25 Jul 2025 Michael Pugh · Prevention of Future Deaths report Kent and Medway
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Concerns raised 2
Failure to carry out and record ACCT observations at unpredictable times View source Inadequate training on the ACCT process View source
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Michael Pugh · 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 Pugh was found dead in his prison cell on 29 June 2024 while subject to an ACCT. No observations were carried out between 07.22 and 09.57 on the day he was discovered, and the record was completed retrospectively; concerns also included new officers’ incomplete understanding of the ACCT observation and recording requirements.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to carry out and record ACCT observations at unpredictable times
Wider context from the report “(1) The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POEL training and the other 1 month experience. Both officers gave evidence that following their POEL training their understanding of the ACCT process was incomplete; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00.
” Source location Michael Pugh · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate training on the ACCT process
Wider context from the report “(1) The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POEL training and the other 1 month experience. Both officers gave evidence that following their POEL training their understanding of the ACCT process was incomplete ; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process ”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00.
” Source location Michael Pugh · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all new prison officers with a full day of suicide and self-harm prevention training, including ACCT procedures and observation recording requirements.
Verbatim wording from the response “All new members of staff receive a full day of training on suicide and self-harm prevention during their POELT training. This includes training on the ACCT process and the appropriate timings and intervals of when ACCT observations need to be carried out and recorded. Following completion of POELT training, new entry officers have a two week local induction before ‘going live’ and becoming fully operational. Part of this local induction programme at Swaleside includes ACCT upskilling and a session based on completion of ACCT documents and recording of ACCT observations. The local training team keep a record of these sessions. Any further training needs for staff would be identified and delivered locally.” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide role-specific ACCT training to staff undertaking key ACCT case-management roles, including assessors and case coordinators.
Verbatim wording from the response “Additionally, any member of staff who undertakes a key role relating to ACCT case management, for example ACCT assessors or case co-ordinators, receives training specific to these roles.” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an online Safety Learning Reference Library with ACCT guidance, templates, training materials and observation-recording resources accessible to staff.
Verbatim wording from the response “In addition to the training HMPPS has an online Safety Learning Reference Library which holds various guidance, templates and training material, all of which are accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT where staff can access a ‘Recording Observations’ video guide as well as a written guide, both of which” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote the Safety Learning Reference Library to new staff during induction and signpost it to all staff during the next national safety focus initiative.
Verbatim wording from the response “include examples of best practice for carrying out ACCT observations. Going forward HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during their induction and, furthermore, will signpost the Safety Learning Reference Library to all staff during the HMPPS annual national safety focus initiative being held next month.” Source location Response from HM Prison & Probation Service
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18 Jul 2025 Patryk Gladysz · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Ongoing challenges in prison officer checks of roll calls and ACCT observations View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Patryk Gladysz · 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
Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and training.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Ongoing challenges in prison officer checks of roll calls and ACCT observations
Wider context from the report “(5) Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges .
” Source location Patryk Gladysz · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief prison staff on roll-check responsibilities, including timely completion and obtaining a wellbeing response from each prisoner.
Verbatim wording from the response “Prison staff have received briefings with regards to their responsibilities during roll checks, including the need for timely completion and the requirement for a response to be gained from the prisoner to ensure their wellbeing. This has resulted in an improvement in documented roll check timings. The Governor of HMP Wandsworth has now also implemented a monthly assurance check, which cross references documented ACCT observations against CCTV footage. Appropriate action is taken against any member of staff who does not complete these checks in line with national policy.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement monthly assurance checks comparing documented ACCT observations with CCTV footage and take action on non-compliance.
Verbatim wording from the response “Prison staff have received briefings with regards to their responsibilities during roll checks, including the need for timely completion and the requirement for a response to be gained from the prisoner to ensure their wellbeing. This has resulted in an improvement in documented roll check timings. The Governor of HMP Wandsworth has now also implemented a monthly assurance check, which cross references documented ACCT observations against CCTV footage. Appropriate action is taken against any member of staff who does not complete these checks in line with national policy.” Source location Response from HM Prison and Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HM Prison and Probation Service or the Ministry of Justice is responsible for addressing concerns about prison staff knowledge, checks and suicide prevention observations.
