2 May 2025 Sarah Frances BOYLE · Prevention of Future Deaths report Cheshire
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Concerns raised 2
Failure to respond reliably to expressions of self harm or suicidality View source ACCT observations failing to provide therapeutic support View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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
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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 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure 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
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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 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
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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 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
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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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AI-generated summary
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
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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 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
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Concerns raised 1
Lack of a mandatory procedure for communicating known self-harm risk during unplanned release of remand prisoners 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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Christopher Alistair MacGillivray · 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
Christopher Alistair MacGillivray had a history of drug and alcohol issues, attempted suicide and self-harm, and a brain injury. After being remanded in custody and placed on ACCT procedures following reported thoughts of self-harm, he was released on bail without direct communication to his Probation Officer or Manager about his release and risk. He was found hanging at home two days later. The principal concern was the lack of mandatory procedures for communicating known self-harm risks when remand prisoners are released unexpectedly at short notice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a mandatory procedure for communicating known self-harm risk during unplanned release of remand prisoners
Wider context from the report “(1) The prison service instruction (PSI) 64/2011 sets out the procedures that must be followed to manage prisoner safety. The Annex sets out a mandatory process for the planned release of a prisoner who has been on an ACCT.
Offender Management in Custody (OMiC) guidance provides for direct communication between Prison Offender Manager and Community Offender Manager in respect of prisoners at risk of self harm for SENTENCED PRISONERS ONLY.
(2) The PSI is silent in respect of unplanned releases for 'prisoners on remand' with a known risk of self-harm and who may be released at short notice.
There is no apparent direction/mandatory procedure for communication of the known risk of self-harm for unplanned release.
(3) There is a risk of future deaths of prisoners in the category as at para 2 above. Urgent amendment to PSI/Annex and OMiC is required to set out procedures that must be followed in the management of the unplanned release of prisoners at risk of self-harm/suicide.
” Source location Christopher Alistair MacGillivray · Prevention of Future Deaths report
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17 Jan 2024 Kane Christopher Boyce · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to recognise the ACCT threshold without a verbalised self-harm statement View source
This report raised 9 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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Kane Christopher Boyce · 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
Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.
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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 recognise the ACCT threshold without a verbalised self-harm statement
Wider context from the report “4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI
A number of prison officers believed Kane’s birthday was incapable of amounting to a “key date or anniversary” for the purposes of PSI 64/2011. It seems to me to common sense that a birthday, being the anniversary of one’s birth, could amount to a potential trigger date for heightened emotions when considering a prisoner’s risk of self harm and suicide. That is not to say it would be so for each and every prisoner, but perhaps something to be cognisant of when dealing with an emotional and intoxicated prisoner. I have seen no evidence that this is covered in Sodexo’s training for staff on the ACCT process, if indeed any series of training exists.
A number of prison officers gave evidence that an ACCT was not necessary because Kane had not said to anyone that he was going to harm himself (either fatally or otherwise). Serco’s Safer Prison Operating Policy (August 2022) is confusing on this point and seems to suggest at paragraph 3.4 that staff should only open an ACCT when a statement of self-harm has been verbalised. This is not consistent with the PSI. Sodexo have not offered for scrutiny any local policy, guidance or training material on the threshold for opening an ACCT, but even if such exists, it appears some staff continue to labour under the misapprehension that a prisoner must say they are thinking of harming themselves before an ACCT can be opened .
” Source location Kane Christopher Boyce · 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 Deliver the national ACCT, ACCT Assessor and Case Coordinator training packages using nationally trained Sodexo facilitators and HMPPS facilitators.
Verbatim wording from the response “Sodexo follow the national Prison Service Instruction 64/2011 which provides the framework underpinning any local policy. Sodexo deliver to staff the national training package issued by HMPPS for ACCT, version 6 and ACCT Assessor. To enable this Sodexo facilitators complete the national ACCT Train the Trainer course delivered by HMPPS facilitators. Relevant Sodexo staff also receive the national training package delivered directly by HMPPS facilitators on ACCT Case Coordinators.” Source location Response from Sodexo
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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 ACCT refresher training to all staff when operational management returns to Sodexo, unless they have completed it earlier.
