21 Feb 2017 JACK OLIVER PORTLAND · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 3
Inadequate communication with families during the ACCT process View source Insufficient detail in ACCT caremaps and post-closure reviews View source Delays in completing ACCT post-closure reviews View source
This report raised 13 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. 4
Woodhill Prison
Develop the family pathway during the May/June 2017 policy review to support active family involvement wherever possible.
View source
Woodhill Prison
Undertake further Case Manager work using local examples and contributions from families and prisoners to promote family involvement.
View source
Woodhill Prison
Implement weekly wing-manager and monthly Duty Governor quality checks of ACCT and post-closure reviews, including caremap assessment and corrective feedback.
View source
Woodhill Prison
Complete Safer Prisons post-closure checks using a quality-assurance template to verify timescales, caremap actions and closure-questionnaire invitations.
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AI-generated summary
JACK OLIVER PORTLAND · 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
Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.
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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 communication with families during the ACCT process
Wider context from the report “(2) The standard letter notifying a family of the opening of an ACCT was non-specific and dependent upon prisoner consent , yet it was identified that the engagement of families in the ACCT process was important, particularly in the context of risk assessment . It appeared that the same letter is still in use, directing families to telephone extensions for prison staff and healthcare or a 24-hour help line. The family evidence was that communication with the prison in response to a letter received during the first ACCT was of significant concern and that they were not notified of the second ACCT. There was evidence suggesting that the helpline is now attended regularly and messages dealt with but the overall communication paths appear to remain the same .
” Source location JACK OLIVER PORTLAND · 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 Insufficient detail in ACCT caremaps and post-closure reviews
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review , late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” Source location JACK OLIVER PORTLAND · 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 Delays in completing ACCT post-closure reviews
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review , communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” Source location JACK OLIVER PORTLAND · Prevention of Future Deaths 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 Develop the family pathway during the May/June 2017 policy review to support active family involvement wherever possible.
Verbatim wording from the response “During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.” Source location 2017-0049-Response-by-NOMS
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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 Undertake further Case Manager work using local examples and contributions from families and prisoners to promote family involvement.
Verbatim wording from the response “During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.” Source location 2017-0049-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 Implement weekly wing-manager and monthly Duty Governor quality checks of ACCT and post-closure reviews, including caremap assessment and corrective feedback.
Verbatim wording from the response “In order to provide assurance that new procedures are fully embedded and effective, a review of the establishment’s ACCT quality assurance processes took place in 2016. This led to the introduction of two new quality checks, one undertaken weekly by the wing manager and the other on a monthly basis by the Duty Governor, which assess the quality and completeness of ACCT reviews and post-closure reviews. Both checks include a section which requires managers to assess and comment specifically on the quality of caremaps, and where deficiencies are found, feedback is given to the case manager and/or wing manager who are required to take the appropriate action to rectify this.” Source location 2017-0049-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 Complete Safer Prisons post-closure checks using a quality-assurance template to verify timescales, caremap actions and closure-questionnaire invitations.
Verbatim wording from the response “After closure of an ACCT a post closure check will be completed by the Safer Prisons team. A quality assurance template is used to check that the post closure process has been completed within timescales, that caremap actions were considered and completed prior to closure and that the prisoner has been invited to complete the closure questionnaire. As with all quality assurance checks any feedback required will be provided to the Case Manager involved.” Source location 2017-0049-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 The prison can only prompt family contact, and effective involvement depends on the prisoner’s consent.
Verbatim wording from the response “Family contact
The value of family involvement for prisoners, and the significant resettlement opportunities that contact with family members presents, are recognised. However, the prison can only prompt this contact (and it could only be effective) with the consent of the prisoner.” Source location 2017-0049-Response-by-NOMS
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17 Feb 2017 Dean Gary Saunders · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Failure to meaningfully involve families in the ACCT process View source Failure to provide effective ACCT process training View source
This report raised 6 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
Dean Gary Saunders · 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
Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.
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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 meaningfully involve families in the ACCT process
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process , including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family.
” Source location Dean Gary Saunders · 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 provide effective ACCT process training
Wider context from the report “4. FOR NOMS:- Training regarding the ACCT process . In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated . Meaningful action in required in this regard.