Verbatim wording from the response “I would expect your concerns around poor knowledge among prison staff, prison officer checks during roll calls and suicide prevention observations to be addressed by HM Prison and Probation Service and/or the Ministry of Justice in their responses to you.” Source location Response from Department for Health and Social Care
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2 May 2025 Sarah Frances BOYLE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 5
Failure to respond reliably to expressions of self harm or suicidality View source ACCT observations failing to provide therapeutic support View source Insufficient staffing capacity to complete ACCT checks and documentation View source
Inconsistent completion of the ACCT process View source Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations View source See 2 more concerns
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sarah Frances BOYLE · 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
Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to respond reliably to expressions of self harm or suicidality
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed ;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Source location Sarah Frances BOYLE · 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 observations failing to provide therapeutic support
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming . Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Source location Sarah Frances BOYLE · 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 Insufficient staffing capacity to complete ACCT checks and documentation
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime . It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed ;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Source location Sarah Frances BOYLE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent completion of the ACCT process
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process ”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Source location Sarah Frances BOYLE · 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 Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Source location Sarah Frances BOYLE · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a local safety summit and upskill staff on suicide and self-harm risks, triggers and protective factors.
Verbatim wording from the response “I recognise your concerns that Styal has had a higher number of self-inflicted deaths than other establishments in the women’s estate, and would like to reassure you that following the cluster of self-inflicted deaths, support has been provided to the prison from the national safety team as part of the HMPPS cluster death support process. This has included assistance with delivering a local safety summit and upskilling for staff on a range of issues, including awareness of risks, triggers and protective factors for suicide and self-harm.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure meaningful support actions are identified and implemented at each ACCT case review.
Verbatim wording from the response “In the light of your concerns and on the basis of other feedback and learning, the Governor of Styal is taking further steps to ensure meaningful support actions are identified at each case review and implemented. Case reviews are subject to quality assurance processes, and any case coordinators identified as needing additional support receive weekly one-to-one upskilling sessions. Furthermore, through the support of the group safety team, learning and best practice identified from other cases within the women’s estate is shared and applied at Styal to facilitate continuous improvement.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide weekly one-to-one upskilling sessions for case coordinators requiring additional support.
Verbatim wording from the response “In the light of your concerns and on the basis of other feedback and learning, the Governor of Styal is taking further steps to ensure meaningful support actions are identified at each case review and implemented. Case reviews are subject to quality assurance processes, and any case coordinators identified as needing additional support receive weekly one-to-one upskilling sessions. Furthermore, through the support of the group safety team, learning and best practice identified from other cases within the women’s estate is shared and applied at Styal to facilitate continuous improvement.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the local safety team by introducing a safety analyst and second safety hub manager to support ACCT quality assurance and staff upskilling.
Verbatim wording from the response “All prisoners at Styal who are subject to ACCT case management and have observation levels set at more than one every two hours are located on the residential wings, as opposed to the dormitories, where there are more staff available to conduct the observations. Additionally, women who are being supported through the ACCT process are discussed during the Senior Management Team morning meeting, and where appropriate more staff are deployed to areas in which more such individuals are located to ensure that there is time for meaningful interactions with them. In support of this the local safety team is being expanded with the introduction of a safety analyst and a second safety hub manager, who will assist in the ACCT quality assurance process and provide any necessary upskilling for staff.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
11 Mar 2025 Sean Higgins · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1
Failure to ensure support plans are started or completed before ACCT closure 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.
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AI-generated summary
Sean Higgins · 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
Sean Higgins, who was imprisoned at HMP Rochester, had a history of mental health issues and substance abuse and died after a period of deteriorating mental health, medication non-adherence and repeated self-harm concerns. The inquest concluded that his death was suicide. Concerns included failures to follow prison and mental health policies, inadequate review of relevant records and risk, and ACCT support plans being incomplete when the ACCT was closed.
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 ensure support plans are started or completed before ACCT closure
Wider context from the report “(2) Some of the officers chairing reviews did not understand how to complete the support plan paperwork such that the ACCT was closed when some of the support plans had not started or had not been completed
” Source location Sean Higgins · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and share training covering accurate risk assessment and support-plan quality with ACCT case coordinators and line managers.
Verbatim wording from the response “The Governor of HMP Rochester has provided assurances that these issues have been addressed, and the establishment have produced a training video covering both areas of concern. This has been shared with case coordinators and their line managers and is intended to ensure there is a clear understanding of the process among those responsible for conducting ACCT reviews and developing support plans.” Source location Response from HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct briefing sessions for all ACCT case coordinators on reviewing documentation, assessing risk, and implementing meaningful support plans before ACCT closure.
