20 Dec 2019 Tomasz Nowosad · Prevention of Future Deaths report Manchester City
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Concerns raised 7
Inconsistent use of interpretation services during healthcare interviews and ACCT reviews View source Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment View source Inadequate ACCT review during moves from safer cells to ordinary cells View source
Failure to review ACCT risk information and escalate concerns on arrival View source Failure to hand over relevant ACCT risk information to receiving colleagues View source Failure of receiving-wing staff to attend final ACCT case reviews before transfer View source Failure to make appropriate documentary records for ACCT transfers View source See 4 more concerns
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
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Tomasz Nowosad · 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
Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent use of interpretation services during healthcare interviews and ACCT reviews
Wider context from the report “5 4 It appears that there was no consistent use of the language line interpretation service by HMPS or GMMH staff , and it is suggested that wherever an identified need for the use of this service is recognised it should be used on all healthcare interviews as well as at ACCT reviews While some prisoners may speak some, little or virtually no English, it is essential that every effort is made to ensure that they can understand, so far as it possible, the issues being raised and discussed with them.
” Source location Tomasz Nowosad · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
Wider context from the report “5 1 The context of this case has to be seen in the light of the fact that in 2019 two self-inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above it is suggested that there has been a repeated theme in the majority of these cases that there was an over reliance and emphasis on the assumptions made by a prisoner that they “had no thoughts of self-harm or suicide” This is often simply recorded in ACCT reviews by ticking boxes on the review document . Whilst it is appropriate for this issue to be addressed whenever a prison is on an ACCT either by healthcare staff or at ACCT reviews because in many cases prisoners still go on to harm themselves or commit suicide It should not be regarded as definitive This was recognised and recorded in the latest PPO Investigation Report relating to a death that occurred on 5 April 2019
This was specifically referred to in paragraph 26 of the report which said “In previous investigation into self-inflicted deaths at Manchester, we identified weaknesses in the risk assessment of prisoners at risk of suicide and self-harm We found in particular that staff placed too much emphasis on prisoner’s presentation and did not give sufficient consideration to their risk factors”
” Source location Tomasz Nowosad · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate ACCT review during moves from safer cells to ordinary cells
Wider context from the report “5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH staff
” Source location Tomasz Nowosad · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review ACCT risk information and escalate concerns on arrival
Wider context from the report “5 9 It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide and how it has been managed to date and whether or not that needs to be reviewed on arrival Any concerns should be escalated
” Source location Tomasz Nowosad · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to hand over relevant ACCT risk information to receiving colleagues
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” Source location Tomasz Nowosad · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of receiving-wing staff to attend final ACCT case reviews before transfer
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” Source location Tomasz Nowosad · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make appropriate documentary records for ACCT transfers
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” Source location Tomasz Nowosad · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.
Verbatim wording from the response “A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020.” Source location 2019-0445-Response-from-HMPPS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.
Verbatim wording from the response “Second, interpretation services (5.4). You express concern about inconsistent use of such services by staff. A national contract with The Big Word ensures the availability of interpretation services across the prison estate. The new ACCT guidance will emphasise the importance of their use throughout the process, and the new ACCT form will include prompts to consider the use of the service at every significant point, including assessments and case reviews. In advance of the roll out of the new version of ACCT, the Governor of HMP Manchester has taken action to improve the use of the service at the prison, for example by making conference style telephones available for use at case reviews.” Source location 2019-0445-Response-from-HMPPS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redevelop ACCT training and deliver it to new staff and as refresher training for existing staff.
Verbatim wording from the response “The associated training packages are currently being redeveloped and will be delivered to all new staff through POEL training and made available as refresher training for existing staff. A specific session on the risks and triggers for self-harm and suicide will form a major part of this training.” Source location 2019-0445-Response-from-HMPPS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold and document ACCT case reviews before prisoner location moves, with receiving-location representation and transfer of relevant information.
Verbatim wording from the response “The new ACCT guidance is much clearer about the need to involve the prisoner in all decisions that are taken, including those concerning location. In advance of implementing the new system, it is now the practice at HMP Manchester for a case review to be held prior to any location move, including moves from healthcare to residential wings. These reviews are attended by a representative from the new location, providing an opportunity to discuss any concerns and issues relating to risk, including how a change to location and regime might affect risk. Notes of the review and any decisions made are recorded in both the ACCT document and in the NOMIS case notes. Where an enhanced assessment has been completed by the psychology department, this is also forwarded to the new location.” Source location 2019-0445-Response-from-HMPPS
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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 support is considered sufficient to manage acute risk in most cases without additional safer-cell provision.