” Source location Dean Gary Saunders · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to open an ACCT for a person likely to be upset View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Michelle Barnes · 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
Michelle Barnes was found dead in her cell at HMP Low Newton on 16 December 2015, five days after giving birth and three days after returning to prison. The report identified concerns that an ACCT was not opened after she was told her child would be taken into care, that the support to be offered was not clearly defined or documented, and that other factors probably contributed to her death according to the inquest.
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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 open an ACCT for a person likely to be upset
Wider context from the report “After the prisoner made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those officers, chose not to open an ACCT, notwithstanding she described Michelle as being very upset and crying but instead made an entry in the wing observation book that staff were to “offer support”. It should have been clear to all that Michelle was likely to be upset upon receiving such news . Nothing was documented to indicate or to explain what “support” could or should be offered by staff. There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence.
” Source location Michelle Barnes · Prevention of Future Deaths 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 Remind ACCT case managers to open and accurately record ACCT documents and use multidisciplinary reviews when prisoners are at risk.
Verbatim wording from the response “ACCT case managers at Low Newton were reminded in November 2016 of the importance of opening an ACCT document when a prisoner is at risk of suicide or self-harm, and the importance of recording this accurately and clearly, and making sure there is a multi-disciplinary approach to ACCT reviews.” Source location Michelle-Barnes-R
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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 and disseminate national guidance on multidisciplinary working and ACCT to support continuity of care.
Verbatim wording from the response “In order to improve joined-up working to manage and support prisoners at risk of suicide or self-harm, new guidance around multi-disciplinary working and ACCT was issued by NOMS in October 2016 and disseminated to all prisons. The guidance aims to ensure that professionals carefully consider a prisoner’s needs and that they are provided with continuity of care, even when support will be delivered by different individuals or providers.” Source location Michelle-Barnes-R
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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 is intended for identified suicide or self-harm risk, while general distress is addressed through other existing support mechanisms.
Verbatim wording from the response “You express concern that safer custody practices do not consider prisoners in a holistic manner. As you are aware, prisoners considered at risk of suicide and self-harm are managed through the ACCT process. The review of ACCT process undertaken in 2015, found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. It is recognised that when used effectively ACCT is a holistic tool, bringing together multi-disciplinary teams to contribute to the management of an individual’s risk, which may include mental health concerns, substance abuse and a range of other factors. The other support mechanisms described above also form part of the holistic approach, alongside everyday interaction, support and challenge by staff.” Source location Michelle-Barnes-R
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27 Nov 2016 Matthew RUSSELL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3
Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation View source Failure of caseworkers to be aware of and attend ACCT Case Reviews View source Inadequate foundation and ongoing ACCT-procedure training for staff View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Matthew RUSSELL · 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
Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.
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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 multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend .
• Risk Assessments in relation to individual prisoners.
” Source location Matthew RUSSELL · 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 of caseworkers to be aware of and attend ACCT Case Reviews
Wider context from the report “f. Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their care .
” Source location Matthew RUSSELL · 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 foundation and ongoing ACCT-procedure training for staff
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure , with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend.
• Risk Assessments in relation to individual prisoners.
” Source location Matthew RUSSELL · Prevention of Future Deaths 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 Use a daily Open ACCT Log and morning briefing to identify open ACCTs, arrange assessments and ensure mental-health attendance at reviews.
Verbatim wording from the response “Safer custody at HMP Highdown now provide CNWL with a Daily Open ACCT Log, which is sent to three managers within the team. This is then circulated to all staff on duty that day and a daily copy posted on the Inreach Staff Office Notice Board.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
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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 Roll out mandatory e-learning on ACCT processes and healthcare roles and responsibilities to CNWL secure-settings staff.
Verbatim wording from the response “CNWL have developed a new e-learning package that details the ACCT process and outlines the specific roles and responsibilities of healthcare within this process. This will be rolled out within the next 3 months.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
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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 CNWL cannot always ensure mental health team attendance at every ACCT review because of mental health service capacity constraints.
Verbatim wording from the response “CNWL mental health pathway recognises the need for the Mental Health team to attend ACCT case reviews for all patients on the mental health caseload. Our pathway recognises as good practice that the Mental Health team should attend all ACCT reviews. However, while this is accepted as a gold standard for prison mental health teams, CNWL is sometimes unable to meet this standard due to the capacity of mental health services. Attendance is monitored via the monthly contract review meeting attended by the prison, and capacity and local inter-agency operational issues are discussed and recorded.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
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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 prison is responsible for delivering ACCT training, so CNWL depends on the establishment’s training schedule for staff access.
