Concerns raised 1
Lack of clarity in PSI64/2011 guidance on first case review of an ACCT assessment View source
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
John Mayhew · 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 Mayhew died at HMP Durham on 15 January 2017 from self-inflicted hanging. He had a recent history of suicide attempts and made comments concerning potential self-harm or suicide after returning to custody, but the ACCT was closed at the initial case review without a care plan. The report raised concerns about the lack of involvement of the person who initiated the ACCT and the ambiguity of the relevant PSI 64/2011 attendance requirements.
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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 clarity in PSI64/2011 guidance on first case review of an ACCT assessment
Wider context from the report “(1) Clarification is needed as to how to construe the part of PSI64/2011 dealing with first case review of an ACCT assessment, in particular the proviso in the words “whenever possible” as to which type of potential attendee it might apply.
(2) Consideration should be given to re-drafting this part of the PSI.
(3) Consideration might thereafter, be given, as to providing guidance on how this part of the PSI, if modified, should be applied in practice by all staff in all prisons.
” Source location John Mayhew · Prevention of Future Deaths report
Open source report
19 Oct 2018 Robert Scott McLoughlin · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to conduct ACCT reviews during required periods View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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
Robert Scott McLoughlin · 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
Robert Scott McLoughlin, an inmate at HMP Leeds, was found suspended by a ligature on 20 February 2016 and died in hospital on 25 February 2016. The report raised concerns about very low staffing levels, including the absence of a Landing Officer, resulting in ACCT reviews not taking place for several hours.
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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 ACCT reviews during required periods
Wider context from the report “(1) The staffing levels at HMP Leeds were very low. On the evening of the 19th February 2016 when Mr McLoughlin self-harmed there was one Officer Support Grade on his wing. In addition there were only six Prison Officers on the night shift. On the morning of the 20th February 2016 the staffing levels were such that there was no Landing Officer on Mr McLoughlin’s landing. As a result ACCT reviews did not take place between approximately 0730 hours and 1340 hours .
” Source location Robert Scott McLoughlin · Prevention of Future Deaths report
Open source report
18 Dec 2017 MARK ANTHONY DOYLE · Prevention of Future Deaths report Inner North London
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Concerns raised 6
Failure to identify and record prisoner-specific trigger factors on ACCT records View source Failure to consider relevant ACCT file material when determining observation frequency View source Failure to involve prison staff who know the prisoner in ACCT reviews View source
Failure to share relevant healthcare information on prisoners’ ACCT records View source Failure to read recent risk-relevant ACCT daily record entries during case reviews View source Poor understanding of when to contact a prisoner’s family during ACCT reviews View source See 3 more concerns
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Care UK
Embed procedures for identifying and sharing relevant prisoner risks and triggers with prison staff, supported by senior-management audits.
View source
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AI-generated summary
MARK ANTHONY DOYLE · 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
Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing prison officers.
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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 identify and record prisoner-specific trigger factors on ACCT records
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover ;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Source location MARK ANTHONY DOYLE · 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 consider relevant ACCT file material when determining observation frequency
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file ;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Source location MARK ANTHONY DOYLE · 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 involve prison staff who know the prisoner in ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner ; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Source location MARK ANTHONY DOYLE · 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 share relevant healthcare information on prisoners’ ACCT records
Wider context from the report “(2) Although, ████████, Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared , in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record .
” Source location MARK ANTHONY DOYLE · 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 read recent risk-relevant ACCT daily record entries during case reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk ;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Source location MARK ANTHONY DOYLE · 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 Poor understanding of when to contact a prisoner’s family during ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood .
” Source location MARK ANTHONY DOYLE · 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 Embed procedures for identifying and sharing relevant prisoner risks and triggers with prison staff, supported by senior-management audits.
Verbatim wording from the response “Response: Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:–” Source location Response from Care UK
Open published response
18 Dec 2017 Stephen Mark SHAYLOR · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Intermittent night welfare checks and ACCT observations View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Care UK
Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.
