risk discussed at a case review, update the Care Plan, including the support actions and note the rationale for the decisions of the case review team.”

    Source location

    2026-0071 - Response from Director General of Operations HMPPS
    Page 3 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce and complete four local ACCT quality-assurance checks covering opening, reviews, complex-case oversight and closure.

    Verbatim wording from the response

    “Since the death of Emmett Morrison, locally, the Quality Assurance processes have been updated, with four Quality Assurance checks introduced in line with the Prison Safety Policy Framework. These new checks are now completed at HMP Long Lartin as follows:”

    Source location

    2026-0071 - Response from Director General of Operations HMPPS
    Page 3 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor and upload ACCT assurance findings, sharing them for follow-up through case management and monthly Safety Meetings.

    Verbatim wording from the response

    “Findings from these assurance checks are shared with the case co-ordinator, line manager and Safer Custody Managers for further action where required. All Quality Assurance checks are monitored and uploaded onto a Quality Assurance analysis tool, with findings fed back at the monthly Safety Meeting for follow-up action where appropriate.”

    Source location

    2026-0071 - Response from Director General of Operations HMPPS
    Page 4 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a single ACCT case-management allocation system assigning open cases to trained Supervising Officers or Custodial Managers.

    Verbatim wording from the response

    “Additionally, since the death, the prison has implemented a new single case management allocation system. All open ACCTs are now assigned to a Supervising Officer or, for complex cases, a Custodial Manager. Only staff who have completed the required two-day ACCT case review team course can be allocated ACCTs or conduct reviews.”

    Source location

    2026-0071 - Response from Director General of Operations HMPPS
    Page 4 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Schedule ACCT reviews around allocated coordinators’ duties and use a buddy system to maintain continuity and prevent over-allocation.

    Verbatim wording from the response

    “As of 19 February 2026, the prison has 20 open ACCTs, each managed by an individual Case Co-ordinator. Reviews are scheduled for times when the allocated Case Co-ordinator is on duty, with others stepping in only in exceptional circumstances. A buddy system has also been introduced so a nominated colleague can cover tasks during absences, ensuring continuity of care and preventing over-allocation.”

    Source location

    2026-0071 - Response from Director General of Operations HMPPS
    Page 4 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Book refresher training for staff who misunderstood care-plan requirements when prisoners missed reviews.

    Verbatim wording from the response

    “Witnesses who believed they could not add Care Plan actions because the prisoner had not attended the review are being booked onto refresher training, and the prison has also prioritised Suicide and Self-Harm Awareness Training (SASH) on monthly lockdown training days.”

    Source location

    2026-0071 - Response from Director General of Operations HMPPS
    Page 4 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide one-to-one ACCT coaching to 21 Case Coordinators with support from Safety Leads.

    Verbatim wording from the response

    “In addition, National Safety Team colleagues provided one-to-one ACCT coaching to 21 Case Co-ordinators, supported by Safety Leads, in January 2026.”

    Source location

    2026-0071 - Response from Director General of Operations HMPPS
    Page 4 · response
    Published 12 February 2026

    Open published response

  8. Lancashire and Blackburn with Darwen

    AI-generated summary

    Aaron Lee Taylor · 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

    Aaron Lee Taylor was discovered in his prison cell on 28 August 2023, having died between the evening of 27 August and the morning of 28 August 2023. The inquest heard that he had taken steps intending to take his own life and identified multiple failures in measures to prevent self-harm and suicide, including inadequate assessments, documentation, policy compliance and mental health interventions.

    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

    Lack of ACCT training and awareness of ACCT responsibilities among prison officers

    Wider context from the report

    “(1) Evidence was heard that despite several prison officers being aware of a serious incident of self-harm involving a prisoner with a history of self-harm, an Assessment, Care in Custody Teamwork process (ACCT) was not opened. No evidence was provided confirming all prison officers were ACCT trained and/or were all aware of their responsibilities in relation to ACCT ”

    Source location

    Aaron Lee Taylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide all new entry officers with suicide and self-harm prevention training covering ACCT and changes in risks, triggers and protective factors.

    Verbatim wording from the response

    “I would like to assure you that HMPPS is committed to providing prison officers with the right support, training and tools to do their jobs. All new entry officers receive a full day of training on suicide and self-harm prevention during their prison officer training. This training includes modules on the ACCT process as well as understanding and managing changes to risks, triggers and protective factors. Following completion of the prison officer training, new entry officers also have a two week local induction before becoming fully operational. In addition to the classroom training, there is an online Safety Learning Reference Library holding various guidance, templates and training material that is accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT which staff can access at any time.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 11 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain an accessible online Safety Learning Reference Library, including ACCT guidance, templates and training materials, and promote it to HMP Garth staff.