Verbatim wording from the response “ACCT training is prison provided training. CNWL works closely with the establishment to facilitate staff access training as far as possible within their probationary period.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
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4 Oct 2016 Haydn James Burton · Prevention of Future Deaths report Central Hampshire
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Concerns raised 2
Failure to implement ACCT plans in accordance with national policy View source Inadequate observations under ACCT plans View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
HM Prison and Probation Service
Deliver local ACCT refresher training to 48 staff on 13 and 20 December 2016, then provide it at least monthly.
View source
HM Prison and Probation Service
Develop a plan to provide refresher training for ACCT case managers and assessors and increase the number of staff trained in those roles.
View source
HM Prison and Probation Service
Recruit and deploy 12 new Prison Officers who complete entry-level training covering suicide, self-harm awareness and the ACCT process.
View source
HM Prison and Probation Service
Operate additional management assurance and quality checks of ACCT documentation, care, case management, Caremap actions and NOMS records, with monthly trend review and follow-up.
View source See 1 more action
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AI-generated summary
Haydn James Burton · 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
Haydn James Burton, a prisoner at HMP Winchester, was found suspended from a ligature point in his cell on 15 July 2015 and died in hospital on 18 July 2015 from the delayed effects of ligature suspension. The concerns included inadequate implementation of ACCT plans and observations, uncertainty about confidentiality rules in the Prison Listener scheme, and limitations in recording and communicating information about closed ACCT plans.
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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 implement ACCT plans in accordance with national policy
Wider context from the report “(1) The evidence in this case indicated that prison staff at Winchester Prison are not implementing ACCT plans in accordance with national policy notwithstanding the training they have received and in particular the observations conducted are inadequate. I therefore consider that the process and future training needs to be reviewed
” Source location Haydn James Burton · 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 observations under ACCT plans
Wider context from the report “(1) The evidence in this case indicated that prison staff at Winchester Prison are not implementing ACCT plans in accordance with national policy notwithstanding the training they have received and in particular the observations conducted are inadequate . I therefore consider that the process and future training needs to be reviewed
” Source location Haydn James Burton · 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 local ACCT refresher training to 48 staff on 13 and 20 December 2016, then provide it at least monthly.
Verbatim wording from the response “I note your concern that evidence at the inquest suggested that staff at Winchester are inconsistent in their implementation of the Assessment, Care in Custody and Teamwork (ACCT) process, and that the practice of undertaking ACCT observations is inadequate. I am grateful to you for raising this concern, and would like to reassure you that the Governor of Winchester, ████████, is committed to ensuring that all operational staff are successfully trained in ACCT procedures to enable them consistently to follow national ACCT policy contained within Prison Service Instruction (PSI) 64/2011 Safer Custody. Local ACCT refresher training is due to take place on 13 and 20 December 2016 for 48 members of staff and will be delivered at least monthly thereafter. HMP Winchester is also holding a Safety Awareness Day on 21 December 2016.” Source location 2016-0346-Response-by-NOMS
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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 a plan to provide refresher training for ACCT case managers and assessors and increase the number of staff trained in those roles.
Verbatim wording from the response “This local training will cover the whole ACCT process, including how to open an ACCT, and will consider lessons learnt from previous deaths in custody, including the requirement to ensure that the ACCT assessment is completed within 24 hours, the need to make appropriate mental health referrals, and the fact that ACCT case reviews must be multidisciplinary and attended by all those involved in the provision of care for the individual concerned. A plan is being developed to deliver refresher training for ACCT case managers and assessors already in post, and to increase the number of staff trained in these roles.” Source location 2016-0346-Response-by-NOMS
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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 Recruit and deploy 12 new Prison Officers who complete entry-level training covering suicide, self-harm awareness and the ACCT process.
Verbatim wording from the response “In addition, more staff are being recruited, and 12 new Prison Officers are expected to complete the Prison Officer Entry Level Training (POELT) course that includes training on suicide and self-harm awareness and the ACCT process and start work at Winchester by March 2017.” Source location 2016-0346-Response-by-NOMS
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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 additional management assurance and quality checks of ACCT documentation, care, case management, Caremap actions and NOMS records, with monthly trend review and follow-up.