Verbatim wording from the response “cells available to governors. At HMP Manchester there are currently fourteen safer cells. Ten are in the healthcare unit, five of which are equipped with CCTV. Four non-CCTV cells are around the prison healthcare electro-chronic doors. Whilst there are currently no plans to increase the number of safer cells, we will keep this under review.” Source location 2019-0445-Response-from-HMPPS
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Concerns raised 3
Failure to accurately record ACCT observations in the ACCT document View source Failure to carry out required ACCT observations for vulnerable prisoners View source Inadequate and insufficiently repeated ACCT training for prison officers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Daniel AKAM · 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
Daniel Akam, a vulnerable prisoner with a history of depression, self-harm, low mood and anxiety, was found unresponsive in his cell with a rope ligature around his neck and was declared deceased. The report identified concerns about an inadequate final ACCT review, missed and inaccurately recorded observations, and inadequate ACCT training for prison officers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately record ACCT observations in the ACCT document
Wider context from the report “Failure to carry out ACCT observations recorded in the ACCT log
(1) CCTV evidence in the inquest established that 18 observations on Mr Akam were not carried out.
(2) The same 18 missed observations were recorded in the ACCT document as having been carried out, when they had not been .
(3) Five different prison officers purportedly signed various of these entries .
(4) Whilst the above missed observations occurred 24 hours prior to Daniel Akam’s death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner. If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase.
(5) The fact that the five separate officers did not carry out observations, when they recorded that they did , indicates that the problem is systemic.
” Source location Daniel AKAM · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to carry out required ACCT observations for vulnerable prisoners
Wider context from the report “Failure to carry out ACCT observations recorded in the ACCT log
(1) CCTV evidence in the inquest established that 18 observations on Mr Akam were not carried out .
(2) The same 18 missed observations were recorded in the ACCT document as having been carried out, when they had not been.
(3) Five different prison officers purportedly signed various of these entries.
(4) Whilst the above missed observations occurred 24 hours prior to Daniel Akam’s death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner . If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase .
(5) The fact that the five separate officers did not carry out observations , when they recorded that they did, indicates that the problem is systemic.
” Source location Daniel AKAM · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate and insufficiently repeated ACCT training for prison officers
Wider context from the report “ACCT training for prison officers
(6) In addition, the evidence revealed that the prison officers did not appear to know what their own obligations and responsibilities were in relation to the ACCT procedure and processes . The general evidential picture was that of inadequate ACCT training for officers , who universally indicated that it would be helpful to have refresher training.
(7) Unless adequate and repeated ACCT training is provided for all officers, particularly for those junior and more inexperienced officers , the lives of vulnerable prisoners will not be safeguarded in accordance with the purpose of the ACCT procedure.
” Source location Daniel AKAM · Prevention of Future Deaths report
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19 Nov 2019 Shaun William Dewey · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure to highlight remand prisoners’ higher risk of self-harm or suicide on the ACCT document View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Shaun William Dewey · 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
Shaun William Dewey, a remand prisoner, was found hanging in his cell at HMP Bristol and died on 13 April 2018 after suspending himself from a ligature tied to the bed frame. The inquest identified anxiety, depression, separation from family, uncoordinated supervision, erratic medication use, and insufficient application of prison, healthcare and mental health systems as contributory factors. Concerns included whether remand prisoners’ higher risk of self-harm or suicide should be reflected in staff training, prisoner care, ACCT documentation and national guidance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to highlight remand prisoners’ higher risk of self-harm or suicide on the ACCT document
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Source location Shaun William Dewey · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and include a revised ACCT process in the new prison-safety policy framework, incorporating evaluation feedback before national rollout.
Verbatim wording from the response “During 2020 we will be replacing PSI 64/2011 with a policy framework on prison safety, and as part of this process the lists of risks and triggers will be reviewed and updated. We will ensure that the evidence about the risks posed by remand status, which you have drawn to my attention, is used to inform that work. The new policy framework will include a new version of the Assessment, Care in Custody and Teamwork (ACCT) process designed to make the system easier to operate and improve the quality of care offered to prisoners. The new version of the form and associated guidance were piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
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6 Nov 2019 Darren Barry WILLIAMS · Prevention of Future Deaths report Milton Keynes
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Concerns raised 2
Failure to take relevant information from previous ACCTs into consideration when opening a new ACCT View source Lack of Healthcare attendance at ACCT reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Darren Barry WILLIAMS · 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
Darren Williams was found hanging from a bed frame in his cell at HMP Woodhill on 4 January, and the inquest jury concluded that he took his own life. The report identifies failures in ACCT procedures, action planning, information sharing and the provision of support. Concerns included ACCT reviews taking place without Healthcare attendance and relevant information from previous ACCTs not being considered when new ACCTs were opened.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to take relevant information from previous ACCTs into consideration when opening a new ACCT
Wider context from the report “I have two concerns; firstly, it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance.
Secondly in this particular case there were four separate ACCT’s and it was apparent that not all relevant information available from previous ACCT’s was taken into consideration when a new ACCT was opened .
” Source location Darren Barry WILLIAMS · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of Healthcare attendance at ACCT reviews
Wider context from the report “I have two concerns; firstly, it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance .
Secondly in this particular case there were four separate ACCT’s and it was apparent that not all relevant information available from previous ACCT’s was taken into consideration when a new ACCT was opened.