Verbatim wording from the response “When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before.” Source location Response from Sodexo
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21 Oct 2022 Carl Shaun Langdell · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to prevent prisoners at known chronic risk of suicide or self-harm from possessing items when alone in locked cells overnight View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Carl Shaun Langdell · 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
Carl Shaun Langdell was discovered in his locked, single-occupancy prison cell with a significant neck wound and died after suffering cardiac arrest despite emergency treatment. The concerns included his identified chronic risk of suicide or self-harm, recent bizarre and agitated behaviour after refusing medication, and his being permitted to possess an unspecified item while alone in his cell overnight. The inquest recorded a finding of suicide and attributed the death to haemorrhage from a neck incision.
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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 prevent prisoners at known chronic risk of suicide or self-harm from possessing items when alone in locked cells overnight
Wider context from the report “(2) He had been identified by a consultant psychiatrist as at “chronic risk of suicide attempts/self-harm attempts which is likely to remain due to the nature of his personality disorder” .
(3) In January 2021 he was observed to be acting in a bizarre and agitated manner after refusing his prescribed medication for the previous month.
(4) Despite this history and the known risk he was permitted under the prevailing ████████ rules at HMP Wakefield to be in possession of ████████ when alone in his locked cell overnight.
” Source location Carl Shaun Langdell · 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 Review the prison’s local policy governing the issue and return of the relevant hygiene items, including risk assessment and blade checks.
Verbatim wording from the response “During the inquest, you heard evidence that following Mr Langdell’s death, the Governor ordered a review of the prison’s local ████████ policy and confirmed that it sets out the action that must be taken when staff issue ████████, which includes a risk assessment and staff ensuring they check that the blades are present when the razor is returned.” Source location Response from HM Prison and Probation Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct estate-wide pilots testing alternatives to current wet-shave provision and associated control measures to identify improvements.
Verbatim wording from the response “At a national level, we recognise the risks associated with the current ████████ provision and are actively seeking to identify improvements to the current provision. Throughout this year we have conducted several pilots across the prison estate, testing alternatives to the current wet shave provision and control measures in establishments. These pilots are due to conclude in the spring of 2023, at which time they will be evaluated” Source location Response from HM Prison and Probation Services
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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 Evaluate the pilots, including concerns, issues, and effects on violence and self-harm.
Verbatim wording from the response “At a national level, we recognise the risks associated with the current ████████ provision and are actively seeking to identify improvements to the current provision. Throughout this year we have conducted several pilots across the prison estate, testing alternatives to the current wet shave provision and control measures in establishments. These pilots are due to conclude in the spring of 2023, at which time they will be evaluated” Source location Response from HM Prison and Probation Services
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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 Make informed recommendations on future shaving provision in prison establishments based on the pilot evaluation.