Verbatim wording from the response “To further embed understanding of existing procedures, HMP Rochester’s Safety Team has conducted briefing sessions with all case coordinators, specifically focused on the concerns raised at the inquest. These sessions have been designed to reinforce the importance of thoroughly reviewing all relevant documentation, including ongoing case notes when assessing risk. They have also emphasised the need to create meaningful support plans that are actioned and fully implemented before initiating the closure of the ACCT.” Source location Response from HMPPS
Open published response
20 Dec 2024 Haydar Jefferies · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Haydar Jefferies · 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
Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.
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 process to protect non-suicidal prisoners in acute mental health crisis
Wider context from the report “7. The ACCT process is not designed nor effective to protect prisoners in acute mental health crisis who do not appear to be suicidal .
” Source location Haydar Jefferies · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ACCT process and policy fall outside NHS England’s ownership, so NHS England cannot comment on this concern.
Verbatim wording from the response “Ownership of the ACCT process and policy lies with HMPPS. NHS England are therefore not able to comment on this point and would recommend that this is directed to HMPPS for a full response.” Source location Response from NHS England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the ACCT process and policy rests with HMPPS, which should provide the full response on this concern.
Verbatim wording from the response “Ownership of the ACCT process and policy lies with HMPPS. NHS England are therefore not able to comment on this point and would recommend that this is directed to HMPPS for a full response.” Source location Response from NHS England
Open published response
4 Dec 2024 Kayleigh Ann MELHUISH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2
Failure by healthcare staff to check and update ACCT care plan support actions during reviews View source Failure to complete or review ACCT care plans and support actions at every review View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kayleigh Ann MELHUISH · 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
Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by 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 by healthcare staff to check and update ACCT care plan support actions during reviews
Wider context from the report “2. Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated ; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.
” Source location Kayleigh Ann MELHUISH · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete or review ACCT care plans and support actions at every review
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews ;
c. Little or no understanding of when constant supervision can be used and how is it used;
” Source location Kayleigh Ann MELHUISH · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ACCT case-review training and refresher training for case coordinators.
Verbatim wording from the response “These issues are covered in the case review training that is provided to ACCT case coordinators, and a case review refresher course is also available for staff to attend. A new quality assurance process for ACCT has also been developed and provides an opportunity for managers to offer feedback to case co-ordinators to enhance their performance.” Source location Response from HMPPS/MoJ and HMP Eastwood Park
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and operate an ACCT quality-assurance process providing feedback, support and escalation for case-management concerns.
Verbatim wording from the response “These issues are covered in the case review training that is provided to ACCT case coordinators, and a case review refresher course is also available for staff to attend. A new quality assurance process for ACCT has also been developed and provides an opportunity for managers to offer feedback to case co-ordinators to enhance their performance.” Source location Response from HMPPS/MoJ and HMP Eastwood Park
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete consideration of adding a SystmOne tick-box confirming review of care plans and support actions.
Verbatim wording from the response “Matter of Concern 2: Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.” Source location Response from Practice Plus Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain regular audits of ACCT reviews to verify that care plans and support actions are reviewed and updated appropriately.
Verbatim wording from the response “To address this matter effectively, we remain committed to maintaining robust oversight through regular audits of ACCT reviews. These audits will ensure that care plans and associated support actions are being reviewed and updated appropriately.” Source location Response from Practice Plus Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with the prison to ensure clinical staff complete updated ACCT training and have access to regular training sessions.
Verbatim wording from the response “Additionally, we will continue to collaborate closely with the prison to ensure all relevant staff complete updated ACCT training. This will reinforce the importance of thorough and consistent care plan reviews as part of the ACCT process. As at today’s date, 78% of all clinical staff have completed ACCT training and we continue to work with the prison to ensure access to regular ACCT training sessions.” Source location Response from Practice Plus Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring the ACCT review process.
Verbatim wording from the response “Practice Plus Group conduct regular audits of the ACCT process, in October and November 2024 Healthcare attended 100% of all ACCT reviews and this is documented on SystmOne. We will continue to monitor this process.” Source location Response from Practice Plus Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and approve the local operating procedure for ACCT attendance.
