Recurring concern

Unreliable ACCT suicide and self-harm prevention processes

First to latest report 16 Sep 2013 — 29 Jun 2026

Reports that mention this concern
92
Times this concern has been raised
184
Stated actions linked to this concern
276

What this concern includes

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.

What is not included
  • Excludes generic organisational quality assurance, staffing or training failures that are not explicitly tied to ACCT.
  • Excludes unrelated prison, healthcare or mental-health processes that do not form part of ACCT.
  • Excludes outcomes, individual clinical judgments or underlying causes unless the assertion identifies a failure of an ACCT control.

Reports and published responses 92 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester City

    AI-generated summary

    Michael James Meyler · 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

    Michael James Meyler died in hospital on 1 January 2011 after being found hanging by the neck in his prison cell on 28 December 2010 and sustaining a hypoxic brain injury. The principal concerns were that information about his recent self-harm and suicide risk was not adequately circulated, read, or attached to his ACCT plan, limiting the ability of prison staff and healthcare personnel to make informed decisions about his welfare.

    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 attach existing Risk of Self-Harm / Suicide documents to ACCT documents

    Wider context from the report

    “3. I am concerned that if an ACCT document is opened for any reason that if there should be a Risk of Self-Harm / Suicide document in existence for the prisoner, that it MUST be attached to the ACCT document. In this case the ACCT document was opened principally as an “instrument of support” where it was believed that the prisoner’s primary issues involved contact with his family and his children in particular. It was not known by those who opened the ACCT document and who conducted the various ACCT reviews that he had a history of self-harm which involved both taking an overdose and cutting his wrists on several occasions in the immediate months before he was committed to prison as a consequence of his distress over a long-term relationship breaking down. Furthermore, in the light of the information contained in the Risk of Self-Harm / Suicide document which came to their attention after the death of the deceased, all the Prison Officers involved indicated that they would have referred the deceased on for a Mental Health Inreach Assessment had they known of the details of his previous history. All the Prison Officers concerned felt that they had not been able to make “informed decisions” regarding the welfare of the prisoner concerned as they were not in possession of all the facts at the relevant times. ”

    Source location

    Michael James Meyler · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  2. Worcestershire

    AI-generated summary

    Reggie Johns · 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

    Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.

    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 hold required multidisciplinary review meetings

    Wider context from the report

    “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status. (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare. This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review. Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed. (3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view. Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel. Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents. ”

    Source location

    Reggie Johns · Prevention of Future Deaths report
    Page 3 · concerns

    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 the nurse's professional view in the ACCT document

    Wider context from the report

    “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status. (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare. This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review. Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed. (3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view. Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel. Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents. ”

    Source location

    Reggie Johns · Prevention of Future Deaths report
    Page 3 · concerns

    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

    Review Prison Service Instruction 64/2011 to identify and address areas of non-compliance at HMP Hewell.

    Verbatim wording from the response

    “I can also confirm that following the inquest into Mr Johns’ death ████████ and ████████ Prison Governor, HMP Hewell have reviewed Prison Service Instruction 64/2011 (updated) – in order to identify any areas of non-compliance and to address these.”

    Source location

    2013-0202-Response-by-Worcestershire-Health-Care-NHS
    Page 2 · response
    Published 16 September 2013

    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 Operational Orders requiring ACCT reviews to be multidisciplinary and obtain views from all appropriate departments.

    Verbatim wording from the response

    “Since Mr Johns' death, the enclosed Operational Orders have been issued entitled ‘Chairing ACCT Reviews’ and ‘ACCT Reviews’ which provide guidance for selecting appropriate ACCT case managers, and confirm that it is the case manager's responsibility to ensure that each review is multi-disciplinary with views from all appropriate departments being taken into consideration.”

    Source location

    2013-0202-Response-by-NOMS
    Page 2 · response
    Published 16 September 2013

    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

    Disseminate and reiterate requirements for reviewing and documenting ACCT records for prisoners arriving at HMP Hewell.

    Verbatim wording from the response

    “At the time of Mr Johns’ inquest when this issue was discussed, ████████ wrote to all staff within the healthcare team at HMP Hewell to set out their expectations in respect of prisoners arriving in Reception at HMP Hewell on an ACCT. These are as follows:”

    Source location

    2013-0202-Response-by-Worcestershire-Health-Care-NHS
    Page 2 · response
    Published 16 September 2013

    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

    Established ACCT reception review and recording requirements are considered sufficient to address concerns about identifying and managing prisoner risk.

    Verbatim wording from the response

    “At the time of Mr Johns’ inquest when this issue was discussed, ████████ wrote to all staff within the healthcare team at HMP Hewell to set out their expectations in respect of prisoners arriving in Reception at HMP Hewell on an ACCT. These are as follows:”

    Source location

    2013-0202-Response-by-Worcestershire-Health-Care-NHS
    Page 2 · response
    Published 16 September 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026