Verbatim wording from the response “to consider any concerns or issues which may have arisen and measured against the impact they have had on violence and self-harm. This evaluation will enable us to make informed recommendations on future shaving provision in prison establishments.” Source location Response from HM Prison and Probation Services
Open published response
Concerns raised 1
Failure to apply ACCT opening criteria to information indicating current self-harm or suicide risk 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
Khalid Abiaz · 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
Khalid Abiaz, a prisoner at HMP Swansea, died in the early hours of 13 September 2016 after being found suspended by a ligature. The report identified concerns that an ACCT was not opened despite suicide warning markers and relevant historical information, and that prison and bank nursing staff may not have received sufficiently frequent or up-to-date ACCT 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 Failure to apply ACCT opening criteria to information indicating current self-harm or suicide risk
Wider context from the report “2. I heard evidence from the nurse who saw Khalid on reception. This person is an experienced mental health nurse who is now a charge nurse on bank. The nurse told me that he still does at times work through the bank as a mental health nurse in HMP Swansea. At the time of Khalid’s death the Nurse was the mental health nurse working on reception and he completed the first reception health screen for Khalid and he did not open an ACCT. It was unclear what documents the nurse had seen on reception for Khalid but he did not ask prison staff if he could see any documents. The Nurse gave evidence that even if he had known that there was a suicide warning marker on Khalid’s prison escort record this would not have been enough combined with what Khalid said to him to open an ACCT, he relies on Khalid’s presentation. Khalid had been assessed by a consultant psychiatrist as a significant risk to himself a matter of weeks before he was seen by the Nurse in reception. HMP Swansea prison staff and the Nurse were not aware of this information but even if the Nurse had known this information his evidence was that this would not necessarily have been enough for him to open an ACCT, he would consider presentation. The revised ACCT version 6 and accompanying policy guidance set out above makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. The answers of the Nurse raise a concern around the level and adequacy of the training on ACCT. The Nurse stated that he has reflected on his practice but that he still places emphasis on what the prisoner says and how they present when considering whether to open an ACCT. I heard evidence that bank nurses were supervised in the prison but that training on ACCT remained the responsibility of HMP Swansea. I am concerned that bank nurse may not receive access to ACCT training including at the required regularity and I am concerned that unless this happens there remains a risk of similar deaths occurring in the future in HMP Swansea
” Source location Khalid Abiaz · 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 Produce and deliver ACCT version 6 training materials and presentations across the prison estate.
Verbatim wording from the response “As you note in your report, in July 2021 ACCT version 6 (v6) was rolled out across the prison estate. The revised form and guidance are intended to assist staff in providing high quality multidisciplinary care and support to individuals at risk of suicide and self-harm. Training materials and presentations have been produced and delivered across the estate in order to support staff in their understanding and delivery of the ACCT v6 process. This includes risk identification and how best to provide support to individuals.” 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 Prioritise staff with identified concerns for updated ACCT refresher training and provide an ACCT version 6 upskilling session.
Verbatim wording from the response “Our policy (Prison Service Instruction 64/2011 Safer Custody) is clear that all staff who have contact with prisoners must undertake training on ACCT, and that refresher training must be provided according to local needs. This training forms part of the initial training undertaken by all Prison Officers. A new version of the training, which includes information about ACCT v6, has recently been produced and a programme is in place to ensure that all staff at HMP Swansea attend this as refresher training by November 2024. In the light of your report, the individuals about whom you have expressed specific concerns will be prioritised for this training, and for an upskilling session specifically related to ACCT v6 that has also been made available by the national Safety Team.” Source location Response from HM Prison Probation Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the new risk-identification training module to fifteen staff working mainly in reception, induction and healthcare.
Verbatim wording from the response “In order to improve the identification of risk in new prisoners and to build confidence in decision making around the opening of ACCT documents, fifteen members of staff who predominantly work in the reception area, induction wing, and healthcare received the new training module in July 2022. The Governor has issued guidance on risk identification and the establishment is scheduling additional training focusing on risks, triggers and protective factors for staff working in these key areas.” Source location Response from HM Prison Probation Service
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 Issue guidance on risk identification and schedule additional training on risks, triggers and protective factors for staff in key areas.
Verbatim wording from the response “In order to improve the identification of risk in new prisoners and to build confidence in decision making around the opening of ACCT documents, fifteen members of staff who predominantly work in the reception area, induction wing, and healthcare received the new training module in July 2022. The Governor has issued guidance on risk identification and the establishment is scheduling additional training focusing on risks, triggers and protective factors for staff working in these key areas.” Source location Response from HM Prison Probation Service
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 Request that bank nurses are not deployed in reception and that permanently employed ACCT-trained nursing staff complete initial screenings there.
Verbatim wording from the response “HMPPS is committed to making ACCT training available to staff working for our partner organisations. At HMP Swansea, healthcare staff are encouraged to access all suicide and self-harm prevention training delivered within the establishment and the new modules will continue to be offered to them. The Governor has also formally requested through the Head of Healthcare, that bank nurses are not deployed in the reception area of the prison and are instead utilised in other areas within the establishment. This is to ensure that permanent nursing staff who have undertaken the ACCT training are allocated to the reception area to complete initial screenings.” Source location Response from HM Prison Probation Service
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 Healthcare staff concerns are addressed by Swansea Bay University Health Board, the healthcare provider at HMP Swansea.
