21 Dec 2021 Saul Richard THOMAS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Lack of up-to-date staff training in required prison processes, including the ACCT process View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Saul Richard THOMAS · 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
Saul Richard Thomas died in his cell at HMP Hewell on 19 May 2019 after being transferred there from HMP Birmingham, where he had expressed paranoid thoughts and was undergoing psychiatric assessment. The concerns included failures to open an ACCT document, communicate important mental-health information during the prison transfer, and adequately assess and manage his mental health at HMP Hewell; the inquest found that these failures probably or possibly caused or contributed 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 up-to-date staff training in required prison processes, including the ACCT process
Wider context from the report “(1) In the questionnaire which formed part of their conclusion, the jury found that an ACCT document should have been opened for Mr. Thomas at HMP Birmingham at some point after 11.5.19, and that a failure so to do probably caused or contributed to his death. I heard evidence from a senior member of staff at the prison that as many as a third of all staff at HMP Birmingham still do not have up-to-date training relating both to ████████ and to the ACCT process . I was also concerned to hear from one prison officer that he had had no ACCT training since 2014 . Until such training is provided to all staff working at the prison, there remains a risk of similar deaths occurring in the future;
” Source location Saul Richard THOMAS · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase HMP Birmingham’s capacity to deliver ACCT version 6 training.
Verbatim wording from the response “HMP Birmingham have increased the capacity of their ACCT version 6 training, and now have a plan in place to train 80% of their staff in suicide and self-harm (SASH) over the coming six months. The training plan prioritises staff working in areas of the prison that are considered high risk, including the Care and Separation Unit (CSU), Healthcare Unit, Reception and the Reverse Cohorting Unit (RCU). To achieve this the Governing Governor has asked the Prison Group Director for additional training to be made available to reduce the number of staff requiring training. In addition, HMP Birmingham will ensure all future new staff will receive SASH training as part of their induction.” Source location 2021-0423-Response-from-HMPPS_Published
Open published response
22 Oct 2021 Anthony John Larcher · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1
Lack of healthcare staff attendance at ACCT reviews View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony John Larcher · 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
On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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 healthcare staff attendance at ACCT reviews
Wider context from the report “iii. I have concerns that future deaths could occur due to the lack of attendance of healthcare staff at ACCT reviews, especially where the ACCT is closed . I request that consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT version 6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare staff at all ACCT reviews.
” Source location Anthony John Larcher · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out ACCT v6 nationally with multidisciplinary case reviews and healthcare attendance or written contributions where relevant.
Verbatim wording from the response “The second concern you raise is in relation to healthcare attendance at ACCT reviews. I understand that evidence was heard at the inquest about the new version of ACCT (ACCT v6) which was rolled out nationally in July 2021. The ACCT v6 guidance is clear that case reviews must be multi-disciplinary and that healthcare staff must be invited to attend the first ACCT case review, as well any subsequent reviews where healthcare involvement is relevant to supporting an individual. Attendance at case reviews must be driven by the individual’s specific needs and support required to ensure consistency and continuity of care as the case review team work together to drive meaningful outcomes and take ownership for their agreed Support Actions. Team members should try to attend case” Source location 2021-0356-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue ACCT v6 guidance and provide awareness and upskilling materials to establishments and staff.
Verbatim wording from the response “reviews in person, however, where this is not possible they can still contribute through the written contribution form which is included in the ACCT documentation. ACCT user guidance was issued to all establishments in advance of the roll out of ACCT v6 to ensure that staff were familiar with the new version and confident with the key changes made to the document. All establishments were provided with bite size awareness training packages to deliver to staff and upskilling materials to equip staff with the necessary skills to complete ACCT v6, and revised training modules are being rolled out nationally for all staff involved in the delivery of ACCT.” Source location 2021-0356-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out revised ACCT training modules nationally for staff involved in ACCT delivery.
Verbatim wording from the response “reviews in person, however, where this is not possible they can still contribute through the written contribution form which is included in the ACCT documentation. ACCT user guidance was issued to all establishments in advance of the roll out of ACCT v6 to ensure that staff were familiar with the new version and confident with the key changes made to the document. All establishments were provided with bite size awareness training packages to deliver to staff and upskilling materials to equip staff with the necessary skills to complete ACCT v6, and revised training modules are being rolled out nationally for all staff involved in the delivery of ACCT.” Source location 2021-0356-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HMPPS is responsible for responding to national guidance and ensuring healthcare attendance at reviews of prisoners at risk.
