Recurring concern

Unreliable ACCT suicide and self-harm prevention processes

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First reported 16 Sep 2013•Latest report 29 Jun 2026

Definition

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.

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: 92
Individual concerns: 184
Date range: 2013–2026
Stated actions: 276

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service41

Ministry of Justice27

NHS England15

Care UK6

Department of Health and Social Care6

HM Prison Service6

Central and North West London NHS Foundation Trust5

Hewell Prison5

Oxleas NHS Foundation Trust5

HM Inspectorate of Prisons4

Practice Plus Group4

Birmingham and Solihull Mental Health NHS Foundation Trust3

Birmingham Prison3

G4S3

Greater Manchester Mental Health NHS Foundation Trust3

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

2 Dec2013
Manchester City
Concerns raised1
1. Failure to attach existing Risk of Self-Harm / Suicide documents to ACCT documents
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

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
16 Sep2013
Worcestershire
Concerns raised2
1. Failure to hold required multidisciplinary review meetings
2. Failure to record the nurse's professional view in the ACCT document
This report raised 5 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 3
1. Action
  Review Prison Service Instruction 64/2011 to identify and address areas of non-compliance at HMP Hewell.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completed
2. Action
  Issue Operational Orders requiring ACCT reviews to be multidisciplinary and obtain views from all appropriate departments.
  Stated by Bristol Prison and Hewell PrisonStated completed
3. Action
  Disseminate and reiterate requirements for reviewing and documenting ACCT records for prisoners arriving at HMP Hewell.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completed
Respondent positions 1
1. Position
  Established ACCT reception review and recording requirements are considered sufficient to address concerns about identifying and managing prisoner risk.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustExisting arrangements considered sufficient
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

Concerns raised2

Failure to hold required multidisciplinary review meetings

Failure to record the nurse's professional view in the ACCT document

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Respondent positions 1