Verbatim wording from the response “The Trust has reviewed our involvement and input into the ACCT process, and revised the Local Operating Procedure for ACCT attendance (attached). This was discussed and signed off at the service level Quality and Standards meeting on 22nd January 2025.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor ACCT training, refresher completion, and record-keeping standards through a scheduled audit programme.
Verbatim wording from the response “To ensure adherence with this procedure, the Quality and Standards meeting will monitor completion of ACCT training and refreshers through an audit schedule, which will also include monitoring improvements in standards across record keeping in ACCT and SystmOne.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Quality Improvement Plan supporting the ACCT procedure and associated monitoring.
Verbatim wording from the response “A Quality Improvement Plan has been developed to support this and is attached.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to SystmOne are limited because the software provider controls implementation of database changes.
Verbatim wording from the response “Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness.
However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted.” Source location Response from Practice Plus Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementation of a SystmOne care-plan review tick-box would require action by TPP, which owns and operates the software.
Verbatim wording from the response “Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness.
However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted.” Source location Response from Practice Plus Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A SystmOne tick-box would not ensure that meaningful care-plan reviews and updates were conducted.
Verbatim wording from the response “Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness.
However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted.” Source location Response from Practice Plus Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regular audits of ACCT reviews are considered an effective alternative for ensuring care plans and support actions are reviewed and updated.
Verbatim wording from the response “To address this matter effectively, we remain committed to maintaining robust oversight through regular audits of ACCT reviews. These audits will ensure that care plans and associated support actions are being reviewed and updated appropriately.” Source location Response from Practice Plus Group
Open published response
25 Oct 2024 Mark Stephen Beresford · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure to understand and assess risk in ACCT processes and risk assessments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mark Stephen Beresford · 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
Mark Stephen Beresford died at Bassetlaw District General Hospital on 7 July 2023 after applying a ligature while detained at HMP Ranby, having been discovered unresponsive and resuscitated. The jury found that he was suffering significant mental ill health and identified failings in the assessment and management of his mental health and self-harm risk, ACCT observations, completion of an action plan, response to his cell bell, and staffing. The report also raises concerns about prison leadership’s understanding and assessment of risk and its lack of candour and reflection during the inquest.
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 understand and assess risk in ACCT processes and risk assessments
Wider context from the report “I heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances .
The supervising officer involved in the decision to close Mark’s ACCT on the morning of 3 July 2023, gave evidence that there was no likelihood Mark would commit further ACCTs of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents and the officer did not consult a supervising officer as required by PSI 64/2011. It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances.
Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and/or the coroner.
He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added:
“I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.”
When it was pointed out to him that that was not supported by either of the witnesses involved – who were both very clear that there had been no consultation - he apologised and suggested he had misunderstood.
I am troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken.
The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death.
Mark was housed on HB3 North. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period. The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3S only. Every other prison witness asked about this agreed that there should be an officer covering each side of HB3 over lunch.
Curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none. Although, he did later apologise for his difficulty answering other questions asked of him, explaining that he does not usually work in safer custody.
1. That, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby .
2. That there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody.
” Source location Mark Stephen Beresford · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide regular staff training and guidance on operating the ACCT process.
Verbatim wording from the response “I understand that during the course of the inquest into Mr Beresford’s death the jury heard evidence from members of uniformed staff regarding their role in the management of the ACCT process. Embedding effective management of prisoners at risk of suicide and self-harm through the ACCT process is vital for all establishments, and HMP Ranby continues to provide regular training and guidance to staff in its operation.” Source location Response from HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate ACCT guidance covering when to open an ACCT and when to hold a review after risk changes.
Verbatim wording from the response “You will be aware that since Mr Beresford’s death guidance has been sent to staff to improve their understanding of ACCT, including the need to consider opening an ACCT and where a prisoner is already on an ACCT to hold a case review if the individual’s level of risk changes. Where a case review is required, a new booking system ensures that these take” Source location Response from HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a booking system to ensure required ACCT case reviews occur within an appropriate timescale.
Verbatim wording from the response “You will be aware that since Mr Beresford’s death guidance has been sent to staff to improve their understanding of ACCT, including the need to consider opening an ACCT and where a prisoner is already on an ACCT to hold a case review if the individual’s level of risk changes. Where a case review is required, a new booking system ensures that these take” Source location Response from HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a three-stage quality assurance process to identify individual or wider ACCT upskilling needs.