Verbatim wording from the response “3. Consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT V6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare at all ACCT reviews.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare matters in the prison estate are commissioned by NHS England and Improvement, which has already provided a response.
Verbatim wording from the response “NHS England and NHS Improvement (NHSEI) is responsible for the commissioning of healthcare for the prison estate. I am aware that NHSEI has provided a response to you on the matters of concern in your report relating to healthcare. I will not repeat the detail of that response. However, I offer the following comments.” Source location 2021-0356-Response-from-Department-of-Health-Social-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the Assessment, Care in Custody and Teamwork process lies with HMPPS, which will respond on that matter.
Verbatim wording from the response “In relation to healthcare participation in the Assessment, Care in Custody and Teamwork (ACCT) process, and in particular, the consideration of closing an ACCT, I am advised that NHSEI has worked with HMPPS to review the ACCT process and healthcare attendance and findings are anticipated in early 2022. Responsibility for the ACCT process lies with HMPPS and I am informed that it will respond to you fully on this matter.” Source location 2021-0356-Response-from-Department-of-Health-Social-Care_Published
Open published response
30 Sep 2021 Stephen David COPE · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2
Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication View source ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen David COPE · 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 David Cope died by suspension in his own cell block at Belmarsh prison on 18 November 2019. The principal concern was the transfer and review of prisoners on an ACCT, particularly the closure of an ACCT shortly after a prisoner’s transfer before support services had sufficient time to assess and communicate about them.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her .
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual .
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Source location Stephen David COPE · 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 ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual.
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT , which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Source location Stephen David COPE · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ACCT version 6 across the prison estate, strengthening multidisciplinary reviews, information sharing, support-action oversight, post-closure monitoring and transfer procedures.
Verbatim wording from the response “You may be aware that HMPPS has developed a revised version of ACCT, known as ACCT version 6, (ACCT V6) that was implemented across the prison estate in July 2021. The changes introduced in this new version are intended to assist staff to provide high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. Some of the key changes include an emphasis on information sharing, improved case reviews and a strengthened post-closure period.” Source location 2021-0332-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share a learning bulletin with all establishments and publish it on the HMPPS intranet to improve communication and information sharing when transferring prisoners on open ACCTs.
Verbatim wording from the response “A learning bulletin about transferring prisoners on an open ACCT which emphasises the importance of good communication and information-sharing has been shared with all establishments and is available on the HMPPS intranet.” Source location 2021-0332-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the ACCT process lies with HMPPS, which has responded on this matter.
Verbatim wording from the response “Responsibility for the Assessment, Care in Custody and Teamwork (ACCT) process lies with HMPPS and I am aware that it has responded to you on this matter. A new version of the ACCT has been introduced with changes that include an increased emphasis on information sharing, strengthened case reviews and post-closure procedures. In particular, I note that updated guidance accompanying the ACCT makes clear that when a change of circumstance takes place, such as transfer to another prison, an urgent case review must take place, prior to transfer, and as soon as possible at the receiving prison, informed by handover.” Source location 2021-0332-Response-from-Department-of-Health-Social-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ACCT processes are sufficient, so a mandatory period before closing an ACCT should not be imposed.
Verbatim wording from the response “As a key aim of ACCT is to focus on the needs of the individual, we do not believe that it is appropriate to mandate a period during which an ACCT cannot be closed. However, I wish to assure you that the processes in place work to provide the support needed in order to reduce the risk of self-harm and suicide and to ensure that an ACCT is not closed until it is considered safe to do so.” Source location 2021-0332-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Effective ACCT risk assessment and completed support actions make mandatory monitoring after transfer on an open ACCT unnecessary.
Verbatim wording from the response “Therefore, if the process is followed effectively and defensible decisions are made based on effective risk assessment then a mandatory period of monitoring for those who transfer on an open ACCT should not be required. The ACCT document will not be closed until all support actions have been completed and there is multi-disciplinary agreement that the level of risk has reduced.” Source location 2021-0332-Response-from-HMPPS_Published
Open published response
17 Sep 2021 Colin BLACKBURN · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 14
Failure to review the Care Map at ACCT Case Reviews View source Failure to hold an ACCT Case Review immediately before transfer View source Failure to hold an Initial ACCT Case Review within 24 hours of a concern View source
Failure to carry out required ACCT observations View source Failure to conduct multidisciplinary ACCT Case Reviews View source Failure to hold an ACCT Case Review after a ligature incident View source Failure of ACCT Case Review participants to familiarise themselves with the ACCT document View source Failure to record triggers or warning signs on the ACCT inside cover View source Failure of ACCT Case Manager involvement after prisoner transfer View source Delays in holding scheduled ACCT Case Reviews View source Failure to document ligature incidents on the NOMIS record View source Failure to ensure prison staff understand their ACCT obligations View source Delays in assigning an ACCT Case Manager View source Failure to make timely entries on the ACCT Care Map View source See 11 more concerns
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.
