24 Mar 2015 Stuart Megginson BAUMBER · Prevention of Future Deaths report Peterborough
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Concerns raised 1
Lack of a national pro forma for ACCT opening and decision-making View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Stuart Megginson BAUMBER · 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
Stuart Megginson BAUMBER died by hanging in his cell at HMP Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013, after being remanded in custody for arson. The jury found that occasions existed when the ACCT process should have been initiated and that inadequate understanding and training contributed to this not happening. The report also raised concerns about ligature points on cell doors, healthcare screening that did not mention section 136 detentions, and items available to prisoners that could facilitate suicide.
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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 Lack of a national pro forma for ACCT opening and decision-making
Wider context from the report “7. PSI 64/2011 and the Quick Time Learning Bulletin (issue 12 august 2012) which clarified opening an ACCT was the subject of much scrutiny. There seems to be no national pro forma document to guide staff through the process and document the decision making . By contrast, the Act 2 Care risk assessment in the Scottish prison system does provide a structured approach. A pro forma regime would have the advantage of providing an audit trail and can be reviewed for training purposes if shortcomings emerge.
” Source location Stuart Megginson BAUMBER · Prevention of Future Deaths report
Open source report
9 Mar 2015 Craig Douglas Bell · Prevention of Future Deaths report Manchester City
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Concerns raised 3
Failure to use CCTV monitoring as an adjunct to ACCT observation procedures View source Lack of suitably senior psychiatric clinician attendance at discharge case reviews View source Lack of graduated risk management planning after transfer to an ordinary wing location View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Craig Douglas Bell · 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
Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.
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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 use CCTV monitoring as an adjunct to ACCT observation procedures
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures . No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death.
” Source location Craig Douglas Bell · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of suitably senior psychiatric clinician attendance at discharge case reviews
Wider context from the report “3. I am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case review/meeting . In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning. In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012. This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance. The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented.
” Source location Craig Douglas Bell · 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 Lack of graduated risk management planning after transfer to an ordinary wing location
Wider context from the report “4. I am concerned by the lack of planning or consideration of a graduated risk management plan in such circumstances . This was identified by the clinical reviewer. In other words increased frequency of day time interactions and throughout the whole day and MHIT and Psychiatrist contacts very shortly after the move . In this case the deceased was on the waiting list for a MHIT contact and was due to be seen within 2 weeks by the Psychiatrist.
” Source location Craig Douglas Bell · Prevention of Future Deaths report
Open source report
28 Dec 2014 Alex Kelly · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 2
Conflict between ACCT and disciplinary procedures View source Failure of ACCT reviews to address reasons for behaviour View source
This report raised 26 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alex Kelly · 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
Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.
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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 Conflict between ACCT and disciplinary procedures
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures ; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Source location Alex Kelly · 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 ACCT reviews to address reasons for behaviour
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour ; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Source location Alex Kelly · 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 Publish guidance reminding staff to present ACCT plans at adjudications so self-harm risks inform adjudication decisions.
Verbatim wording from the response “The third concern that you have addressed to the Governor of HMYOI Cookham Wood relates to what you describe as a conflict between regimes, in the sense that the ACCT process and behaviour improvement plan were not sufficiently joined up with the adjudications process.” Source location 2014-0555-Response-by-Ministry-of-Justice
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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 Arrange ACCT training for the Resettlement Team.
Verbatim wording from the response “ACCT training has been arranged, facilitated by Cookham Woods ACCT trainers for the Resettlement Team as a whole.” Source location 2014-0555-Response-by-Medway-Youth-Offending-Service
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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 case workers to undertake annual ACCT and enhanced-review training, with attendance recorded and monitored by the YOT Manager.
Verbatim wording from the response “All Case Workers are now obliged to attend annual training in relation to the ACCT process and the use of enhanced reviews. A record of this training is maintained and monitored by the YOT Manager at Cookham Wood.” Source location 2014-0555-Response-by-Medway-Youth-Offending-Service
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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 ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.