Verbatim wording from the response “place within an appropriate timescale. A three-stage quality assurance process is also in place to identify areas where individual or wider upskilling is required.” Source location Response from HMPPS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for delivering suicide and self-harm risk management and the ACCT process at HMP Ranby sits with the Head of Safety.
Verbatim wording from the response “As you will also be aware responsibility for the delivery of the management of those prisoners at risk of suicide and self-harm and the effective management of the ACCT process at HMP Ranby sits with the Head of Safety.” Source location Response from HMPPS
Open published response
25 Oct 2024 George Kyriacos Petrou · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure of mental health in-reach staff to follow guidance when deciding whether prisoners require suicide watch or ACCT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
George Kyriacos Petrou · 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
George Kyriacos Petrou was found deceased in his cell at HMP Pentonville on 1 March 2021 after partially suspending himself by ligature in the bathroom of his cell. The report raised concerns that some mental health in-reach staff placed significant weight on prisoners declining suicide watch or ACCT measures, contrary to guidance, policy and procedures, and that insufficient reassurance was provided that this had been addressed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of mental health in-reach staff to follow guidance when deciding whether prisoners require suicide watch or ACCT
Wider context from the report “1) Evidence from members of staff at the Trust, working in the prison at that time, gave the distinct impression that there were a number of members of the mental health in-reach team that placed significant weight on a prisoner telling them that they did not want to be placed on any form of suicide watch and/or ACCT . This was contrary to the guidance, policy and procedures in place . While not being placed on an ACCT was not a causative factor in Mr Petrou’s case, it nonetheless raises a risk of death in the future . In my view, witnesses from the Trust provided insufficient reassurance that this matter has been addressed .
” Source location George Kyriacos Petrou · Prevention of Future Deaths report
Open source report
7 Aug 2024 Kevin John McDonnell · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to conduct meaningful and purposeful ACCT observations and conversations View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Kevin John McDonnell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin John McDonnell was discovered deceased in his prison cell on 29 September 2022, having died by ligature asphyxiation; the inquest concluded that he had died by suicide. The principal concerns included failures to conduct planned ACCT reviews and checks, share identified suicide-risk information, provide necessary mental-health support, and preserve accurate documentary evidence after his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct meaningful and purposeful ACCT observations and conversations
Wider context from the report “1. Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose . Witnesses repeatedly described these checks as simply “proof of life” checks . One witness gave the example of an ACCT observation being completed simply by hearing a noise from within the cell or observing the prisoner collecting his lunch from two landings above. Such cursory observations of prisoners at risk of suicide and self-harm is inconsistent with the aims and objectives of the ACCT PSI (64/2021).
” Source location Kevin John McDonnell · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase and continue SASH/ACCT awareness training and refresher upskilling for staff.
Verbatim wording from the response “HMPPS is committed to ensuring that all staff are equipped with the necessary skills and knowledge to perform their role effectively and safely. I have been informed by the Governor of HMP Nottingham that the prison have increased their delivery of SASH/ACCT awareness and upskilling via training days and one-to-one refresher sessions, resulting in a greater number of staff being trained in these areas. The prison will continue to offer ACCT training and upskilling sessions to all staff to increase these numbers further.” Source location Response from HM Prison and Probation Service
Open published response
1 Aug 2024 Matthew Paul Braben · Prevention of Future Deaths report West London
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Concerns raised 2
Failure to ensure the ACCT post-closure process is followed after moves to another location View source Insufficient training of staff in the ACCT process View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Matthew Paul Braben · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Paul Braben died by asphyxia at HMP Wormwood Scrubs on 16 August 2021 after being found in his cell with his neck, wrists and ankles tied. The report identified concerns including failures to identify and respond to suicide risk, inadequate communication and record-keeping, failures relating to ACCT processes, and the impact of prisoners being held in their cells for up to 23 hours a day.
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 ensure the ACCT post-closure process is followed after moves to another location
Wider context from the report “2. The robustness of the process for ensuring that the ACCT post-closure process is followed , particularly following a move to another location .
” Source location Matthew Paul Braben · 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 Insufficient training of staff in the ACCT process
Wider context from the report “3. Training of staff in the ACCT process .
” Source location Matthew Paul Braben · Prevention of Future Deaths report
Open source report
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Includes deficiencies in controls dedicated to the ACCT process, including quality assurance, observations, reviews, documentation, information sharing, staffing or training, where the failure undermines reliable ACCT risk prevention or management.