×
AI-generated summary
Colin BLACKBURN · 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
Colin Blackburn died at HMP Hewell on 6 July 2019 after spending 15 days on remand and having been found with a ligature around his neck on three prior occasions. Concerns included multiple accepted failings in the management of his ACCT suicide and self-harm risk, and uncertainty about the correct process for urgent mental-health referrals, particularly at weekends.
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 review the Care Map at ACCT Case Reviews
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews ;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 hold an ACCT Case Review immediately before transfer
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 hold an Initial ACCT Case Review within 24 hours of a concern
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern ;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 carry out required ACCT observations
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out ;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 conduct multidisciplinary ACCT Case Reviews
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary , with healthcare and mental healthcare sometimes not being invited to attend ;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 hold an ACCT Case Review after a ligature incident
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19 ;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 Case Review participants to familiarise themselves with the ACCT document
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand ;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 record triggers or warning signs on the ACCT inside cover
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover ;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 Case Manager involvement after prisoner transfer
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19 ;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 Delays in holding scheduled ACCT Case Reviews
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19 .
” Source location Colin BLACKBURN · 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 document ligature incidents on the NOMIS record
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record ;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 prison staff understand their ACCT obligations
Wider context from the report “I am not satisfied that sufficient action has yet been taken to ensure that all members of prison staff understand their obligations in respect of prisoners who are subject to the ACCT process. This is because:
(i) there is no evidence yet that the changes described above have led to a change in how prison staff deal with ACCT documents ; and
(ii) I heard evidence during the inquest from a number of senior officers who, even now, found it difficult to comprehend that their involvement with Mr. Blackburn and his ACCT document fell short of an acceptable standard .
” Source location Colin BLACKBURN · 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 Delays in assigning an ACCT Case Manager
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19 ;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · 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 make timely entries on the ACCT Care Map
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19 ;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · Prevention of Future Deaths report
Open source report
4 Jun 2021 Geoffrey Harrison HUTTON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3
Failure of the ACCT Case Manager allocation and oversight system View source Lack of formal training for ACCT Case Manager allocation and duties View source Failure to ensure ACCT training for staff carrying out night observations 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.
×
AI-generated summary
Geoffrey Harrison HUTTON · 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
Geoffrey Harrison Hutton died by suicide in his cell at HMP Long Lartin on 8 February 2019 after hanging himself with a ligature made from a laundry-bag drawstring. He had significant hearing impairment, longstanding mental health and substance misuse issues, and was subject to an ACCT document. The substantive concerns included failures relating to social-care referral and support for his hearing and communication needs, ineffective ACCT case-manager oversight, and insufficient ACCT training for some staff carrying out observations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the ACCT Case Manager allocation and oversight system
Wider context from the report “(2) There appears to be no effective system for allocating ACCT Case Managers at HMP Long Lartin . The officer (Officer A) who, when she opened the final ACCT document for Mr. Hutton, appointed herself as Case Manager for this ACCT, did so knowing that she would have no contact with him over the following two weeks. Officer A gave evidence that:
(a) this was common practice at the prison;
(b) officers were discouraged from not naming a Case Manager when they opened an ACCT, even if (as here ) it was opened at night;
(c) she was hoping that another officer might “take it over” from her.
As she predicted, she herself did indeed have no further contact with Mr. Hutton. Furthermore, this problem was not passed on or identified, and no other officer took over the Case Manager role. Therefore there was no effective oversight of an ACCT involving a potentially very vulnerable individual .
Of particular concern is that another appears to have filled in Officer A’s details in the “name” and “signature” boxes at the foot of the ACCT Caremap, and dated them 7.2.19 (the day before Mr. Hutton’s death ), thereby giving the impression that Officer A had reviewed and satisfied herself that the actions identified in the Caremap had been dealt with. In fact, the most important action on the Caremap, which required a social care referral, had not been completed.
This lack of effective oversight was not confined to Mr. Hutton’s final ACCT document. For his first ACCT document at HMP Long Lartin, only a month earlier, the named Case Manager had no involvement with it until the fourth ACCT Case Review, and made no entries on the Caremap ( which was signed off by a different officer ).