Verbatim wording from the response “The Governor has recently introduced additional management assurance checks to ensure that staff are completing ACCT documents correctly and to the required standard, and that the appropriate level of care is given any person who requires additional support provided during the ACCT process. These assurance checks are completed by Orderly Officers, Duty Governors and the Safer Custody Team. The results are collated and will be discussed at the monthly Safer Custody meeting where trends will be identified and appropriate actions taken. In addition quality assurance checks will consider the role of ACCT Case Managers to confirm compliance, and identify any development needs. ACCT Caremap actions are checked by the Safer Custody Supervising Officer and Custodial Manager who ensure that appropriate actions have been identified and taken forward.” Source location 2016-0346-Response-by-NOMS
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Concerns raised 5
Premature closure of ACCTs before identified inadequacies are detected and needs are properly served View source Failure of the ACCT document to accompany prisoners around the prison View source Failure to read and use available documentary information in ACCT reviews View source
Failure to complete ACCT documentation fully View source Failure to invite all appropriate individuals to ACCT reviews View source See 2 more concerns
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Glen Parva Young Offender Institution Ministry of Justice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Glen Parva Young Offender Institution and Ministry of Justice
Use the Safer Custody toolkit to provide local ACCT procedures aligned with national policy.
View source
Glen Parva Young Offender Institution and Ministry of Justice
Conduct regular management checks and quality assurance of ACCT documentation and procedures.
View source
Glen Parva Young Offender Institution and Ministry of Justice
Remind ACCT case managers to use multidisciplinary reviews, address prisoners’ needs in care maps, and complete actions before closure.
View source
Glen Parva Young Offender Institution and Ministry of Justice
Implement national review recommendations, including revisions to ACCT policy and forms.
View source
Glen Parva Young Offender Institution and Ministry of Justice
Continue monitoring ACCT system performance to assess delivery of anticipated improvements.
View source
Glen Parva Young Offender Institution and Ministry of Justice
Remind staff to complete ACCT documents fully, record relevant information, and move documents with prisoners.
View source
Glen Parva Young Offender Institution and Ministry of Justice
Use a local ACCT review template requiring confirmation that relevant documentation has been read before reviews.
View source See 4 more actions
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AI-generated summary
Liam Adrian John Lambert · 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
Liam Adrian John Lambert was a young offender at Glen Parva Young Offenders Institution who died after ligaturing himself in a single cell on the evening of 19 March 2015. The report identified concerns about bullying and assaults, inadequate completion and use of the ACCT self-harm documentation, its inappropriate closure, prison resourcing, and delays in the emergency response and access for paramedics.
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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 Premature closure of ACCTs before identified inadequacies are detected and needs are properly served
Wider context from the report “2. This ACCT was only open for a short period. It did not serve Liam’s needs properly and was closed before any review system picked up the inadequacies.
” Source location Liam Adrian John Lambert · 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 of the ACCT document to accompany prisoners around the prison
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Source location Liam Adrian John Lambert · 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 and use available documentary information in ACCT reviews
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used , and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Source location Liam Adrian John Lambert · 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 complete ACCT documentation fully
Wider context from the report “1. The ACCT document was not completed fully , did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Source location Liam Adrian John Lambert · 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 invite all appropriate individuals to ACCT reviews
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews . Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Source location Liam Adrian John Lambert · 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 Use the Safer Custody toolkit to provide local ACCT procedures aligned with national policy.
Verbatim wording from the response “You will be aware that Prison Service Instruction 64/2011 Safer Custody sets out the relevant policy, and that chapter 5 describes the processes associated, Assessment, Care in Custody and Teamwork (ACCT) document. A Safer Custody toolkit was introduced at Glen Parva in August 2016, providing clear local instructions that are in accordance with the national policy.” Source location 2016-0335-Response-by-NOMS
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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 regular management checks and quality assurance of ACCT documentation and procedures.
Verbatim wording from the response “In September 2016 all staff were reminded at staff briefings of the need for all ACCT documents to be completed fully, and that they should record all relevant information in the ACCT document, and in the wing observation book and on P-NOMIS where appropriate. Staff were also reminded that ACCT documents must accompany prisoners when they move around the prison. Management checks are now regularly undertaken to ensure that staff are correctly completing the documents, and all ACCT documents are quality assured and monitored by the Head of Safer Custody.” Source location 2016-0335-Response-by-NOMS
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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 ACCT case managers to use multidisciplinary reviews, address prisoners’ needs in care maps, and complete actions before closure.