View source
Care UK
Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
View source
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AI-generated summary
Stephen Mark SHAYLOR · 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
Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.
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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 Intermittent night welfare checks and ACCT observations
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming.
” Source location Stephen Mark SHAYLOR · 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 Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.
Verbatim wording from the response “Night welfare checks are carried out by Health Care Assistants (HCAs). At the start of the night shift, the nurse and HCA will print off the relevant welfare check list which will show all new additions made that day, as well as those prisoners who are already on the list. HCAs will then use that list and the printed template to assist them in conducting checks overnight. A copy of the template used was provided under cover of my first letter.” Source location 2017-0380-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 Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
Verbatim wording from the response “3. The ACCT process is a prison process and is operated and owned by HMPPS using prison documentation. To that extent, the overview and monitoring of the ACCT process does not sit with the healthcare team. However, any member of staff working at the prison can open an ACCT if they identify risks. Healthcare staff from the SMS, primary health or mental health team will attend ACCT reviews and record this on SystmOne. Therefore, these health care staff are responsible for contributing their knowledge regarding any risk factors which may include issues pertaining to substance misuse or detox. In my previous letter I had intended to underline that the use of the night welfare check has never been intended to replace ACCT documentation. This is simply because there are many prisoners suffering from substance withdrawal who would not require an ACCT; i.e.” Source location 2017-0380-Response-by-Care-UK
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 HMPPS owns and operates the ACCT process; healthcare staff contribute risk information but do not oversee or monitor it.
Verbatim wording from the response “3. The ACCT process is a prison process and is operated and owned by HMPPS using prison documentation. To that extent, the overview and monitoring of the ACCT process does not sit with the healthcare team. However, any member of staff working at the prison can open an ACCT if they identify risks. Healthcare staff from the SMS, primary health or mental health team will attend ACCT reviews and record this on SystmOne. Therefore, these health care staff are responsible for contributing their knowledge regarding any risk factors which may include issues pertaining to substance misuse or detox. In my previous letter I had intended to underline that the use of the night welfare check has never been intended to replace ACCT documentation. This is simply because there are many prisoners suffering from substance withdrawal who would not require an ACCT; i.e.” Source location 2017-0380-Response-by-Care-UK
Open published response
19 Oct 2017 Sean Patrick Plumstead · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 1
Failure to provide ACCT training to all relevant prison staff View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sean Patrick Plumstead · 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
Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.
Read the report on judiciary.uk
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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 provide ACCT training to all relevant prison staff
Wider context from the report “1. ACCT Training
I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017.
In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training ; at the date the evidence was given 61% of staff had received ACCT training ; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training .
Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows:
• As at September 2016 77.29% of forward- facing prison service staff
• As at September 2016 64.27% of all prison service staff
• As at September 2017 72% of forward- facing prison service staff
• As at September 2017 57% of prison service staff were “in date” with such training.
The evidence was that the current aim is to achieve the 80% target by mid 2018.
It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing. This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact.
” Source location Sean Patrick Plumstead · 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 SASH suicide and self-harm prevention training to new prisoner-facing staff and roll out refresher training to existing staff.
Verbatim wording from the response “The Introduction to Safer Custody course to which this refers was replaced by the Introduction to Suicide and Self-Harm Prevention course, known as SASH, in May 2017. Like its predecessor courses, the SASH course is being delivered to all new prison officers as part of their entry level training, and to all new staff in other prisoner-facing roles. It has also been developed in modular form so that it can be delivered as refresher training to existing staff.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 staff as SASH trainers to increase capacity for course delivery.
Verbatim wording from the response “The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Refresher-training figures do not mean prisoner-facing staff have never been trained or are deployed unable to recognise suicide and self-harm risk.