I heard evidence from a member of the current Senior Management Team at the prison that:
(a) there is currently no formal training for the allocation of, or fulfilment of the duties of the ACCT Case Manager role;
(b) this will be reviewed, and training will be organised.
The lack of an effective ACCT Case Manager, who is able to provide proper oversight of an ACCT , is an issue which was raised by me in a previous Report to Prevent Future Deaths which followed the death of another prisoner at HMP Long Lartin ( David KIRSCH – report dated 30.10.19 )
” Source location Geoffrey Harrison HUTTON · 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 formal training for ACCT Case Manager allocation and duties
Wider context from the report “(2) There appears to be no effective system for allocating ACCT Case Managers at HMP Long Lartin. The officer (Officer A) who, when she opened the final ACCT document for Mr. Hutton, appointed herself as Case Manager for this ACCT, did so knowing that she would have no contact with him over the following two weeks. Officer A gave evidence that:
(a) this was common practice at the prison;
(b) officers were discouraged from not naming a Case Manager when they opened an ACCT, even if (as here ) it was opened at night;
(c) she was hoping that another officer might “take it over” from her.
As she predicted, she herself did indeed have no further contact with Mr. Hutton. Furthermore, this problem was not passed on or identified, and no other officer took over the Case Manager role. Therefore there was no effective oversight of an ACCT involving a potentially very vulnerable individual.
Of particular concern is that another appears to have filled in Officer A’s details in the “name” and “signature” boxes at the foot of the ACCT Caremap, and dated them 7.2.19 (the day before Mr. Hutton’s death ), thereby giving the impression that Officer A had reviewed and satisfied herself that the actions identified in the Caremap had been dealt with. In fact, the most important action on the Caremap, which required a social care referral, had not been completed.
This lack of effective oversight was not confined to Mr. Hutton’s final ACCT document. For his first ACCT document at HMP Long Lartin, only a month earlier, the named Case Manager had no involvement with it until the fourth ACCT Case Review, and made no entries on the Caremap ( which was signed off by a different officer ).
I heard evidence from a member of the current Senior Management Team at the prison that:
(a) there is currently no formal training for the allocation of, or fulfilment of the duties of the ACCT Case Manager role ;
(b) this will be reviewed, and training will be organised.
The lack of an effective ACCT Case Manager, who is able to provide proper oversight of an ACCT, is an issue which was raised by me in a previous Report to Prevent Future Deaths which followed the death of another prisoner at HMP Long Lartin ( David KIRSCH – report dated 30.10.19 )
” Source location Geoffrey Harrison HUTTON · 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 ACCT training for staff carrying out night observations
Wider context from the report “(3) Not all prison staff who carry out ACCT observations on vulnerable prisoners at night have received ACCT training .
This issue became apparent when the Operational Support Grade member of staff ( OSG ) who found Mr. Hutton on the morning of his death gave evidence to the inquest. Not only had he not received any training about the ACCT procedure at the time of these events, that remains the case now.
I heard evidence from a member of the current Senior Management Team at the prison that OSGs are currently required to carry out ACCT observations at night, but that ACCT training for them is not mandatory and some have therefore not received such training .
It is of concern that those carrying out potentially critical observations on very vulnerable prisoners may not be aware of what the ACCT procedure involves , or what it may require of them if they have any concerns about a prisoner.
” Source location Geoffrey Harrison HUTTON · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ACCT version 6 across the prison estate to support multidisciplinary, person-centred care for people at risk.
Verbatim wording from the response “Your second concern relates to the system for allocating ACCT case managers. You may be aware that HMPPS has introduced a revised version of ACCT which went live across the prison estate in July 2021; ACCT version 6. The changes are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. The term Case Manager has been replaced with Case Coordinator to reflect the fact that everyone involved in the ACCT process is responsible for ensuring that good quality support is provided. Specific training for ACCT Case Coordinators is being provided and staff must undertake the relevant modules before taking up the role.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide specific training and require relevant modules for ACCT Case Coordinators before they take up the role.
Verbatim wording from the response “Your second concern relates to the system for allocating ACCT case managers. You may be aware that HMPPS has introduced a revised version of ACCT which went live across the prison estate in July 2021; ACCT version 6. The changes are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. The term Case Manager has been replaced with Case Coordinator to reflect the fact that everyone involved in the ACCT process is responsible for ensuring that good quality support is provided. Specific training for ACCT Case Coordinators is being provided and staff must undertake the relevant modules before taking up the role.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a database to support allocation of ACCT Case Coordinators using staffing and caseload information.