Verbatim wording from the response “I understand that a response is also being provided by Swansea Bay University Health Board, the healthcare provider at HMP Swansea, so in relation to your concerns about healthcare staff I have limited my comments to explaining the training that HMPPS makes available to our partners.” Source location Response from HM Prison Probation Service
Open published response
17 Sep 2021 Colin BLACKBURN · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3
Failure of ACCT Case Review participants to familiarise themselves with the ACCT document View source Delays in holding scheduled ACCT Case Reviews View source Delays in assigning an ACCT Case Manager View source
This report raised 15 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
Colin BLACKBURN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Colin Blackburn died at HMP Hewell on 6 July 2019 after spending 15 days on remand and having been found with a ligature around his neck on three prior occasions. Concerns included multiple accepted failings in the management of his ACCT suicide and self-harm risk, and uncertainty about the correct process for urgent mental-health referrals, particularly at weekends.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of ACCT Case Review participants to familiarise themselves with the ACCT document
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand ;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in holding scheduled ACCT Case Reviews
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19 .
” Source location Colin BLACKBURN · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in assigning an ACCT Case Manager
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19 ;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” Source location Colin BLACKBURN · Prevention of Future Deaths report
Open source report
4 Jun 2021 Geoffrey Harrison HUTTON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Failure of the ACCT Case Manager allocation and oversight system View source
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.
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AI-generated summary
Geoffrey Harrison HUTTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Geoffrey Harrison Hutton died by suicide in his cell at HMP Long Lartin on 8 February 2019 after hanging himself with a ligature made from a laundry-bag drawstring. He had significant hearing impairment, longstanding mental health and substance misuse issues, and was subject to an ACCT document. The substantive concerns included failures relating to social-care referral and support for his hearing and communication needs, ineffective ACCT case-manager oversight, and insufficient ACCT training for some staff carrying out observations.
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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 of the ACCT Case Manager allocation and oversight system
Wider context from the report “(2) There appears to be no effective system for allocating ACCT Case Managers at HMP Long Lartin . The officer (Officer A) who, when she opened the final ACCT document for Mr. Hutton, appointed herself as Case Manager for this ACCT, did so knowing that she would have no contact with him over the following two weeks. Officer A gave evidence that:
(a) this was common practice at the prison;
(b) officers were discouraged from not naming a Case Manager when they opened an ACCT, even if (as here ) it was opened at night;
(c) she was hoping that another officer might “take it over” from her.
As she predicted, she herself did indeed have no further contact with Mr. Hutton. Furthermore, this problem was not passed on or identified, and no other officer took over the Case Manager role. Therefore there was no effective oversight of an ACCT involving a potentially very vulnerable individual .
Of particular concern is that another appears to have filled in Officer A’s details in the “name” and “signature” boxes at the foot of the ACCT Caremap, and dated them 7.2.19 (the day before Mr. Hutton’s death ), thereby giving the impression that Officer A had reviewed and satisfied herself that the actions identified in the Caremap had been dealt with. In fact, the most important action on the Caremap, which required a social care referral, had not been completed.
This lack of effective oversight was not confined to Mr. Hutton’s final ACCT document. For his first ACCT document at HMP Long Lartin, only a month earlier, the named Case Manager had no involvement with it until the fourth ACCT Case Review, and made no entries on the Caremap ( which was signed off by a different officer ).
I heard evidence from a member of the current Senior Management Team at the prison that:
(a) there is currently no formal training for the allocation of, or fulfilment of the duties of the ACCT Case Manager role;
(b) this will be reviewed, and training will be organised.
The lack of an effective ACCT Case Manager, who is able to provide proper oversight of an ACCT , is an issue which was raised by me in a previous Report to Prevent Future Deaths which followed the death of another prisoner at HMP Long Lartin ( David KIRSCH – report dated 30.10.19 )
” Source location Geoffrey Harrison HUTTON · Prevention of Future Deaths report
Open source report
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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 Implement ACCT version 6 across the prison estate to support multidisciplinary, person-centred care for people at risk.