Verbatim wording from the response “Crucially, this does not mean that untrained staff who are unable to recognise prisoners at risk are being deployed in the prison. The training targets relate to the completion of the local refresher training. So, whilst the figures that you quote show a temporary reduction in the proportion of staff who are “in date” in terms of the local requirement to have undertaken such training within the last three years, this does not mean that there are staff in prisoner-facing roles who have never been trained. Moreover, the refresher training that the staff are now undertaking is much more extensive, and contains more detailed information about risk, than the ACCT training that was previously available. For this reason I am confident that the changes that have been made to the training programme will have the effect of improving staff awareness and capacity to identify and address risk.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Refresher-training completion was delayed because the longer course, resourcing challenges and limited availability of qualified trainers constrained delivery.
Verbatim wording from the response “The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Open published response
11 Oct 2017 Mark Daniel VAGNONI · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1
Inability to carry out risk assessments with mental health input during patrol state View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
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AI-generated summary
Mark Daniel VAGNONI · 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
Mark Daniel Vagnoni, who had paranoid schizophrenia and was on remand at HM Prison Bedford, was found hanging in his cell on 11 July 2016 and died two days later. Concerns included the arrangements for risk assessment and observation after an ACCT was opened, the accessibility of information about previous ACCTs in NOMIS, and the lack of Wing Transfer documentation containing relevant risk information.
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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 Inability to carry out risk assessments with mental health input during patrol state
Wider context from the report “1. The ACCT was opened during patrol state. The first review was planned the following morning. Apart from 30 minute observations and the information on NOMIS (which was scant) there was no ability to carry out a risk assessment with mental health input. It seems to me that prisoners are especially vulnerable during this patrol state period and greater observations and/or other strategies should be undertaken until the first review can take place.
” Source location Mark Daniel VAGNONI · Prevention of Future Deaths report
Open source report
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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 Risk-based ACCT observation levels already account for increased night-state risk when full review and mental-health input are unavailable.
Verbatim wording from the response “Prison Service Instruction 64/2011 Safer Custody states that the level of ACCT observations needs to be set on the basis of a consideration of the level of risk, and with particular regard to any factors which may increase risk, and this would include an inability to undertake a full ACCT case review with mental health input during the night state. National policy also states that observation levels must be clearly documented on the front cover of the ACCT document, with observations made at unpredictable times.” Source location 2017-0286-Response-by-HM-Prison-Probation-Service
Open published response
13 Sep 2017 Sam MOLYNEUX · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to place prisoners at risk of suicide or self-harm on an ACCT View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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
Sam MOLYNEUX · 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
Sam Molyneux, a prisoner at HMP Liverpool, was found hanging from a ligature in his cell on 1 April 2016 and was pronounced dead at 22:55. The inquest identified a failure to open an ACCT, concerns about the response to assaults and possible bullying, and a delay in accessing him because the cell door could be barricaded.
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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 place prisoners at risk of suicide or self-harm on an ACCT
Wider context from the report “During the course of the inquest it became apparent that in old prisons not all wings have been adapted to have anti-barricade doors. In this case Mr Molyneux had barricaded his door and this delayed prison staff gaining access to him during a Code Blue Situation. He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death . Local directions in the Prison during the inquest have addressed this situation in HMP Liverpool at Walton. That said HM Prison and Probation service might wish to consider amending “Management of Prisoners at risk of harm to self, to others and from others (Safer Custody)” to include consideration of where reasonably practicable avoiding locating prisoners behind a door which is not designed to circumvent barricading.
” Source location Sam MOLYNEUX · Prevention of Future Deaths report
Open source report
28 Jul 2017 SARAH LYNNE REED · Prevention of Future Deaths report London (City)
View report summary
Concerns raised 2
Failure of ACCT Review team members to fully review the ACCT document View source Failure to conduct ACCT reviews on a multidisciplinary basis View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
SARAH LYNNE REED · 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
Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.
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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 ACCT Review team members to fully review the ACCT document
Wider context from the report “(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision .
” Source location SARAH LYNNE REED · 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 ACCT reviews on a multidisciplinary basis
Wider context from the report “(8) The jury also found that the above decision was not multi-disciplinary , which it should have been (as the senior Governor conceded in evidence).