Verbatim wording from the response “At HMP Long Lartin a new database is being implemented to support the allocation of ACCT Case Coordinators. This contains information on staff rotas, periods of leave and how many open ACCTs each Case Coordinator currently has. This will facilitate effective allocation decisions and support a renewed focus on providing consistent and proper oversight and ownership of cases. In addition, the staffing resources within the safer custody team have been reviewed and an additional manager has been introduced, providing capacity to complete more assurance work around ACCT processes.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an additional safer custody team manager to increase capacity for ACCT assurance work.
Verbatim wording from the response “At HMP Long Lartin a new database is being implemented to support the allocation of ACCT Case Coordinators. This contains information on staff rotas, periods of leave and how many open ACCTs each Case Coordinator currently has. This will facilitate effective allocation decisions and support a renewed focus on providing consistent and proper oversight and ownership of cases. In addition, the staffing resources within the safer custody team have been reviewed and an additional manager has been introduced, providing capacity to complete more assurance work around ACCT processes.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make suicide and self-harm training, including ACCT material, mandatory for Operational Support Grade staff.
Verbatim wording from the response “Your final concern relates to the fact that some Operational Support Grade (OSG) staff who carry out ACCT observations at night have not received ACCT training. We are making changes to the training provided to OSG staff, making it mandatory for OSGs to complete suicide and self-harm (SASH) training, which includes material on ACCT. Initial OSG training will also be changed, so that from early 2022 all new OSGs will receive the relevant SASH training modules as routine.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide relevant suicide and self-harm training modules routinely to all new Operational Support Grade staff from early 2022.
Verbatim wording from the response “Your final concern relates to the fact that some Operational Support Grade (OSG) staff who carry out ACCT observations at night have not received ACCT training. We are making changes to the training provided to OSG staff, making it mandatory for OSGs to complete suicide and self-harm (SASH) training, which includes material on ACCT. Initial OSG training will also be changed, so that from early 2022 all new OSGs will receive the relevant SASH training modules as routine.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
25 May 2021 James Devenny · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1
Unclear threshold for informing prison staff about significant self-harm risk 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.
×
AI-generated summary
James Devenny · 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
James Devenny died in his cell at HMP Elmley on 2 September 2019, having been found hanging from a light fitting using a bedsheet ligature. The jury identified concerns including staff not being aware of his previous self-harm history, the absence of a medical assessment before his separation from other prisoners, an inappropriate response to mental health referrals, and inadequate access to phones and support services. The report also records concerns about prison officers not being routinely briefed about prisoners’ previous significant self-harm and related patterns of thoughts, feelings, events and behaviours.
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 Unclear threshold for informing prison staff about significant self-harm risk
Wider context from the report “(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT . Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm.
” Source location James Devenny · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ACCT version 6 across the male estate, including strengthened risk-identification requirements and revised staff training and awareness materials.
Verbatim wording from the response “You will recall that evidence was given at the inquest about the updated version of Assessment Care in Custody and Teamwork version 6 (ACCT v6), which was due to be rolled out shortly after the inquest. I am pleased to confirm that ACCT v6 went live across the male estate in July 2021. Along with updates and improvements made to the ACCT document there is also an increased emphasis placed on up-skilling staff in relation to risk identification, and revised training modules and awareness materials have been made available to all staff at the prison.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Key Worker scheme, providing each person in custody with a dedicated worker and weekly meetings to identify risks, triggers and changes in self-harm or suicide risk.
Verbatim wording from the response “The prison also now operates the Key Worker scheme, whereby all people in custody have a dedicated Key Worker who meets with them on a weekly basis. The intention of Key Work is to enable better relationships between staff and people in prison, and to support those in custody to settle into prison life. Key Workers are expected to be aware of an individual’s history and to work with them to help and support them with any issues. As part of this role key workers review National Offender Management Information System (NOMIS) case notes and look at any previous issues or risks, including self-harm. They are therefore well placed to recognise any changes in the level of an individual’s risk of self-harm or suicide and to be aware of any potential trigger dates which may indicate that an ACCT should be opened to provide increased support.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and routinely use an updated safety diagnostic tool consolidating violence, self-harm and other relevant risk information for staff.