    Verbatim wording from the response

    “I would like to assure you that HMPPS is committed to providing prison officers with the right support, training and tools to do their jobs. All new entry officers receive a full day of training on suicide and self-harm prevention during their prison officer training. This training includes modules on the ACCT process as well as understanding and managing changes to risks, triggers and protective factors. Following completion of the prison officer training, new entry officers also have a two week local induction before becoming fully operational. In addition to the classroom training, there is an online Safety Learning Reference Library holding various guidance, templates and training material that is accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT which staff can access at any time.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 11 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue HMP Garth staff instructions reiterating when and how to open ACCTs, who should open them, and how to complete ACCT records.

    Verbatim wording from the response

    “At HMP Garth a staff information notice has been issued promoting the Safety Learning Reference Library and a Governor’s order was issued to all staff in October 2025 reiterating the process on when and how an ACCT should be opened and by whom, and on how the ACCT record should be completed.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 11 November 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing ACCT training, induction and accessible guidance are considered sufficient to address concerns about staff suicide and self-harm prevention training.

    Verbatim wording from the response

    “I would like to assure you that HMPPS is committed to providing prison officers with the right support, training and tools to do their jobs. All new entry officers receive a full day of training on suicide and self-harm prevention during their prison officer training. This training includes modules on the ACCT process as well as understanding and managing changes to risks, triggers and protective factors. Following completion of the prison officer training, new entry officers also have a two week local induction before becoming fully operational. In addition to the classroom training, there is an online Safety Learning Reference Library holding various guidance, templates and training material that is accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT which staff can access at any time.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 11 November 2025

    Open published response

  9. Bedfordshire and Luton

    AI-generated summary

    Steven HART · 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

    Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

    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 escalate risk after incidents requiring review of observations or ligature controls

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”

    Source location

    Steven HART · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind staff and provide additional training and support on escalating incidents and conducting ACCT reviews when risk increases.

    Verbatim wording from the response

    “Staff have been reminded, and received additional training and support where necessary, on the importance of escalating incidents and ensuring that ACCT reviews take place when risk increases.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 3 October 2025

    Open published response

  10. Kent and Medway

    AI-generated summary

    Azroy Dawes-Clarke · 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

    Azroy Dawes-Clarke died in hospital on 10 November 2021 after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and treatment. The substantive concerns included inadequate communication and healthcare involvement, disproportionate and prolonged restraint, delays in recognising the arrest and starting CPR, unsuitable ligature-resistant materials, and gaps in staff training on ACCT procedures, first aid, basic life support, and the legal framework for medical emergencies.

    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

    Insufficient ACCT process training and competence among frontline and civilian staff

    Wider context from the report

    “(2) Officers involved in Mr Dawes-Clarke’s ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork. Capacity to provide training to frontline officers and other civilian staff within the prison appeared to be limited. ”

    Source location

    Azroy Dawes-Clarke · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue rolling out SASH, speed training and ACCT upskilling to improve staff recognition of suicide and self-harm risks and case management.

    Verbatim wording from the response

    “You raised that staff at inquest described different levels of familiarity and training in respect of the Assessment, Care in Custody and Teamwork (ACCT) process. HMP Elmley is committed to providing appropriate local training to upskill both operational and non-operational staff. This includes reinforcement of ACCT procedures through the ongoing rollout of Suicide and Self-Harm (SASH) training and “speed training” for bite-sized learning. Since Mr Dawes-Clarke’s death much work has been undertaken to help increase awareness and recognition of risk factors that increase the possibility of suicide and/or self-harm. A focus on continuing to upskill and support better case management as well as ACCT training for all staff working with prisoners is ongoing.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 30 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Attend ACCT case reviews to share experience and guidance with staff.

    Verbatim wording from the response

    “The quality of ACCT management and compliance with policy is routinely assured, as per the nationally mandated quality assurance process, and findings from this assurance is fed back to staff to enable ongoing awareness and improvement. Additionally, Elmley’s safety team have devised an action plan to support improving case management including ACCT upskill training, attending case reviews to share experience and guidance and developing an improved booking system to enable better multi-disciplinary attendance and consistency of case co-ordinators.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 30 July 2025

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026