Verbatim wording from the response “In September 2016 ACCT case managers were reminded of the importance of a multi-disciplinary approach to ACCT reviews, particularly when making decisions to close the document. They were also reminded to check that the ACCT care map addresses the prisoner’s needs and that all the actions must be completed satisfactorily before the ACCT document is closed. Management checks are now regularly undertaken to ensure that staff correctly follow these procedures, and all ACCT documents are quality assured and monitored by the Head of Safer Custody. The Governor is confident that the new system of more consistent management checks, introduced in July 2016, has significantly improved the implementation of the ACCT process at the prison.” Source location 2016-0335-Response-by-NOMS
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 national review recommendations, including revisions to ACCT policy and forms.
Verbatim wording from the response “The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. The review made 20 recommendations, including revision to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the performance of the ACCT system to ensure that the anticipated improvements are delivered.” Source location 2016-0335-Response-by-NOMS
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 Continue monitoring ACCT system performance to assess delivery of anticipated improvements.
Verbatim wording from the response “The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. The review made 20 recommendations, including revision to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the performance of the ACCT system to ensure that the anticipated improvements are delivered.” Source location 2016-0335-Response-by-NOMS
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 complete ACCT documents fully, record relevant information, and move documents with prisoners.
Verbatim wording from the response “In September 2016 all staff were reminded at staff briefings of the need for all ACCT documents to be completed fully, and that they should record all relevant information in the ACCT document, and in the wing observation book and on P-NOMIS where appropriate. Staff were also reminded that ACCT documents must accompany prisoners when they move around the prison. Management checks are now regularly undertaken to ensure that staff are correctly completing the documents, and all ACCT documents are quality assured and monitored by the Head of Safer Custody.” Source location 2016-0335-Response-by-NOMS
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 a local ACCT review template requiring confirmation that relevant documentation has been read before reviews.
Verbatim wording from the response “A notice has been issued to remind staff of their responsibilities when attending ACCT case reviews, and a local template for reviews was introduced in October 2016. This prompts case managers to check that all relevant documentation is available and requires them to confirm that they have read it before undertaking the review. A new scheduling system was also introduced in October 2016, and this will ensure that sufficient time is allocated to all future case review meetings.” Source location 2016-0335-Response-by-NOMS
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 national ACCT policy and system are sound; the identified problems concern compliance with policy and quality of care delivery.
Verbatim wording from the response “The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. The review made 20 recommendations, including revision to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the performance of the ACCT system to ensure that the anticipated improvements are delivered.” Source location 2016-0335-Response-by-NOMS
Open published response
12 Aug 2016 Stephen St Clair · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 1
Failure to open an ACCT document when behaviour indicates a need for additional monitoring View source
This report raised 2 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
Stephen St Clair · 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 St Clair, a prisoner at HMP Isle of Wight, was found in his cell on 4 November 2013 with a severe cut to his throat and was pronounced dead at 05.55 hours. The report describes concerns about signs of paranoia and possible psychosis not being recognised as suicide or self-harm risk, and about the absence of corresponding wording in the Prison Service suicide risk guidance, which may have contributed to an ACCT not being opened.
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 open an ACCT document when behaviour indicates a need for additional monitoring
Wider context from the report “4. I am concerned that as this additional wording was not included in PSI 64/2011, the Prison Officers did not feel obligated to open an ACCT document , which may have resulted in Mr St Clair being monitored more closely, thereby avoiding him taking his own life.
” Source location Stephen St Clair · Prevention of Future Deaths report
Open source report
Concerns raised 2
Lack of sufficient ACCT training among staff View source Failure to adhere to mandatory ACCT process provisions 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 Brandon Betteridge · 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 Brandon Betteridge was remanded to HMP Durham on 22 May 2015 and was found dead in his cell on 26 May 2015 after hanging himself. Concerns included gaps in staff training and failures to follow mandatory ACCT procedures, including the closure of the ACCT without healthcare staff present. The inquest found that the absence of his prescription medication and the fact that he was not on an open ACCT probably contributed more than minimally to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of sufficient ACCT training among staff
Wider context from the report “(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training. I was told that ACCT training is now part of Healthcare staff induction training. A prison GP with 11 years’ experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs. A Senior Officer who chaired the first review of the ACCT at which the ACCT was closed) believed it was good practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT process has been in existence for a number of years, some staff were working without having received any training and some either not had sufficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to. The inquest has indicated a clear training need.