” Source location SARAH LYNNE REED · 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 Redesign the ACCT document for nationwide reintroduction, including consideration of a summary sheet of observations and conversations.
Verbatim wording from the response “The ACCT document is currently being redesigned with a view to its nationwide re-introduction in early 2018. As part of this redesign, we will consider your suggestion that a summary sheet of ACCT observations and conversations be included.” Source location 2017-0208-Response-by-NOMS
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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 learning bulletins reinforcing multidisciplinary ACCT reviews, required timescales, written contributions and prompt recording of observations.
Verbatim wording from the response “delaying simply to allow a specific person to attend or contribute, it makes clear that there must be continuity of membership of the ACCT multidisciplinary team. The basis for this is that team members can make a meaningful contribution only if they are fully briefed and familiar with the prisoner’s situation. In order to reinforce this message, a learning bulletin (ACCT - Case Reviews, CAREMAPS and Levels of Conversations and Observations) was issued to all prisons in July this year. The bulletin reminded staff that ACCT review meetings must be multidisciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner’s management cannot attend the review, they must submit written contributions.” Source location 2017-0208-Response-by-NOMS
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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 ACCT policy permits reviews and necessary decisions to proceed without waiting for a particular attendee, while requiring multidisciplinary continuity.
Verbatim wording from the response “Whilst national policy acknowledges that in certain circumstances it may be preferable to hold a review and make any necessary decisions promptly, rather than” Source location 2017-0208-Response-by-NOMS
Open published response
7 Jun 2017 Callum Oliver SMITH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2
Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment View source Inadequate training of healthcare/mental healthcare staff on the ACCT process View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Inspire Better Health
Deliver the rolling SASH programme, mandate existing healthcare staff attendance, and provide new starters with training within six months.
View source
Inspire Better Health
Incorporate an ACCT overview into the induction process for new staff, including documented acknowledgement of understanding.
View source
Inspire Better Health
Reinforce SASH requirements through monthly team meetings using bite-sized ACCT-opening scenarios and discussion.
View source
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AI-generated summary
Callum Oliver SMITH · 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
Callum Oliver SMITH was in the care of HMP Bristol when he was found hanging in his cell and died from hanging. The inquest concluded that his death was caused by suicide while he was suffering extreme anxiety and distress. Concerns included inadequate risk assessment and mental health assessment, poor communication and record-sharing, and repeated failures to open an ACCT due to training and staff-understanding issues.
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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 healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment
Wider context from the report “1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011.
2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011.
3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide.
4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff.
” Source location Callum Oliver SMITH · 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 training of healthcare/mental healthcare staff on the ACCT process
Wider context from the report “1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011.
2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011.
3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide.
4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff.
” Source location Callum Oliver SMITH · 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 the rolling SASH programme, mandate existing healthcare staff attendance, and provide new starters with training within six months.
Verbatim wording from the response “All healthcare staff will therefore revisit the PSI through Suicide and Self Harm (SASH) training and local training/meetings.” Source location 2017-0185-Response-by-Prison-Health-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 Incorporate an ACCT overview into the induction process for new staff, including documented acknowledgement of understanding.
Verbatim wording from the response “ACCT overview to be incorporated into new staff induction process.” Source location 2017-0185-Response-by-Prison-Health-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 Reinforce SASH requirements through monthly team meetings using bite-sized ACCT-opening scenarios and discussion.
Verbatim wording from the response “SASH training requirements to be at reinforced monthly team meetings.” Source location 2017-0185-Response-by-Prison-Health-Services
Open published response
28 Mar 2017 John WILLIAMS · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure of prison officers to understand ACCT contents View source Failure to review and record events in the ACCT document View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring 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
John 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
John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.
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 prison officers to understand ACCT contents
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover .
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within. Again, It appears there may be benefit in additional training and/or supervision.
” Source location John WILLIAMS · 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 review and record events in the ACCT document
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover.
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within . Again, It appears there may be benefit in additional training and/or supervision.
” Source location John WILLIAMS · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.