” Source location Darren Barry WILLIAMS · Prevention of Future Deaths report
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30 Oct 2019 David John KIRSCH · Prevention of Future Deaths report Worcestershire
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Concerns raised 7
Failure to allocate a Case Manager to oversee ACCT documents View source Inadequate completion of Caremaps in ACCT documents View source Failure to ensure accountable sign-off of ACCT Caremaps View source
Failure to notify the designated Case Manager about ACCT documents View source Failure to escalate open ACCT documents in accordance with policy View source Lack of prison officer knowledge of ACCT reasons and monitoring issues View source Failure to conduct direct assessment of suicide and self-harm risk during ACCT reviews View source See 4 more concerns
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Each statement is shown once, even when linked to more than one concern.
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David John KIRSCH · 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
David John Kirsch was found deceased in his cell on 19 March 2018 after inflicting a large wound to his neck with the lid of a tin. The principal concerns were the lack of allocated case-manager oversight for his ACCT document, deficiencies in recording and addressing risks, failure to escalate the case, and inadequate staff knowledge and assessment of his suicide risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to allocate a Case Manager to oversee ACCT documents
Wider context from the report “(1) No Case Manager had been allocated to oversee Mr. Kirsch's ACCT document . This lack of oversight resulted in a number of deficiencies in the ACCT process, including:
(a) 11 different people chairing the 13 ACCT reviews which took place in the 6 weeks between Mr. Kirsch's return from hospital on 5.2.18 and his death on 19.3.18;
(b) Inadequate completion of the Caremap within the ACCT document, which ought to have highlighted the issues behind Mr. Kirsch's concerning behaviour and suicide attempts in January 2018, and identified actions to be taken to try to address those issues. In this case, evidence was heard that:
(i) When he had first started his sentence in 2008, Mr. Kirsch had told people that he would not live to complete it;
(ii) In August 2017 he had had two notable episodes of bizarre behaviour which, it was thought, may have been down to having taken the psychoactive substance Spice on those occasions;
(iii) Evidence from staff who had witnessed the suicide attempts in January 2018 indicated that they thought he may have taken Spice on those occasions;
(iv) Throughout 2017 and early 2018 he had been rather obsessed with a complaint he had made about an entry on his NOMIS record, and that in the days leading up to his death he had reported that this had been keeping him up at night;
(v) He was concerned that his daughter, who had become an adult relatively recently, had not tried to make contact with him;
(vi) He was worried about visits from his family, and how he was going to tell them what he had done in January 2018;
(vii) He had been involved in a fight on 13.3.18 with another prisoner (something out of character for him), which had resulted in his transfer to another wing, away from a fellow prisoner who was an important part of his support network;
(viii) He had recently sought out a member of the healthcare team in tears, because he was worried that he had not been able to get across his version of events in the adjudication hearing held after the fight incident;
(ix) On the afternoon of his death, two fellow prisoners had expressed concerns to a Supervising Officer that Mr. Kirsch was "looking particularly down" and was not himself. This conversation was passed on to the Supervising Officer on Mr. Kirsch's wing who spoke to him. In that conversation, Mr. Kirsch made a concerning comment about having bitten someone, and denied (untruthfully) that he had had any involvement with the mental health team at the prison. These concerns and conversations were not recorded anywhere in the main body of the ACCT document.
Save for the fact of the fight on 13.3.18 and of his resulting transfer to another wing, none of these matters was noted in the Caremap on Mr. Kirsch's ACCT document, and so no actions were identified to try to address them.
(c) The ACCT document was opened on 20.1.18. Between then and 5.2.18 Mr. Kirsch had been receiving treatment for his injuries in hospital, and had been on constant bedwatch there. When he returned to the prison on 5.2.18, no entries were made to the Caremap at all for the first four weeks thereafter.
” Source location David John KIRSCH · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate completion of Caremaps in ACCT documents
Wider context from the report “(1) No Case Manager had been allocated to oversee Mr. Kirsch's ACCT document. This lack of oversight resulted in a number of deficiencies in the ACCT process, including:
(a) 11 different people chairing the 13 ACCT reviews which took place in the 6 weeks between Mr. Kirsch's return from hospital on 5.2.18 and his death on 19.3.18;
(b) Inadequate completion of the Caremap within the ACCT document , which ought to have highlighted the issues behind Mr. Kirsch's concerning behaviour and suicide attempts in January 2018, and identified actions to be taken to try to address those issues. In this case, evidence was heard that:
(i) When he had first started his sentence in 2008, Mr. Kirsch had told people that he would not live to complete it;
(ii) In August 2017 he had had two notable episodes of bizarre behaviour which, it was thought, may have been down to having taken the psychoactive substance Spice on those occasions;
(iii) Evidence from staff who had witnessed the suicide attempts in January 2018 indicated that they thought he may have taken Spice on those occasions;
(iv) Throughout 2017 and early 2018 he had been rather obsessed with a complaint he had made about an entry on his NOMIS record, and that in the days leading up to his death he had reported that this had been keeping him up at night;
(v) He was concerned that his daughter, who had become an adult relatively recently, had not tried to make contact with him;
(vi) He was worried about visits from his family, and how he was going to tell them what he had done in January 2018;
(vii) He had been involved in a fight on 13.3.18 with another prisoner (something out of character for him), which had resulted in his transfer to another wing, away from a fellow prisoner who was an important part of his support network;
(viii) He had recently sought out a member of the healthcare team in tears, because he was worried that he had not been able to get across his version of events in the adjudication hearing held after the fight incident;
(ix) On the afternoon of his death, two fellow prisoners had expressed concerns to a Supervising Officer that Mr. Kirsch was "looking particularly down" and was not himself. This conversation was passed on to the Supervising Officer on Mr. Kirsch's wing who spoke to him. In that conversation, Mr. Kirsch made a concerning comment about having bitten someone, and denied (untruthfully) that he had had any involvement with the mental health team at the prison. These concerns and conversations were not recorded anywhere in the main body of the ACCT document.