Verbatim wording from the response “Your second concern relates to the system for allocating ACCT case managers. You may be aware that HMPPS has introduced a revised version of ACCT which went live across the prison estate in July 2021; ACCT version 6. The changes are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. The term Case Manager has been replaced with Case Coordinator to reflect the fact that everyone involved in the ACCT process is responsible for ensuring that good quality support is provided. Specific training for ACCT Case Coordinators is being provided and staff must undertake the relevant modules before taking up the role.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
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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 specific training and require relevant modules for ACCT Case Coordinators before they take up the role.
Verbatim wording from the response “Your second concern relates to the system for allocating ACCT case managers. You may be aware that HMPPS has introduced a revised version of ACCT which went live across the prison estate in July 2021; ACCT version 6. The changes are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. The term Case Manager has been replaced with Case Coordinator to reflect the fact that everyone involved in the ACCT process is responsible for ensuring that good quality support is provided. Specific training for ACCT Case Coordinators is being provided and staff must undertake the relevant modules before taking up the role.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
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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 Implement a database to support allocation of ACCT Case Coordinators using staffing and caseload information.
Verbatim wording from the response “At HMP Long Lartin a new database is being implemented to support the allocation of ACCT Case Coordinators. This contains information on staff rotas, periods of leave and how many open ACCTs each Case Coordinator currently has. This will facilitate effective allocation decisions and support a renewed focus on providing consistent and proper oversight and ownership of cases. In addition, the staffing resources within the safer custody team have been reviewed and an additional manager has been introduced, providing capacity to complete more assurance work around ACCT processes.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an additional safer custody team manager to increase capacity for ACCT assurance work.
Verbatim wording from the response “At HMP Long Lartin a new database is being implemented to support the allocation of ACCT Case Coordinators. This contains information on staff rotas, periods of leave and how many open ACCTs each Case Coordinator currently has. This will facilitate effective allocation decisions and support a renewed focus on providing consistent and proper oversight and ownership of cases. In addition, the staffing resources within the safer custody team have been reviewed and an additional manager has been introduced, providing capacity to complete more assurance work around ACCT processes.” Source location 2021-0191-Response-from-HMPPS_Published
Open published response
25 May 2021 James Devenny · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3
Failure to routinely brief Prison Officers about prisoners’ previous significant self-harm in custody View source Unclear threshold for informing prison staff about significant self-harm risk View source Failure to routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm 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
James Devenny · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Devenny died in his cell at HMP Elmley on 2 September 2019, having been found hanging from a light fitting using a bedsheet ligature. The jury identified concerns including staff not being aware of his previous self-harm history, the absence of a medical assessment before his separation from other prisoners, an inappropriate response to mental health referrals, and inadequate access to phones and support services. The report also records concerns about prison officers not being routinely briefed about prisoners’ previous significant self-harm and related patterns of thoughts, feelings, events and behaviours.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to routinely brief Prison Officers about prisoners’ previous significant self-harm in custody
Wider context from the report “(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody . It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm.
” Source location James Devenny · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear threshold for informing prison staff about significant self-harm risk
Wider context from the report “(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT . Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm.
” Source location James Devenny · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm
Wider context from the report “(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm .
” Source location James Devenny · Prevention of Future Deaths report
Open source report
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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 Implement ACCT version 6 across the male estate, including strengthened risk-identification requirements and revised staff training and awareness materials.
Verbatim wording from the response “You will recall that evidence was given at the inquest about the updated version of Assessment Care in Custody and Teamwork version 6 (ACCT v6), which was due to be rolled out shortly after the inquest. I am pleased to confirm that ACCT v6 went live across the male estate in July 2021. Along with updates and improvements made to the ACCT document there is also an increased emphasis placed on up-skilling staff in relation to risk identification, and revised training modules and awareness materials have been made available to all staff at the prison.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and routinely use an updated safety diagnostic tool consolidating violence, self-harm and other relevant risk information for staff.