Verbatim wording from the response “An updated safety diagnostic tool which provides information about individuals is available to all staff. This includes information on violence and self-harm, and other relevant information drawn from NOMIS. The tool makes it easier to access all relevant risk information in one place and is routinely used by safer custody staff who flag any new receptions and any individuals they are concerned about to wing staff and other relevant departments within the prison.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
7 May 2021 Corin Bonaparte · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Failure to open an ACCT following disclosure of recent deliberate self-harm 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.
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. 10
Action
Implement the approved revised healthcare ACCT operating procedure requiring documentation of reported or observed self-harm and opening an ACCT where required.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Obtain staff acknowledgements confirming that all healthcare staff have read and understood the revised ACCT guidance.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Deliver ACCT/SASH training to healthcare staff who require it, with sessions booked and attendance recorded and monitored.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Include healthcare staff in multidisciplinary ACCT V6 training at HMP Dartmoor to refresh responsibilities, vulnerability awareness and ACCT-opening criteria.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Add Head of Healthcare sign-off to confirm completion of new-staff induction covering the ACCT process.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Hold weekly collaborative healthcare meetings to discuss ACCT practice, record keeping, transfers, discharge, mental-health awareness and shared learning.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Audit healthcare involvement in the ACCT process through the P.R.O.T.E.C.T. patient-safety audit and escalate findings through quality-assurance governance where required.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Roll out the revised ACCT v6 process across the prison estate.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Deliver ACCT v6 training to prison staff, including healthcare colleagues, at HMP Dartmoor.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021. View source
Action
Deliver SASH training to healthcare staff and prioritise attendance at monthly sessions.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021. View source See 7 more actions
×
AI-generated summary
Corin Bonaparte · 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
Corin Bonaparte, a young man aged 23, was found hanging in his cell at HMP Dartmoor on 28 February 2017 after his former partner ended contact with him during a telephone call. Resuscitation efforts were unsuccessful. Concerns included the failure to open an ACCT after he disclosed deliberate self-harm, suggesting inadequate training, and an eight-minute delay in an ambulance leaving the prison because an escort was being sought.
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 following disclosure of recent deliberate self-harm
Wider context from the report “(1) Addressed to the Head of Healthcare and the Governor, HMP Dartmoor
Corin sought help from the mental health department at HMP Dartmoor. He revealed to a nurse in the mental health department the fact that he had recently deliberately harmed himself and made this fact known to other mental health workers. An ACCT was not opened despite the provisions in Chapter 2 of PSI 64 / 2011 which made the opening of an ACCT in these circumstances mandatory. In the light of the evidence from relevant witnesses at the inquest hearing it could not be confidently assumed that their actions would be any different if similar circumstances were to arise in the future . This suggested a lack of adequate training.
” Source location Corin Bonaparte · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the approved revised healthcare ACCT operating procedure requiring documentation of reported or observed self-harm and opening an ACCT where required.
Verbatim wording from the response “The Head of Healthcare and clinical team at HMP Dartmoor have reviewed and made additions to the Local Operating Procedure (LOP) for healthcare involvement in the ACCT (Assessment, Care, Custody & Teamwork) process. The additions that have been made specify that recently reported or observed self-harm must be documented and that, in accordance with the requirements of PSI 64/2011, an ACCT must be opened. The revised LOP was submitted to the Local Quality Assurance Meeting and approved on 22nd June 2021. A staff signatory sheet will be signed by all staff acknowledging they have read and understood this guidance by 12th July 2021.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain staff acknowledgements confirming that all healthcare staff have read and understood the revised ACCT guidance.
Verbatim wording from the response “The Head of Healthcare and clinical team at HMP Dartmoor have reviewed and made additions to the Local Operating Procedure (LOP) for healthcare involvement in the ACCT (Assessment, Care, Custody & Teamwork) process. The additions that have been made specify that recently reported or observed self-harm must be documented and that, in accordance with the requirements of PSI 64/2011, an ACCT must be opened. The revised LOP was submitted to the Local Quality Assurance Meeting and approved on 22nd June 2021. A staff signatory sheet will be signed by all staff acknowledging they have read and understood this guidance by 12th July 2021.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ACCT/SASH training to healthcare staff who require it, with sessions booked and attendance recorded and monitored.
Verbatim wording from the response “With regard to promoting staff training and awareness, the prison last held ACCT / Suicide and Self-Harm (SASH) training on 8th December 2020 and this was attended by twelve health staff. Following this all healthcare staff in post had completed prison ACCT training. Training was then placed on hold due to the Covid-19 outbreak, as a result of which, at the time of the inquest, we had four new members of staff requiring training. However, for two of these members of staff this would have constituted refresher training as they had transferred from other prison establishments and had received ACCT training before.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include healthcare staff in multidisciplinary ACCT V6 training at HMP Dartmoor to refresh responsibilities, vulnerability awareness and ACCT-opening criteria.