Save for the fact of the fight on 13.3.18 and of his resulting transfer to another wing, none of these matters was noted in the Caremap on Mr. Kirsch's ACCT document, and so no actions were identified to try to address them .
(c) The ACCT document was opened on 20.1.18. Between then and 5.2.18 Mr. Kirsch had been receiving treatment for his injuries in hospital, and had been on constant bedwatch there. When he returned to the prison on 5.2.18, no entries were made to the Caremap at all for the first four weeks thereafter .
” Source location David John KIRSCH · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure accountable sign-off of ACCT Caremaps
Wider context from the report “(2) The person whose name had been entered as Case Manager on the ACCT document ████████ confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it. More worryingly, another unknown person appears to have signed off the first page of the Caremap using ████████ initials .
” Source location David John KIRSCH · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to notify the designated Case Manager about ACCT documents
Wider context from the report “(2) The person whose name had been entered as Case Manager on the ACCT document ████████ confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it . More worryingly, another unknown person appears to have signed off the first page of the Caremap using ████████ initials.
” Source location David John KIRSCH · Prevention of Future Deaths report
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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 open ACCT documents in accordance with policy
Wider context from the report “(3) Despite the ACCT document having been open for more than 6 weeks, it was not escalated to a more senior member of staff, as per prison policy .
” Source location David John KIRSCH · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of prison officer knowledge of ACCT reasons and monitoring issues
Wider context from the report “(4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document being opened, and of the issues set out therein which needed to be monitored . By way of example:
(a) the Supervising Officer on Mr. Kirsch's wing who had the conversation with him described at 1(b)(ix) above, was not aware that DK had attempted suicide twice in January 2018 , and had not realised that Mr. Kirsch was being untruthful about his involvement with the mental health team;
(b) another Supervising Officer who had conducted an earlier ACCT review on 8.2.18 also conceded in evidence that at the time he conducted the review he had "probably not" had any idea about the two suicide attempts the previous month .
” Source location David John KIRSCH · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct direct assessment of suicide and self-harm risk during ACCT reviews
Wider context from the report “(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self-harm . When asked how he had proposed to assess Mr. Kirsch's level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation .
” Source location David John KIRSCH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce revised national ACCT case-manager training covering case management, Caremaps and information sharing.
Verbatim wording from the response “Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.” Source location 2019-0362-Response-from-NOMS_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide prison-wide access to an online log identifying all open ACCT documents and their assigned case managers through daily briefings.
Verbatim wording from the response “An online log of all open ACCT documents, complete with details of the assigned case manager, is now accessible to all staff at the prison. This forms part of the daily briefing document shared with all staff. This prompts case managers to take ownership of their cases, as well as avoiding any confusion about who has been assigned each case.” Source location 2019-0362-Response-from-NOMS_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convene weekly multidisciplinary safety meetings to discuss complex cases and cases approaching six weeks for escalation or enhanced care planning.
Verbatim wording from the response “At Long Lartin, a weekly multi-disciplinary safety intervention meeting is convened where cases that are complex and/or require a higher level of input are now discussed. This provides an opportunity to discuss cases approaching the six-week point in order to identify a more senior member of staff to take over as case manager and/or to devise an enhanced care plan as appropriate.” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
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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 guidance on case management, Caremaps and information sharing to existing Long Lartin ACCT case managers.
Verbatim wording from the response “Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
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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 Review the ACCT process and devise a new version of the ACCT form and associated guidance.
Verbatim wording from the response “A number of the matters that you have raised are related to deficiencies in the implementation of the ACCT process that are not confined to this case or to Long Lartin. We are working hard to address these through the training described in the responses to the specific points. More generally, we have reviewed the ACCT process and devised a new version of the form and associated guidance. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
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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 Pilot the new ACCT form and associated guidance in ten establishments.
Verbatim wording from the response “A number of the matters that you have raised are related to deficiencies in the implementation of the ACCT process that are not confined to this case or to Long Lartin. We are working hard to address these through the training described in the responses to the specific points. More generally, we have reviewed the ACCT process and devised a new version of the form and associated guidance. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
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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 Roll out the new ACCT version across the prison estate.
Verbatim wording from the response “piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal evaluation report and expect to make some further changes before rolling out the new version of ACCT across the prison estate later in 2020. I am confident that this will bring further improvements to the work that staff do to keep prisoners safe.” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
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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 Investigate the apparent unauthorised use of case-manager details on an ACCT document and complete the investigation.