Verbatim wording from the response “An updated safety diagnostic tool which provides information about individuals is available to all staff. This includes information on violence and self-harm, and other relevant information drawn from NOMIS. The tool makes it easier to access all relevant risk information in one place and is routinely used by safer custody staff who flag any new receptions and any individuals they are concerned about to wing staff and other relevant departments within the prison.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
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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 the Key Worker scheme, providing each person in custody with a dedicated worker and weekly meetings to identify risks, triggers and changes in self-harm or suicide risk.
Verbatim wording from the response “The prison also now operates the Key Worker scheme, whereby all people in custody have a dedicated Key Worker who meets with them on a weekly basis. The intention of Key Work is to enable better relationships between staff and people in prison, and to support those in custody to settle into prison life. Key Workers are expected to be aware of an individual’s history and to work with them to help and support them with any issues. As part of this role key workers review National Offender Management Information System (NOMIS) case notes and look at any previous issues or risks, including self-harm. They are therefore well placed to recognise any changes in the level of an individual’s risk of self-harm or suicide and to be aware of any potential trigger dates which may indicate that an ACCT should be opened to provide increased support.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
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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 Previous self-harm incidents will not always be relevant to identifying current self-harm risks and triggers.
Verbatim wording from the response “Your second concern is that prison officers are not routinely briefed about people who have previously significantly self-harmed in custody. While a knowledge of previous self-harm can be useful, and this information will be noted if it is available either on “National Offender Management Information System” the system used for informing about those in custody, or disclosed by the individual in question, previous incidents will not always be relevant in identifying current risks and triggers. As HMP Elmley is a busy local prison with a high turnover of people in their care, there is a focus on recognising risk and triggers for self-harm and suicide and being alert to any changes in an individual which may indicate an increase in risk.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing risk-recognition practices focus staff on current self-harm and suicide risks and changes indicating increased risk.
Verbatim wording from the response “Your second concern is that prison officers are not routinely briefed about people who have previously significantly self-harmed in custody. While a knowledge of previous self-harm can be useful, and this information will be noted if it is available either on “National Offender Management Information System” the system used for informing about those in custody, or disclosed by the individual in question, previous incidents will not always be relevant in identifying current risks and triggers. As HMP Elmley is a busy local prison with a high turnover of people in their care, there is a focus on recognising risk and triggers for self-harm and suicide and being alert to any changes in an individual which may indicate an increase in risk.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
7 May 2021 Corin Bonaparte · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Failure to open an ACCT following disclosure of recent deliberate self-harm View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Implement the approved revised healthcare ACCT operating procedure requiring documentation of reported or observed self-harm and opening an ACCT where required.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Obtain staff acknowledgements confirming that all healthcare staff have read and understood the revised ACCT guidance.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Deliver ACCT/SASH training to healthcare staff who require it, with sessions booked and attendance recorded and monitored.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Include healthcare staff in multidisciplinary ACCT V6 training at HMP Dartmoor to refresh responsibilities, vulnerability awareness and ACCT-opening criteria.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Add Head of Healthcare sign-off to confirm completion of new-staff induction covering the ACCT process.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Hold weekly collaborative healthcare meetings to discuss ACCT practice, record keeping, transfers, discharge, mental-health awareness and shared learning.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021. View source
Action
Audit healthcare involvement in the ACCT process through the P.R.O.T.E.C.T. patient-safety audit and escalate findings through quality-assurance governance where required.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Roll out the revised ACCT v6 process across the prison estate.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 May 2021. View source
Action
Deliver ACCT v6 training to prison staff, including healthcare colleagues, at HMP Dartmoor.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021. View source
Action
Deliver SASH training to healthcare staff and prioritise attendance at monthly sessions.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021. View source See 7 more actions
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AI-generated summary
Corin Bonaparte · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Corin Bonaparte, a young man aged 23, was found hanging in his cell at HMP Dartmoor on 28 February 2017 after his former partner ended contact with him during a telephone call. Resuscitation efforts were unsuccessful. Concerns included the failure to open an ACCT after he disclosed deliberate self-harm, suggesting inadequate training, and an eight-minute delay in an ambulance leaving the prison because an escort was being sought.