” Source location John Brandon Betteridge · 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 adhere to mandatory ACCT process provisions
Wider context from the report “(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training. I was told that ACCT training is now part of Healthcare staff induction training. A prison GP with 11 years’ experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs. A Senior Officer who chaired the first review of the ACCT at which the ACCT was closed) believed it was good practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT process has been in existence for a number of years, some staff were working without having received any training and some either not had sufficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to . The inquest has indicated a clear training need.
” Source location John Brandon Betteridge · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure of RMNs to record post-consultation and post-review information in ACC T documentation View source Reliance by RMNs on summaries of ACC T documentation instead of independent review View source
This report raised 9 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
Andrew Gus PEEBLES · 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
The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.
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 RMNs to record post-consultation and post-review information in ACC T documentation
Wider context from the report “(2) No entries were made by the RMN after consultations/ACC T reviews with the deceased in the ACC T documentation resulting in no information being available to discipline officers managing Mr Peebles
” Source location Andrew Gus PEEBLES · 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 Reliance by RMNs on summaries of ACC T documentation instead of independent review
Wider context from the report “(5) RMN relying upon the summary of the ACC T documentation provided to her by the Senior Officer undertaking the ACC T review rather than assessing the documentation for herself to form a view of the information from a mental health perspective
” Source location Andrew Gus PEEBLES · Prevention of Future Deaths report
Open source report
13 Jun 2016 Kevin Dermott · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Failure to properly observe ACCT procedures View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
HM Prison and Probation Service
Check all ACCT documents daily through Officer Supervisors.
View source
HM Prison and Probation Service
Introduce an additional weekly ACCT document check by a Custodial Manager.
View source
HM Prison and Probation Service
Conduct weekly sample checks of ACCT documents until standards improve and processes are embedded.
View source
HM Prison and Probation Service
Issue a Governor’s Order defining staff responsibility and accountability for ACCT documents.
View source
HM Prison and Probation Service
Require staff to account for unsatisfactory ACCT documents and escalate appropriate cases through warnings or misconduct investigation.
View source
HM Prison and Probation Service
Brief all Offender Supervisors and Custodial Managers on the importance of the ACCT process.
View source
HM Prison and Probation Service
Require staff to notify Safer Custody of prisoner concerns so an immediate ACCT review is organised, with escalation when responsible staff are unavailable.
View source See 4 more actions
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AI-generated summary
Kevin Dermott · 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
Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.
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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 properly observe ACCT procedures
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures .
” Source location Kevin Dermott · 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 Check all ACCT documents daily through Officer Supervisors.
Verbatim wording from the response “The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.” Source location 2016-0220-Response-by-NOMS
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 an additional weekly ACCT document check by a Custodial Manager.
Verbatim wording from the response “The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.” Source location 2016-0220-Response-by-NOMS
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 Conduct weekly sample checks of ACCT documents until standards improve and processes are embedded.
Verbatim wording from the response “The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.” Source location 2016-0220-Response-by-NOMS
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 a Governor’s Order defining staff responsibility and accountability for ACCT documents.
Verbatim wording from the response “A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.” Source location 2016-0220-Response-by-NOMS
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 Require staff to account for unsatisfactory ACCT documents and escalate appropriate cases through warnings or misconduct investigation.
Verbatim wording from the response “A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.” Source location 2016-0220-Response-by-NOMS
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 Offender Supervisors and Custodial Managers on the importance of the ACCT process.
Verbatim wording from the response “A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.” Source location 2016-0220-Response-by-NOMS
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 Require staff to notify Safer Custody of prisoner concerns so an immediate ACCT review is organised, with escalation when responsible staff are unavailable.
Verbatim wording from the response “In order to ensure that any concerns that are raised about a prisoner are being acted upon, staff have been informed that they must contact the Safer Custody department, who will organise an immediate ACCT review for that day. If the named Offender Supervisor cannot attend it will be escalated to the “Oscar” group (comprised of three Offender Supervisors), and where they are not available it will be further escalated to the duty Custodial Manager (who is available 24 hours).” Source location 2016-0220-Response-by-NOMS
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 Operational issues concerning proper observance of ACCT procedures should be addressed by NOMS.
Verbatim wording from the response “The specific issues you raise about the failure to properly observe Assessment, Care in Custody & Teamwork (ACCT) procedures are operational and should be addressed by NOMS.” Source location 2016-0220-Response-by-Department-of-Health
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.