Verbatim wording from the response “A full investigation has been commissioned into the apparent appending of ████████ details on an ACCT document without his knowledge. This is scheduled for completion by the end of January 2020.” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
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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 Introduction to Suicide and Self Harm Prevention training to HMPPS staff with prisoner contact and offer it to partner and contractor staff.
Verbatim wording from the response “Introduction to Suicide and Self Harm Prevention (SASH) training is being delivered to all HMPPS staff with prisoner contact, and is also offered to staff of partners and contractors. The course is made up of six modules, including ‘Recognising Risks and Triggers’, ‘Opening ACCT Documents’, and ‘An Introduction to Mental Health Awareness’.” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
23 Jun 2019 Marcus William George McGuire · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Failure of managers to maintain or communicate accurate information about ACCT improvements View source Failure to provide an embedded single case manager for each ACCT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Marcus William George McGuire · 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
Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.
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 of managers to maintain or communicate accurate information about ACCT improvements
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points.
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager.
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager...”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” Source location Marcus William George McGuire · Prevention of Future Deaths report
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 provide an embedded single case manager for each ACCT
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points .
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager .
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager... ”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management ”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” Source location Marcus William George McGuire · Prevention of Future Deaths report
Open source report
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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 compliance with the single case manager model daily and review it at monthly Safer Custody meetings.
Verbatim wording from the response “Compliance with the single case manager model is being monitored daily, and is reviewed at the monthly Safer Custody meetings. All case managers have been given additional briefing about the importance of consistent delivery of it, and the safety team for the West Midlands Prison Group is providing support and additional assurance measures to ensure that the process is embedded.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
Open published response
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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 safety-team support and additional assurance measures to embed the single case manager process.
Verbatim wording from the response “Compliance with the single case manager model is being monitored daily, and is reviewed at the monthly Safer Custody meetings. All case managers have been given additional briefing about the importance of consistent delivery of it, and the safety team for the West Midlands Prison Group is providing support and additional assurance measures to ensure that the process is embedded.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
Open published response
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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 quality assurance checks for every ACCT document 72 hours after opening, weekly while open, and on closure.
Verbatim wording from the response “The prison has also introduced further quality assurance of every ACCT document, with checks taking place 72 hours after opening, weekly while open, and on closure. If these checks reveal evidence of a failure to comply with the national guidance contained in PSI 64/2011, the members of staff involved are provided with relevant feedback and questioned about their actions. If the non-compliance is serious and/or repeated, disciplinary action may follow.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
Open published response
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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 Train additional single case managers to reduce caseloads and improve attendance at prisoners’ case reviews.
Verbatim wording from the response “In accordance with Prison Service Instruction (PSI) 64/2011, HMP Birmingham operates a single case manager model, and consistency of case management continues to improve. There are ongoing operational challenges in delivering this model in every case but, since the inspection to which you refer, the prison has trained additional case managers and this means that each individual has a lower caseload and is more frequently able to attend their prisoners' case reviews.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
Open published response
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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 Brief all case managers on the importance of consistently delivering the single case manager model.
Verbatim wording from the response “Compliance with the single case manager model is being monitored daily, and is reviewed at the monthly Safer Custody meetings. All case managers have been given additional briefing about the importance of consistent delivery of it, and the safety team for the West Midlands Prison Group is providing support and additional assurance measures to ensure that the process is embedded.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
Open published response
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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 Decisions on actions at HMP Birmingham are outside G4S’s remit because HMPPS now operates and manages the prison.
Verbatim wording from the response “HM Area Coroner will be aware that HMP Birmingham is now operated and managed by HMPPS, ████████ being the current governing Governor. Any decisions in terms of actions to be taken at HMP Birmingham are not therefore within the remit of G4S.” Source location 2019-0209-Response-by-G4S
Open published response
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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 arrangements mitigate risks when the designated case manager cannot conduct a review, including substitute reviews and case transfers.
Verbatim wording from the response “harm or other notable event, and the person concerned is not on duty. When this occurs, another case manager thoroughly reviews the ACCT documentation and, wherever possible, speaks to members of staff who know the prisoner to enable them to understand the relevant risks prior to chairing the review. Similarly, if the case manager is going to be absent for an extended period then the case is transferred to a different case manager.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
Open published response
21 Jun 2019 Ryan Stephen TRIMMER · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1
Failure of the ACCT process to provide effective reviews View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ryan Stephen TRIMMER · 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
Ryan Trimmer was remanded to HMP Lewes on 4 March 2017, had a history of self-harm and suicide attempts, and was found hanging in his cell on 22 April; he died in hospital on 26 April 2017. The inquest identified inadequate ACCT reviews as a matter that caused or contributed to his death. The report also raised concerns about prison staff resourcing on the healthcare wing and the lack of first-aid training among some frontline staff.
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× 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 the ACCT process to provide effective reviews
Wider context from the report “The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews . The Court heard evidence of the ACCT Pilot Scheme underway in certain other prisons. HMP Lewes should be considered as a priority facility for future extension of the ACCT Pilot Scheme.