Verbatim wording from the response “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.” Source location 2014-0555-Response-by-Ministry-of-Justice
Open published response
Concerns raised 4
Failure to give sufficient weight to mental health staff opinions in ACCT reviews View source Failure of ACCT review members to read the ACCT document before reviews View source Failure to ensure mental health staff attend relevant ACCT reviews View source
Failure to share mental health information with other ACCT review members View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Provide and document written or verbal mental health team input when attendance at an ACCT review cannot be arranged.
Stated by Care UK NHSStated plannedThe respondent said that this action was planned when they made their response on 10 December 2014. View source
Action
Provide weekend Mental Health Team staffing, prioritising ACCT review attendance and support for women in crisis, with access to an on-call Mental Health Manager.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Increase multidisciplinary meetings for prisoners with complex care and risk needs to support shared understanding, problem-solving and ACCT contributions.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Introduce briefing sessions to improve information sharing between prison staff and the mental health team during risk-level decisions.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Remind all staff to review previous entries in the ACCT document.
Stated by Care UK NHSStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Disseminate requirements to review ACCT documents and System One notes through clinical governance, staff meetings and Mental Health Team training.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Remind case managers and case-review chairs to review all relevant information before conducting ACCT case reviews.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Ensure a registered nurse with previous patient knowledge attends each ACCT review.
Stated by Care UK NHSStated plannedThe respondent said that this action was planned when they made their response on 10 December 2014. View source
Action
Give mental health staff access to the case review diary to schedule and prepare for upcoming ACCT reviews.
Stated by Care UK NHSStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Establish mental health team input at all ACCT reviews through weekend attendance and case-manager allocation for healthcare-centre prisoners.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source
Action
Ensure Mental Health Team management attends daily healthcare and Governor’s morning meetings, with deputy cover when the manager is unavailable.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 December 2014. View source See 8 more actions
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AI-generated summary
Geraldine Liege Kilborn · 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
Geraldine Liege Kilborn died in HMP Low Newton after repeatedly self-harming over the 22 days following her reception into the prison; the Jury could not determine her intention when she hung herself. The principal concerns were inadequate sharing and weighting of mental-health information during ACCT reviews, limited review of ACCT records by some panel members, and questions about review-panel membership and her location at the time of 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 Failure to give sufficient weight to mental health staff opinions in ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight . It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight .
” Source location Geraldine Liege Kilborn · 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 ACCT review members to read the ACCT document before reviews
Wider context from the report “(2) Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees who might know the prisoner and opined their face to face assessment of the prisoner at the time. In this case, some ACCT review members had limited day to day experience of the deceased, whose temperament and presentation could change “like a light switch” and therefore face to face presentation could well be misleading. Thus in cases where the ACCT review was dealing with a particularly complex challenging prisoner and where an enhanced review was called for, it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular.
” Source location Geraldine Liege Kilborn · 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 ensure mental health staff attend relevant ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” Source location Geraldine Liege Kilborn · 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 mental health information with other ACCT review members
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” Source location Geraldine Liege Kilborn · 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 Provide and document written or verbal mental health team input when attendance at an ACCT review cannot be arranged.
Verbatim wording from the response “In addition Mental Health staff are given access to the case review diary to give them an opportunity to schedule or prepare for any upcoming reviews. If a mutual convenient time cannot be accommodated a written or verbal input will be supplied by the Mental Health team which will be appropriately documented on the case review notes.” Source location 2014-0532-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 Provide weekend Mental Health Team staffing, prioritising ACCT review attendance and support for women in crisis, with access to an on-call Mental Health Manager.
Verbatim wording from the response “Regarding availability of staff, TEWV have already made changes to the availability of the Mental Health Team staff over the weekend. Staff are on duty between 9.30 am – 12.30pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support. The ACCT Case Manager would also have access to an on-call Mental Health Manager. This” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase multidisciplinary meetings for prisoners with complex care and risk needs to support shared understanding, problem-solving and ACCT contributions.