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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 open an ACCT following disclosure of recent deliberate self-harm
Wider context from the report “(1) Addressed to the Head of Healthcare and the Governor, HMP Dartmoor
Corin sought help from the mental health department at HMP Dartmoor. He revealed to a nurse in the mental health department the fact that he had recently deliberately harmed himself and made this fact known to other mental health workers. An ACCT was not opened despite the provisions in Chapter 2 of PSI 64 / 2011 which made the opening of an ACCT in these circumstances mandatory. In the light of the evidence from relevant witnesses at the inquest hearing it could not be confidently assumed that their actions would be any different if similar circumstances were to arise in the future . This suggested a lack of adequate training.
” Source location Corin Bonaparte · Prevention of Future Deaths report
Open source report
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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 Implement the approved revised healthcare ACCT operating procedure requiring documentation of reported or observed self-harm and opening an ACCT where required.
Verbatim wording from the response “The Head of Healthcare and clinical team at HMP Dartmoor have reviewed and made additions to the Local Operating Procedure (LOP) for healthcare involvement in the ACCT (Assessment, Care, Custody & Teamwork) process. The additions that have been made specify that recently reported or observed self-harm must be documented and that, in accordance with the requirements of PSI 64/2011, an ACCT must be opened. The revised LOP was submitted to the Local Quality Assurance Meeting and approved on 22nd June 2021. A staff signatory sheet will be signed by all staff acknowledging they have read and understood this guidance by 12th July 2021.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
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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 Obtain staff acknowledgements confirming that all healthcare staff have read and understood the revised ACCT guidance.
Verbatim wording from the response “The Head of Healthcare and clinical team at HMP Dartmoor have reviewed and made additions to the Local Operating Procedure (LOP) for healthcare involvement in the ACCT (Assessment, Care, Custody & Teamwork) process. The additions that have been made specify that recently reported or observed self-harm must be documented and that, in accordance with the requirements of PSI 64/2011, an ACCT must be opened. The revised LOP was submitted to the Local Quality Assurance Meeting and approved on 22nd June 2021. A staff signatory sheet will be signed by all staff acknowledging they have read and understood this guidance by 12th July 2021.” Source location 2021-0143-Practice-Plus-Group_Published
Open published response
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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 ACCT/SASH training to healthcare staff who require it, with sessions booked and attendance recorded and monitored.
Verbatim wording from the response “With regard to promoting staff training and awareness, the prison last held ACCT / Suicide and Self-Harm (SASH) training on 8th December 2020 and this was attended by twelve health staff. Following this all healthcare staff in post had completed prison ACCT training. Training was then placed on hold due to the Covid-19 outbreak, as a result of which, at the time of the inquest, we had four new members of staff requiring training. However, for two of these members of staff this would have constituted refresher training as they had transferred from other prison establishments and had received ACCT training before.” Source location 2021-0143-Practice-Plus-Group_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include healthcare staff in multidisciplinary ACCT V6 training at HMP Dartmoor to refresh responsibilities, vulnerability awareness and ACCT-opening criteria.
Verbatim wording from the response “In addition to the above, from July 2021, nationally updated ACCT guidance (V6) is being rolled out across all prisons in England & Wales by Her Majesty’s Prison and Probation Service. This training provides further clarity on the roles and responsibilities of healthcare staff within the ACCT process. The training is multi-disciplinary and will be open to all colleagues (including healthcare). The ACCT V6 training will commence at HMP Dartmoor on 5th July 2021 and the Head of Healthcare has received assurance that healthcare staff will be included in the updated training programme. This will provide the opportunity for joint training sessions in which all healthcare staff and discipline colleagues will review and refresh their knowledge of the ACCT process, increase their awareness of vulnerability and risk factors, and enhance their understanding of when an ACCT should be opened.” Source location 2021-0143-Practice-Plus-Group_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add Head of Healthcare sign-off to confirm completion of new-staff induction covering the ACCT process.