” Source location Ryan Stephen TRIMMER · Prevention of Future Deaths report
Open source report
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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 Evaluate the revised ACCT pilot to inform development of a new national process.
Verbatim wording from the response “I note the findings of the jury with regard to the operation of the ACCT process in this case, and it is good to know that you heard evidence about the pilot of the revised version of ACCT. This took place in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to roll out nationally in early 2020. In support of this roll out there will be a clear communication strategy, and support mechanisms will be in place to help embed the revised process within each site. It is too early to give a firm date for the new process to be introduced at HMP Lewes, but we have noted your view that this should be a priority.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
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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 Roll out the revised ACCT process nationally, supported by communications and site-level implementation support.
Verbatim wording from the response “I note the findings of the jury with regard to the operation of the ACCT process in this case, and it is good to know that you heard evidence about the pilot of the revised version of ACCT. This took place in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to roll out nationally in early 2020. In support of this roll out there will be a clear communication strategy, and support mechanisms will be in place to help embed the revised process within each site. It is too early to give a firm date for the new process to be introduced at HMP Lewes, but we have noted your view that this should be a priority.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
16 May 2019 Daniel Davey · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2
Failure to ensure healthcare attendance or input at ACCT reviews View source Inadequate advance notification and information sharing for ACCT reviews View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Davey · 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
Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.
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× 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 ensure healthcare attendance or input at ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews . This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available . The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive. It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer. For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” Source location Daniel Davey · Prevention of Future Deaths report
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 advance notification and information sharing for ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive . It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer . For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” Source location Daniel Davey · Prevention of Future Deaths report
Open source report
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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 Care UK and the prison to support healthcare attendance at ACCT reviews and maintain improved attendance processes.
Verbatim wording from the response “Response:
We continue to work with colleagues in Care UK and the prison to ensure we support attendance at ACCT reviews and maintain the improved processes. We comply with the Care UK Local Operating Policy for Healthcare and Subcontracted teams input into the ACCT process.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
Open published response
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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 Contribute to quality-assurance checks of compliance with the ACCT healthcare-input policy, including PROTECT audits.
Verbatim wording from the response “The Local Operating Procedure identifies there is an expectation that the staff attending the ACCT record this on SystmOne and future reviews are diarised for attendance.
We will actively contribute to quality assurance checks of compliance with this Local Operating Policy including those done as part of the PROTECT audits and are committed to improving our service delivery in response to any actions identified within these checks. In addition we will work with Care UK and the prison in the development of procedures for escalation should healthcare, for any reason, be unable to attend an ACCT review.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
Open published response
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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 Develop escalation procedures with Care UK and the prison for occasions when healthcare cannot attend an ACCT review.
Verbatim wording from the response “The Local Operating Procedure identifies there is an expectation that the staff attending the ACCT record this on SystmOne and future reviews are diarised for attendance.
We will actively contribute to quality assurance checks of compliance with this Local Operating Policy including those done as part of the PROTECT audits and are committed to improving our service delivery in response to any actions identified within these checks. In addition we will work with Care UK and the prison in the development of procedures for escalation should healthcare, for any reason, be unable to attend an ACCT review.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
Open published response
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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 daily healthcare attendance and electronic recording of ACCT reviews.
Verbatim wording from the response “In your report you highlighted “Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone).” This status continues to be supported by Care UK’s Local operating procedure (“LOP”) for “Healthcare attendance at ACCTs”. This LOP was reviewed and updated in February 2019 and ensures a member of healthcare staff is detailed daily to attend the day’s planned ACCT reviews. This member of staff can be contacted daily via radio from 08.00 until 17.00hrs. Any requests for healthcare attendance at new ACCTs opened throughout the day are communicated from the prison to the Healthcare Coordinator. All ACCT reviews are added to the SystmOne Ledger and appointments closed down on the system to demonstrate and record completion of the ACCT review.” Source location 2019-0267-Response-by-Care-UK
Open published response
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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 electronic quality assurance and spot checks to monitor healthcare attendance at ACCT reviews and escalate non-compliance.
Verbatim wording from the response “Care UK continues to work closely with the HMP Bullingdon Safer Custody department to improve partnership working throughout the management of the ACCT process. In order to ensure continued healthcare attendance to ACCT reviews a new electronic quality assurance process has been introduced. This is supported by Safer Custody staff spot checking compliance and escalating where necessary.” Source location 2019-0267-Response-by-Care-UK
Open published response
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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 new ACCT case-management process, including dedicated case managers, review booking oversight and daily healthcare attendance allocation.
Verbatim wording from the response “In June 2019, a new way of operating the ACCT case management system was implemented at Bullingdon, with a specific case manager being allocated to each ACCT case. This system allows ACCT reviews to be booked by the case managers on a spreadsheet that is overseen by the safer custody department. Reviews can be organised earlier through this booking system, giving healthcare better capability to ensure attendance at all reviews, and each day an identified member of healthcare staff is responsible for attending each review or allocating an attendee to go in their place. If there are any issues with healthcare attendance, case managers are asked to inform the safer custody department and remedial action is taken.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
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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 healthcare attendance at ACCT reviews through safer-custody spot checks pending implementation of electronic quality-assurance checks.