Verbatim wording from the response “Since the death of Ms Kilborn the use of multi-disciplinary meetings has increased for those prisoners with complex care and risk needs. This is a proactive approach as, through the multi-disciplinary discussion, all issues can be addressed and understood, problems can be appropriately addressed and consensus decisions reached. This therefore enables the Mental Health Team to contribute appropriately to the ACCT process.” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-NHS-Trust
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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 briefing sessions to improve information sharing between prison staff and the mental health team during risk-level decisions.
Verbatim wording from the response “This is primarily a matter for the healthcare provider, but I can inform you that an amended arrangement has been put in place to facilitate presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues: for prisoners who are located in the healthcare centre, a band 5 nurse is allocated as case manager; and for prisoners located elsewhere a member of the mental health team attends all case reviews. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team, ensuring that all staff are able to make a meaningful contribution to the decision about the level of risk.” Source location 2014-0532-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 all staff to review previous entries in the ACCT document.
Verbatim wording from the response “With regard to the sharing of information from SystmOne, medical confidentiality is ensured and information is shared with the consent of the patient. All staff are reminded of the importance of reviewing previous entries in the ACCT document.” Source location 2014-0532-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 Disseminate requirements to review ACCT documents and System One notes through clinical governance, staff meetings and Mental Health Team training.
Verbatim wording from the response “This relevant point was discussed at our clinical governance meeting and staff meetings within the Mental Health Team. It is also part of the ACCT training delivered to all the staff working in the Mental Health Team. Staff were reminded to read all the relevant information in the ACCT document and on System One notes.” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind case managers and case-review chairs to review all relevant information before conducting ACCT case reviews.
Verbatim wording from the response “At HMP&YOI Low Newton the same staff attend ACCT reviews wherever possible. All relevant information, including developments since the last review, is discussed at the case review. This includes any information from the SystmOne record that it is appropriate for healthcare staff to share. In complex cases the enhanced case review team involves all relevant disciplines and is chaired by a higher level operational manager than a typical ACCT case review, usually the head of safer custody. In response to your report, all case managers and case review chairs have been reminded of the need to familiarise themselves with all relevant information, including the records of previous reviews and recent entries in the ACCT document, before conducting a case review.” Source location 2014-0532-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 Ensure a registered nurse with previous patient knowledge attends each ACCT review.
Verbatim wording from the response “Better communication is a requirement between all stakeholders. Daily reviews will be undertaken by a member of the mental health team, as on any patient allocated into Healthcare with mental health issues. In addition all complex ACCT cases will be discussed at morning handover to increase staff awareness. A registered nurse with previous knowledge of the patient will be in attendance at an ACCT review.” Source location 2014-0532-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 Give mental health staff access to the case review diary to schedule and prepare for upcoming ACCT reviews.
Verbatim wording from the response “In addition Mental Health staff are given access to the case review diary to give them an opportunity to schedule or prepare for any upcoming reviews. If a mutual convenient time cannot be accommodated a written or verbal input will be supplied by the Mental Health team which will be appropriately documented on the case review notes.” Source location 2014-0532-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 Establish mental health team input at all ACCT reviews through weekend attendance and case-manager allocation for healthcare-centre prisoners.
Verbatim wording from the response “This is primarily a matter for the healthcare provider, but I can inform you that an amended arrangement has been put in place to facilitate presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues: for prisoners who are located in the healthcare centre, a band 5 nurse is allocated as case manager; and for prisoners located elsewhere a member of the mental health team attends all case reviews. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team, ensuring that all staff are able to make a meaningful contribution to the decision about the level of risk.” Source location 2014-0532-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 Ensure Mental Health Team management attends daily healthcare and Governor’s morning meetings, with deputy cover when the manager is unavailable.
Verbatim wording from the response “We have also completed the following action to ensure proper and timely communication between prison wing staff and Mental Health Team members: the Mental Health Team Manager attends both the daily healthcare and Governor’s morning meeting to ensure pertinent issues are discussed. A deputy will also attend the healthcare meeting if the MHT manager is not available e.g. on leave.” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ACCT review arrangements ensure relevant information is discussed and staff familiarise themselves with prior records and recent entries.