Verbatim wording from the response “In addition to the above, the Practice Plus Group General Induction Booklet contains a section on the ACCT process and as part of our induction process for new staff, ACCT is discussed within the twelve week induction period. A confirmatory signature is required from the inducting supervisor to evidence completion. To ensure a robust and quality induction experience, additional sign off will now be undertaken by the Head of Healthcare on completion of the induction period. Devon Partnership Trust have a similar process in place for the mental healthcare team, with an induction booklet signed by both the individual staff member and the Mental Health Team Manager. We will monitor this and obtain further assurance that all new starters in the mental health team have sufficient knowledge of how and when to open an ACCT through our quarterly sub-contractor review meetings with DPT.” Source location 2021-0143-Practice-Plus-Group_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly collaborative healthcare meetings to discuss ACCT practice, record keeping, transfers, discharge, mental-health awareness and shared learning.
Verbatim wording from the response “In a further collaborative learning initiative, Practice Plus Group and Devon Partnership Trust have arranged to hold weekly meetings for all healthcare staff to discuss ‘hot topics’ (for example ACCT reviews, clinical record keeping, transfer and discharge processes, mental health awareness sessions and other clinical bitesize sharing best practice sessions). This will further support embedding of lessons learned in to daily practice.” Source location 2021-0143-Practice-Plus-Group_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit healthcare involvement in the ACCT process through the P.R.O.T.E.C.T. patient-safety audit and escalate findings through quality-assurance governance where required.
Verbatim wording from the response “Managing healthcare involvement within the ACCT process is also audited through our Practice Plus Group bespoke prisons patient safety audit, which is called ‘P.R.O.T.E.C.T’. This audit tool was developed from an evidence base of key themes from lessons learnt through deaths in custody, and is undertaken throughout the year on an annual audit schedule. The audit standards assess compliance in mental health referrals, timeliness of assessment, and of mental health team involvement in the ACCT process. Results of the audits are reviewed and discussed through Local Quality Assurance meetings within HMP Dartmoor. Where required themes are escalated to Regional Quality Assurance meetings and to quarterly National Quality Assurance meetings to evaluate the effectiveness of action planning and implementation within the audit cycle.” Source location 2021-0143-Practice-Plus-Group_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the revised ACCT v6 process across the prison estate.
Verbatim wording from the response “ACCT is a prison service document that assists staff in providing multi-disciplinary care and support to individuals at risk of harm to themselves, in order to minimise that risk. It is to be utilised by all members of staff working within prisons, including healthcare colleagues, and it is important staff feel confident in recognising risk and making the decision to open an ACCT in order to support prisoners through their period of crisis.” Source location 2021-0143-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ACCT v6 training to prison staff, including healthcare colleagues, at HMP Dartmoor.
Verbatim wording from the response “In July 2021, a new version of ACCT (Version 6, known as “ACCT v6”) was rolled out across the prison estate. The changes made to ACCT are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person centred approach which meets the needs of each individual in order to minimise their risk of harm to self. Training packages have been developed to assist in the understanding and delivery of the new ACCT process and include sessions on” Source location 2021-0143-Response-from-HMPPS_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver SASH training to healthcare staff and prioritise attendance at monthly sessions.
Verbatim wording from the response “understanding self-harm, the ACCT v6 process and supporting individuals who self-harm. Training is currently being delivered at HMP Dartmoor and is available to all staff, including healthcare colleagues. Introduction to Suicide and Self-Harm Prevention (SASH) training is being delivered to healthcare attendance at the monthly sessions has been prioritised in order to support the up-skilling of staff in recognising risks and triggers for self-harm, as well as to build confidence in decision making around the opening of ACCT documents.” Source location 2021-0143-Response-from-HMPPS_Published
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Includes failures of an explicitly prison-based suicide and self-harm prevention system or strategy, including dedicated ACCT, risk-assessment, monitoring, information-sharing, learning and response controls.