Verbatim wording from the response “New electronic quality assurance checks are to be introduced and embedded by the end of August 2019, and these will include checking healthcare attendance at reviews. In the meantime, the safer custody department is performing spot checks to monitor progress.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
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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 embed electronic quality-assurance checks covering healthcare attendance at ACCT reviews by the end of August 2019.
Verbatim wording from the response “New electronic quality assurance checks are to be introduced and embedded by the end of August 2019, and these will include checking healthcare attendance at reviews. In the meantime, the safer custody department is performing spot checks to monitor progress.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
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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 Evaluate the piloted revised ACCT form and guidance, incorporating healthcare expectations and learning from Mr Davey’s case.
Verbatim wording from the response “At national level we are working to improve the ACCT case management system and piloted a new version of the form and associated guidance in ten prisons during the spring of 2019. We realise the importance of the healthcare contribution to ACCT, and NHS England, and their Welsh equivalents, have been involved in this pilot project. The revised form and guidance are clearer about the expectations of healthcare staff. We are currently evaluating the pilot and plan to implement the new model nationally during 2020. We will ensure that the learning from this case is used to inform the development of the materials that are used to inform the national roll out of the new model.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
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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 revised ACCT form and guidance nationally during 2020.
Verbatim wording from the response “At national level we are working to improve the ACCT case management system and piloted a new version of the form and associated guidance in ten prisons during the spring of 2019. We realise the importance of the healthcare contribution to ACCT, and NHS England, and their Welsh equivalents, have been involved in this pilot project. The revised form and guidance are clearer about the expectations of healthcare staff. We are currently evaluating the pilot and plan to implement the new model nationally during 2020. We will ensure that the learning from this case is used to inform the development of the materials that are used to inform the national roll out of the new model.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
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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 guidance requiring ACCT case managers to discuss in-possession medication routinely and complete risk assessments with healthcare input.
Verbatim wording from the response “Your second concern relates to reviews of in possession medication risk assessments. I understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point. At Bullingdon, if the ACCT case manager is concerned about the immediate welfare of an individual they are required to conduct a review immediately, and to ensure that there is healthcare input to that review. The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until they can confirm that it is safe for the prisoner to continue to have it in their own possession.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
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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 to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Verbatim wording from the response “Response:
As was stated at the inquest, our prescriber’s always record on the prescription form whether the medication they are prescribing should be held in possession. We have reminded our staff to ensure when they are reviewing any medication that they, where necessary, include an update of the ‘Medication In possession risk assessment’ which goes onto SystmOne, which in turn will feed into the ACCT. This ensures that both dispensing staff and prison staff are aware of any changes and respond accordingly, this will include the removal of any medicines currently being held.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
Open published response
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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 existing ACCT attendance procedure and recording arrangements provide sufficient assurance of healthcare attendance and completion.
Verbatim wording from the response “In your report you highlighted “Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone).” This status continues to be supported by Care UK’s Local operating procedure (“LOP”) for “Healthcare attendance at ACCTs”. This LOP was reviewed and updated in February 2019 and ensures a member of healthcare staff is detailed daily to attend the day’s planned ACCT reviews. This member of staff can be contacted daily via radio from 08.00 until 17.00hrs. Any requests for healthcare attendance at new ACCTs opened throughout the day are communicated from the prison to the Healthcare Coordinator. All ACCT reviews are added to the SystmOne Ledger and appointments closed down on the system to demonstrate and record completion of the ACCT review.” Source location 2019-0267-Response-by-Care-UK
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27 Feb 2019 Kelvin Sean Speakman · Prevention of Future Deaths report Worcestershire
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Concerns raised 5
Failure to operate the ACCT process in accordance with national and local policies View source Inadequate ACCT documentation View source Inconsistent or undocumented communication between staff involved in ACCT decisions View source
Failure to rectify recurring ACCT process failings View source Absence or unclear identification of health care department input to ACCT reviews View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kelvin Sean Speakman · 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
Kelvin Sean Speakman was a serving prisoner at HMP Hewell with a long history of mental ill-health and extensive self-harm, including multiple attempts to hang himself. Following an incident of self-ligaturing, he suffered a hypoxic brain injury and died in hospital on 9 May 2016. The report identified shortcomings in the operation and documentation of the ACCT process, including inadequate healthcare input and inconsistent communication between 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 Failure to operate the ACCT process in accordance with national and local policies
Wider context from the report “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate.
The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified.
Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition.
Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken.
This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports).
In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned".
However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again.
Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated.
I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices.
(2)
(3)
” Source location Kelvin Sean Speakman · Prevention of Future Deaths report
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 documentation
Wider context from the report “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate .
The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified.
Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition.
Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken.
This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports).
In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned".
However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again.
Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated.
I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices.
(2)
(3)
” Source location Kelvin Sean Speakman · Prevention of Future Deaths report
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 Inconsistent or undocumented communication between staff involved in ACCT decisions
Wider context from the report “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate.