Verbatim wording from the response “At HMP&YOI Low Newton the same staff attend ACCT reviews wherever possible. All relevant information, including developments since the last review, is discussed at the case review. This includes any information from the SystmOne record that it is appropriate for healthcare staff to share. In complex cases the enhanced case review team involves all relevant disciplines and is chaired by a higher level operational manager than a typical ACCT case review, usually the head of safer custody. In response to your report, all case managers and case review chairs have been reminded of the need to familiarise themselves with all relevant information, including the records of previous reviews and recent entries in the ACCT document, before conducting a case review.” Source location 2014-0532-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 Information sharing is primarily the healthcare provider’s responsibility, although prison arrangements facilitate mental health participation in ACCT reviews.
Verbatim wording from the response “This is primarily a matter for the healthcare provider, but I can inform you that an amended arrangement has been put in place to facilitate presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues: for prisoners who are located in the healthcare centre, a band 5 nurse is allocated as case manager; and for prisoners located elsewhere a member of the mental health team attends all case reviews. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team, ensuring that all staff are able to make a meaningful contribution to the decision about the level of risk.” Source location 2014-0532-Response-by-NOMS
Open published response
27 Oct 2014 Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to ensure multidisciplinary attendance or input at ACCT reviews View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chrylin Angela Maria Norrell-Goldsmith · 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
Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.
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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 attendance or input at ACCT reviews
Wider context from the report “2. Multi-Disciplinary Attendance / Input at ACCT Reviews
Consideration should be given to ensuring that all staff, including prison staff, healthcare staff and In Reach staff understand the importance of requiring and providing multi-disciplinary attendance, or alternatively, multi-disciplinary input at all ACCT reviews .
” Source location Chrylin Angela Maria Norrell-Goldsmith · 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 Issue staff guidance on the importance, timing and procedures for multidisciplinary ACCT case reviews.
Verbatim wording from the response “PSI 64/2011 on Safer Custody aims to support effective multi-disciplinary case management and sharing of information to reduce incidents of harm. In line with PSI 64/2011 Safer Custody, HMP Downview when it re-opens in 2015, will issue a notice to staff explaining the importance of and procedures for conducting multi-disciplinary ACCT case reviews. Particular emphasis will be given to the fact that multi-disciplinary case reviews are to be held at the appropriate times, and where possible, a consistent case manager and” Source location 2014-0470-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 Reintroduce the system notifying on-duty staff about prisoners subject to ACCT and upcoming case reviews.
Verbatim wording from the response “relevant personnel must attend the reviews. Where a relevant member of staff cannot attend an ACCT review, then in exceptional circumstances, and per the instructions of PSI64/2011, a written report will be submitted. When HMP Downview was a female prison, a system was in place to ensure that all staff who arrived for duty were provided with a list of prisoners subject to an ACCT and the date of the next ACCT case review in order that they could arrange to attend the review if they were involved in that prisoner’s care. This system will be reintroduced in Spring 2015. In addition, case managers will record in the ACCT document any significant personnel who are involved with the offender, including, health care, offender management and interventions or learning and development.” Source location 2014-0470-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 Record significant personnel involved in a prisoner’s care in ACCT documents and request their input before reviews.