Verbatim wording from the response “In addition to the above, from July 2021, nationally updated ACCT guidance (V6) is being rolled out across all prisons in England & Wales by Her Majesty’s Prison and Probation Service. This training provides further clarity on the roles and responsibilities of healthcare staff within the ACCT process. The training is multi-disciplinary and will be open to all colleagues (including healthcare). The ACCT V6 training will commence at HMP Dartmoor on 5th July 2021 and the Head of Healthcare has received assurance that healthcare staff will be included in the updated training programme. This will provide the opportunity for joint training sessions in which all healthcare staff and discipline colleagues will review and refresh their knowledge of the ACCT process, increase their awareness of vulnerability and risk factors, and enhance their understanding of when an ACCT should be opened.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add Head of Healthcare sign-off to confirm completion of new-staff induction covering the ACCT process.
Verbatim wording from the response “In addition to the above, the Practice Plus Group General Induction Booklet contains a section on the ACCT process and as part of our induction process for new staff, ACCT is discussed within the twelve week induction period. A confirmatory signature is required from the inducting supervisor to evidence completion. To ensure a robust and quality induction experience, additional sign off will now be undertaken by the Head of Healthcare on completion of the induction period. Devon Partnership Trust have a similar process in place for the mental healthcare team, with an induction booklet signed by both the individual staff member and the Mental Health Team Manager. We will monitor this and obtain further assurance that all new starters in the mental health team have sufficient knowledge of how and when to open an ACCT through our quarterly sub-contractor review meetings with DPT.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly collaborative healthcare meetings to discuss ACCT practice, record keeping, transfers, discharge, mental-health awareness and shared learning.
Verbatim wording from the response “In a further collaborative learning initiative, Practice Plus Group and Devon Partnership Trust have arranged to hold weekly meetings for all healthcare staff to discuss ‘hot topics’ (for example ACCT reviews, clinical record keeping, transfer and discharge processes, mental health awareness sessions and other clinical bitesize sharing best practice sessions). This will further support embedding of lessons learned in to daily practice.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit healthcare involvement in the ACCT process through the P.R.O.T.E.C.T. patient-safety audit and escalate findings through quality-assurance governance where required.
Verbatim wording from the response “Managing healthcare involvement within the ACCT process is also audited through our Practice Plus Group bespoke prisons patient safety audit, which is called ‘P.R.O.T.E.C.T’. This audit tool was developed from an evidence base of key themes from lessons learnt through deaths in custody, and is undertaken throughout the year on an annual audit schedule. The audit standards assess compliance in mental health referrals, timeliness of assessment, and of mental health team involvement in the ACCT process. Results of the audits are reviewed and discussed through Local Quality Assurance meetings within HMP Dartmoor. Where required themes are escalated to Regional Quality Assurance meetings and to quarterly National Quality Assurance meetings to evaluate the effectiveness of action planning and implementation within the audit cycle.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the revised ACCT v6 process across the prison estate.
Verbatim wording from the response “ACCT is a prison service document that assists staff in providing multi-disciplinary care and support to individuals at risk of harm to themselves, in order to minimise that risk. It is to be utilised by all members of staff working within prisons, including healthcare colleagues, and it is important staff feel confident in recognising risk and making the decision to open an ACCT in order to support prisoners through their period of crisis.” Source location 2021-0143-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ACCT v6 training to prison staff, including healthcare colleagues, at HMP Dartmoor.
Verbatim wording from the response “In July 2021, a new version of ACCT (Version 6, known as “ACCT v6”) was rolled out across the prison estate. The changes made to ACCT are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person centred approach which meets the needs of each individual in order to minimise their risk of harm to self. Training packages have been developed to assist in the understanding and delivery of the new ACCT process and include sessions on” Source location 2021-0143-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver SASH training to healthcare staff and prioritise attendance at monthly sessions.
Verbatim wording from the response “understanding self-harm, the ACCT v6 process and supporting individuals who self-harm. Training is currently being delivered at HMP Dartmoor and is available to all staff, including healthcare colleagues. Introduction to Suicide and Self-Harm Prevention (SASH) training is being delivered to healthcare attendance at the monthly sessions has been prioritised in order to support the up-skilling of staff in recognising risks and triggers for self-harm, as well as to build confidence in decision making around the opening of ACCT documents.” Source location 2021-0143-Response-from-HMPPS_Published
Open published response
Concerns raised 1
Failure to prevent ACCT closure when required medical treatment is unavailable or incomplete View source
This report raised 19 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.