The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified.
Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition .
Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken.
This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports).
In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned".
However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again.
Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated.
I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices.
(2)
(3)
” Source location Kelvin Sean Speakman · Prevention of Future Deaths report
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 rectify recurring ACCT process failings
Wider context from the report “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate.
The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified.
Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition.
Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken.
This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports).
In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned".
However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again .
Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated .
I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices.
(2)
(3)
” Source location Kelvin Sean Speakman · Prevention of Future Deaths report
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 Absence or unclear identification of health care department input to ACCT reviews
Wider context from the report “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate.
The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified .
Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition.
Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken.
This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports).
In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned".
However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again.
Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated.
I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices.
(2)
(3)
” Source location Kelvin Sean Speakman · Prevention of Future Deaths report
Open source report
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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 ACCT coaching sessions for case managers, focusing on information sharing and accurate, comprehensive recording.
Verbatim wording from the response “In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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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 prison senior managers to improve adherence to the ACCT process.
Verbatim wording from the response “In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 senior leadership quality-assurance process with daily review of ACCT documents and associated healthcare attendance and action completion.
Verbatim wording from the response “Since January 2019, HMP Hewell has been operating a new quality assurance process. A member of the senior leadership team now carries out a daily review of all ACCT documents, making sure that they have been completed in accordance with instructions. They also check that healthcare staff attended first case reviews and that all necessary actions have been taken.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 Pilot and evaluate an updated ACCT case-management system.
Verbatim wording from the response “On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 Roll out the final revised ACCT case-management system nationally after evaluation.
Verbatim wording from the response “On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 Develop clearer national ACCT guidance covering decision recording and healthcare attendance at case reviews.
Verbatim wording from the response “On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 Roll out a quality-assurance tool alongside the updated ACCT document to assess compliance with the process.
Verbatim wording from the response “A new quality assurance tool is also being rolled out alongside the updated ACCT document, which assesses whether the process is being followed correctly.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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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 bi-monthly assurance checks of ACCT documentation.
Verbatim wording from the response “In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 written reminders requiring healthcare staff to attend, document, and record relevant risk information for ACCT case reviews.
Verbatim wording from the response “In terms of healthcare attendance at all first case reviews, in March 2019 all members of healthcare staff at the prison were reminded by way of a written staff briefing that they must attend all first ACCT case reviews, as well as any subsequent reviews when necessary, and must record their attendance clearly in the ACCT document and on their IT system. They must also record any information relevant to risk. In the event that healthcare staff are exceptionally unable to attend the first review, an ad hoc review will be held as soon as possible after the initial review in order that healthcare views can inform the management of the case. Staff have also been reminded about the HMPPS Learning Bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations), which was issued to all prisons in July 2018.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 a case-review document recording contributors, key conversations, and relevant events.
Verbatim wording from the response “On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
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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 the updated ACCT guidance available to all prison staff through the intranet.
Verbatim wording from the response “On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
Open published response
18 Dec 2018 John Anthony Delahaye · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to ensure healthcare attendance at ACCT reviews View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Anthony Delahaye · 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
John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.
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 ensure healthcare attendance at ACCT reviews
Wider context from the report “3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
” Source location John Anthony Delahaye · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a national learning bulletin reminding prison staff that ACCT reviews must be multidisciplinary, timely and supported by written contributions when attendance is impossible.
Verbatim wording from the response “In July 2018, HMPPS issued a Learning Bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations) to all prisons. The Bulletin reminded staff that ACCT review meetings must be multi-disciplinary and must take place within the specified timescales. It further stated that where any individual involved in the prisoner’s management cannot attend the review, they must submit written contributions.” Source location 2018-0388-Responses
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot an updated ACCT document and revised guidance requiring healthcare attendance at the first review and appropriate participation at subsequent reviews.
Verbatim wording from the response “Following a review of ACCT, we are currently in the process of piloting an updated ACCT document and revised guidance, which is clear that healthcare must attend the first case review, and is expected also to attend every subsequent review (and where this is not possible to provide a written contribution) in cases in which issues of physical or mental health have been identified as relevant. The pilot will run for a 4 month period from mid-February. It will be evaluated, and we hope to roll out the new procedure nationally in the autumn.” Source location 2018-0388-Responses
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Alert relevant staff daily to scheduled first ACCT reviews and quality-assure ACCT completion, required actions and healthcare attendance.
Verbatim wording from the response “In June 2018 all HMP Birmingham ACCT case managers and members of healthcare staff including those from the mental health team and integrated drug services, were reminded by way of a written staff briefing that they must attend all first ACCT case reviews, and any subsequent reviews where necessary. Since Mr Delahaye’s death, staff are now alerted at the Governing Governor’s daily staff meetings of the first ACCT case reviews which are scheduled for the day, and reminded of such by the communications room staff. In September 2018, the establishment set up a new quality assurance process by which members of the Safer Custody team check that all ACCT documents are completed in accordance with instructions and that all necessary actions have been taken.” Source location 2018-0388-Responses
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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.