Verbatim wording from the response “relevant personnel must attend the reviews. Where a relevant member of staff cannot attend an ACCT review, then in exceptional circumstances, and per the instructions of PSI64/2011, a written report will be submitted. When HMP Downview was a female prison, a system was in place to ensure that all staff who arrived for duty were provided with a list of prisoners subject to an ACCT and the date of the next ACCT case review in order that they could arrange to attend the review if they were involved in that prisoner’s care. This system will be reintroduced in Spring 2015. In addition, case managers will record in the ACCT document any significant personnel who are involved with the offender, including, health care, offender management and interventions or learning and development.” Source location 2014-0470-Response-by-NOMS
Open published response
15 Oct 2014 Severyn Witold Glowinski · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Lack of knowledge among Senior Custodial Managers of segregation transfer requirements View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Severyn Witold Glowinski · 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
Severyn Witold Glowinski, a serving prisoner diagnosed with paranoid schizophrenia, was transferred to segregation and remained there for a little under a fortnight. He was found hanging in his cell on the evening of 3 July 2013 while subject to an open ACCT for self-harm. Concerns included poor communication about his care plan, inaccurate paperwork copied from another prisoner’s file, and a lack of awareness of requirements concerning the segregation of prisoners on an open ACCT.
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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 knowledge among Senior Custodial Managers of segregation transfer requirements
Wider context from the report “(3) The Senior Custodial Managers in the wing were unaware of the requirements of prison service orders which meant that an individual on an open ACCT should not be transferred to segregation unless there were exceptional reasons for doing so.
” Source location Severyn Witold Glowinski · Prevention of Future Deaths report
Open source report
3 Sep 2014 Yohannes Kidane · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Lack of sufficient staffing for effective ACCT observations View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Yohannes Kidane · 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
Yohannes Kidane was remanded into custody at Birmingham Prison and was found in his cell with a noose around his neck after previous self-harm incidents. CPR was provided, but he was declared dead on 19 December 2013. The concerns included insufficient night staffing in the healthcare wards, compromised ACCT observations, and the impact of staff not taking breaks on prisoner care and staff wellbeing.
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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 sufficient staffing for effective ACCT observations
Wider context from the report “(2) I am concerned that the ability to undertake effective ACCT observations is compromised by the lack of sufficient staff .
” Source location Yohannes Kidane · 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 Meet with G4S and National Offender Management Service representatives to address non-clinical night duties, including cell-bell responses and ACCT observations.
Verbatim wording from the response “We have met with G4S and representatives from the National Offenders Management Service as the evidence at the inquest identified that a significant part of the duties during the night are non-clinical, for example responding to cell bells, general enquiries and undertaking ACCT observations. I understand that they will be providing a separate response to you.” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
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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 G4S and the National Offender Management Service will provide a separate response concerning non-clinical night duties and ACCT observations.
Verbatim wording from the response “We have met with G4S and representatives from the National Offenders Management Service as the evidence at the inquest identified that a significant part of the duties during the night are non-clinical, for example responding to cell bells, general enquiries and undertaking ACCT observations. I understand that they will be providing a separate response to you.” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing night staffing, including a prison custody officer and emergency assistance arrangements, is considered adequate for ACCT observations.
Verbatim wording from the response “Adequacy of Night Staffing for the conduct of ACCT observations
The night staffing level for HMP Birmingham was reviewed when responsibility for its operation was transferred to G4S, and NOMS is satisfied that it is acceptable. G4S has chosen to deploy a Prison Custody Officer (PCO) to patrol the healthcare centre at night, and this is beyond the public sector benchmark which would require the use an Operational Support Grade (OSG) for this purpose. This allows extra flexibility, as a PCO is trained and authorised to perform additional duties, such as to unlock cell doors if required.” Source location 2014-0392-Response-by-NOMS
Open published response
Concerns raised 1
Failure to ensure ACCT health-screening doctors are trained in required procedures View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Matthew Thomas Purser · 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 Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health records.
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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 ACCT health-screening doctors are trained in required procedures
Wider context from the report “1. The Doctor who saw Mr. Purser for the second health screen on the day after admission had not received ACCT training as required by PS 164/2011 and HMP Swansea Suicide Prevention Policy 2010 and was not aware of the requirement for him to be trained in the procedures .
” Source location Matthew Thomas Purser · Prevention of Future Deaths report
Open source report
12 Mar 2014 Andrew Ronald Hall · Prevention of Future Deaths report Teesside
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Concerns raised 1
Failure to conduct post-closure interviews in accordance with ACCT policy View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew Ronald Hall · 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
Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.