×
AI-generated summary
Andrew Patrick Jones · 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 Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.
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 prevent ACCT closure when required medical treatment is unavailable or incomplete
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred ;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Source location Andrew Patrick Jones · Prevention of Future Deaths report
Open source report
21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 1
SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information 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.
×
AI-generated summary
Andrew Goldstraw · 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 Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent 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 SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT . Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Source location Andrew Goldstraw · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Verbatim wording from the response “The Trust has sent out guidance to all offender care sites in relation to the search function. Whilst this is a function owned by SystmOne CNWL has given staff directions on how to best utilise this function. For instance, when trying to get a history of suicide attempts rather than searching suicide the clinician should search ‘suic’ which will bring up results for suicide, suicidal, suicidal thoughts.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Verbatim wording from the response “We will also remind staff that other organisations use SystmOne and that they may not enter data in an easy to view way. Staff have been advised to use search functionality to find data that may have not been entered properly by staff from other organisations.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.
Verbatim wording from the response “SystmOne is the medical records system for all prisoners and this contract with TPP is managed by NHS England and not directly by CNWL. However, with internal training and audit we hope to be able to overcome a significant proportion of the limitations identified. We will also be raising the Coroner’s concerns and our work around with TPP so that they can consider them in any future developments of the system” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Verbatim wording from the response “Whilst the risk assessment template on SystmOne does ask pre-set questions the clinician is not reliant solely on the information disclosed during the assessment. When completing the risk assessment there is a section on the right hand side of the template with previous values that have been entered in relation to these questions. This allows the clinician to have an understanding of previous answers to these questions and gives them some context when considering a response to a question. For instance if a patient’s response contradicts a previous statement they have made the staff will be able to ascertain this and ask appropriate follow up. When the cursor is put in the box relating to risk incidents and triggers previous entries about this come up on the right hand section of the template.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
14 Jan 2020 Marlon Roy WATSON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1
Lack of full and proper understanding of the ACCT process among healthcare staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marlon Roy WATSON · 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
Marlon Roy Watson was a serving prisoner at HMP Dovegate who died by hanging in his cell on 29 September 2018. The concerns included whether healthcare staff fully understood the ACCT process, and the inquest findings identified issues including reliance on self-referral, administrative errors, unanswered or unacknowledged calls, and lack of access to relevant patient information between healthcare teams.
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 full and proper understanding of the ACCT process among healthcare staff
Wider context from the report “1. At the inquest there was a concern that members of healthcare staff at HMP Dovegate do not have a full and proper understanding of the ACCT process . I would appreciate reassurance that appropriate initial training and refresher training takes place and that (if possible) this is audited.
” Source location Marlon Roy WATSON · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request the prison to provide additional ACCT and refresher training for the GP and all healthcare staff within 12 weeks.
Verbatim wording from the response “Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites.” Source location Response from Care UK
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Arrange additional ACCT and suicide and self-harm awareness refresher training for the GP and all staff.
Verbatim wording from the response “Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites.” Source location 2020-0010-Response-from-HMP-Dovegate-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The prison is responsible for providing ACCT training because ACCT is a prison process.
Verbatim wording from the response “Assessment, Care in Custody and Teamwork (ACCT) is the care planning process for prisoners identified as being at risk of suicide or self-harm. The ACCT process requires that certain actions are taken to ensure that the risk of suicide and self-harm is reduced. This is a prison process and training is provided by the prison as part of a professional’s induction before they work within the prison. The GP received that training on 25th July, 2018 as part of his induction.” Source location Response from Care UK
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ACCT training is a prison process, with delivery assigned to HMP Dovegate rather than Care UK.
Verbatim wording from the response “Assessment, Care in Custody and Teamwork (ACCT) is the care planning process for prisoners identified as being at risk of suicide or self-harm. The ACCT process requires that certain actions are taken to ensure that the risk of suicide and self-harm is reduced. This is a prison process and training is provided by the prison as part of a professional’s induction before they work within the prison. The GP received that training on 25th July, 2018 as part of his induction.” Source location 2020-0010-Response-from-HMP-Dovegate-Redacted
Open published response
Pin
Get email alerts
Request correction
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.