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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 post-closure interviews in accordance with ACCT policy
Wider context from the report “7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted . (Prison staff, healthcare staff and Mental Health team)
” Source location Andrew Ronald Hall · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure all ACCT post-closure reviews occur within the mandated seven-day period.
Verbatim wording from the response “You are concerned that a post-closure review of the ACCT was not conducted (point 7). A system is now in place within the safer custody department to ensure that all post-closure reviews take place within the seven day period mandated in Prison Service Instruction (PSI) 64/2011 Safer Custody. A local policy that an additional post-closure review is conducted after one month has been introduced.” Source location 2014-0122-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 Conduct an additional ACCT post-closure review after one month.
Verbatim wording from the response “You are concerned that a post-closure review of the ACCT was not conducted (point 7). A system is now in place within the safer custody department to ensure that all post-closure reviews take place within the seven day period mandated in Prison Service Instruction (PSI) 64/2011 Safer Custody. A local policy that an additional post-closure review is conducted after one month has been introduced.” Source location 2014-0122-Response-by-NOMS
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20 Dec 2013 Adrian Johnson · Prevention of Future Deaths report Inner South London
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Concerns raised 3
Failure to secure complete health care information for ACCT reviews View source Inconsistent requests for members to attend ACCT reviews View source Failure to establish individual learning from ACCT review involvement View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Adrian Johnson · 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
Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.
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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 secure complete health care information for ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews , but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered . It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Source location Adrian Johnson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent requests for members to attend ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend , nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Source location Adrian Johnson · 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 establish individual learning from ACCT review involvement
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved . It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Source location Adrian Johnson · Prevention of Future Deaths report
Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ACCT case-manager refresher training reinforcing multidisciplinary reviews, relocation handovers, risk-information sharing, and exceptional use of segregation.
Verbatim wording from the response “National policy contained within PSI 64/2011 “Management of prisoners at risk of harm to self, to others and from others (Safer Custody)” reminds staff of the mandatory requirement that ACCT case reviews “Be multi-disciplinary where possible”. Colleagues at HMP Belmarsh have confirmed that the Governor and all managers (including custodial managers and supervising officers) will attend further ACCT Case Manager refresher training, in part to underline the importance of a multidisciplinary attendance at case reviews, and the need to seek contributions from relevant departments, including healthcare staff and mental health” Source location 2013-0364-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 Record mental-health-team interactions with prisoners subject to open ACCTs in both SystmOne and the ACCT document.
Verbatim wording from the response “Within the ACCT process, the ACCT Assessor is expected to gather and review all available risk related information including that contained within the NOMIS notes, the F2050 (prisoner’s core record), and any recent ACCTs etc, to inform the assessment. All relevant risk information should be recorded within the ACCT, and attendees are expected to review and subsequent case review meetings are expected to be familiar with the contents of the ACCT. You will be aware that the Prisons and Probation Ombudsman recommended that a local protocol was devised to ensure that information was shared between safer custody and healthcare staff, and as a result members of the mental health in-reach team now record interaction with prisoners subject to an open ACCT both on SystmOne and within the ACCT document.” Source location 2013-0364-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 Establish an Enhanced Case Review Team including relevant disciplines, additional specialist input, and higher-level operational management.
Verbatim wording from the response “In terms of attendance at ACCT case reviews, the policy recognises that “The ACCT process will operate more effectively if there is continuity in the attendance of staff from relevant departments/services. For example, if education is seen as a relevant department to attend the review, then every effort should be made to ensure the same member of staff attends the reviews, likewise with healthcare input”. The Enhanced Case Review Team will involve all relevant disciplines and include more specialists and a higher level of operational management than a typical ACCT Case Review Team.” Source location 2013-0364-Response-by-NOMS
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Includes deficiencies in controls dedicated to the ACCT process, including quality assurance, observations, reviews, documentation, information sharing, staffing or training, where the failure undermines reliable ACCT risk prevention or management.
