Recurring concern

Ineffective prison suicide and self-harm prevention systems

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First reported 2 Dec 2013•Latest report 13 May 2026

Definition

What this concern includes

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.

Not included

Do not include suicide or self-harm outcomes without evidence of an ineffective prison prevention system or dedicated control.
Excludes generic staffing, training, communication or documentation deficiencies unless the report directly ties them to prison suicide and self-harm prevention.
Excludes suicide and self-harm concerns outside prison settings.
Excludes isolated emergency-response failures that are not presented as part of prison suicide and self-harm prevention arrangements.

Reports: 52
Individual concerns: 86
Date range: 2013–2026
Stated actions: 166

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service23

Ministry of Justice12

NHS England6

HM Prison Service5

Care UK4

Hewell Prison3

HM Inspectorate of Prisons3

Pentonville Prison3

Central and North West London NHS Foundation Trust2

Greater Manchester Mental Health NHS Foundation Trust2

Leicestershire Partnership NHS Trust2

Long Lartin Prison2

Oxleas NHS Foundation Trust2

Practice Plus Group2

Sodexo2

Concerns and responses across reports

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

12 Aug2016
Isle of Wight
Concerns raised3
1. Failure of suicide risk guidance to include irrational behaviour indicative of psychosis
2. Failure to open an ACCT document when behaviour indicates a need for additional monitoring
3. Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stephen St Clair · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stephen St Clair, a prisoner at HMP Isle of Wight, was found in his cell on 4 November 2013 with a severe cut to his throat and was pronounced dead at 05.55 hours. The report describes concerns about signs of paranoia and possible psychosis not being recognised as suicide or self-harm risk, and about the absence of corresponding wording in the Prison Service suicide risk guidance, which may have contributed to an ACCT not being opened.

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 suicide risk guidance to include irrational behaviour indicative of psychosis
Wider context from the report
“2. The next section in PSI 64/2011 deals with “Risk Factors for Self-Harm” and includes a sub-heading entitled “Current Context” where the following is included: “Irrational behaviour, out of touch with reality”. 3. I am concerned that the “Risk Factors for Suicide” does not actually include words to the effect of “Irrational behaviour, out of touch with reality” as the evidence from the Consultant Forensic Psychiatrist suggested that this behaviour was strongly suggestive of psychosis, and as such, the prisoner was in need of additional monitoring to keep him safe and to protect him from self-harm or suicide. ”
Source location
Stephen St Clair · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to open an ACCT document when behaviour indicates a need for additional monitoring
Wider context from the report
“4. I am concerned that as this additional wording was not included in PSI 64/2011, the Prison Officers did not feel obligated to open an ACCT document, which may have resulted in Mr St Clair being monitored more closely, thereby avoiding him taking his own life. ”
Source location
Stephen St Clair · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance
Wider context from the report
“1. The Prison Service Instruction (“PSI”) 64/2011 (Management of prisoners at risk of harm to self, to others and from others (Safer Custody)) addresses the “Risk Factors for Suicide”. There are various subheadings, including “Clinical History” where the following point is made: “Mental illness diagnosis (e.g. depression, bipolar disorder, schizophrenia)” but there is no description of the possible symptoms which might be displayed by those who may be suffering from as yet undiagnosed conditions. ”
Source location
Stephen St Clair · Prevention of Future Deaths report
Page 3 · concerns
Open source report
13 Jun2016
Cheshire
Concerns raised1
1. Failure to properly observe ACCT procedures
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.
Actions described in response 7
1. Action
  Check all ACCT documents daily through Officer Supervisors.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Introduce an additional weekly ACCT document check by a Custodial Manager.
  Stated by HM Prison and Probation ServiceStated in progress
3. Action
  Conduct weekly sample checks of ACCT documents until standards improve and processes are embedded.
  Stated by HM Prison and Probation ServiceStated in progress
1. Action
  Issue a Governor’s Order defining staff responsibility and accountability for ACCT documents.
  Stated by HM Prison and Probation ServiceStated planned
2. Action
  Require staff to account for unsatisfactory ACCT documents and escalate appropriate cases through warnings or misconduct investigation.
  Stated by HM Prison and Probation ServiceStated planned
3. Action
  Brief all Offender Supervisors and Custodial Managers on the importance of the ACCT process.
  Stated by HM Prison and Probation ServiceStated in progress
4. Action
  Require staff to notify Safer Custody of prisoner concerns so an immediate ACCT review is organised, with escalation when responsible staff are unavailable.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 1
1. Position
  Operational issues concerning proper observance of ACCT procedures should be addressed by NOMS.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Kevin Dermott · 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 Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to properly observe ACCT procedures
Wider context from the report
“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”
Source location
Kevin Dermott · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Check all ACCT documents daily through Officer Supervisors.

Verbatim wording from the response
“The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.”

Source location
2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce an additional weekly ACCT document check by a Custodial Manager.

Verbatim wording from the response
“The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.”

Source location
2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct weekly sample checks of ACCT documents until standards improve and processes are embedded.

Verbatim wording from the response
“The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.”

Source location
2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue a Governor’s Order defining staff responsibility and accountability for ACCT documents.

Verbatim wording from the response
“A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.”

Source location
2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require staff to account for unsatisfactory ACCT documents and escalate appropriate cases through warnings or misconduct investigation.

Verbatim wording from the response
“A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.”

Source location
2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Brief all Offender Supervisors and Custodial Managers on the importance of the ACCT process.

Verbatim wording from the response
“A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.”

Source location
2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require staff to notify Safer Custody of prisoner concerns so an immediate ACCT review is organised, with escalation when responsible staff are unavailable.

Verbatim wording from the response
“In order to ensure that any concerns that are raised about a prisoner are being acted upon, staff have been informed that they must contact the Safer Custody department, who will organise an immediate ACCT review for that day. If the named Offender Supervisor cannot attend it will be escalated to the “Oscar” group (comprised of three Offender Supervisors), and where they are not available it will be further escalated to the duty Custodial Manager (who is available 24 hours).”

Source location
2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operational issues concerning proper observance of ACCT procedures should be addressed by NOMS.

Verbatim wording from the response
“The specific issues you raise about the failure to properly observe Assessment, Care in Custody & Teamwork (ACCT) procedures are operational and should be addressed by NOMS.”

Source location
2016-0220-Response-by-Department-of-Health
Page 2 · response
Published 13 June 2016
Open published response
26 May2016
Milton Keynes
Concerns raised1
1. Failure to maintain adequate ACCT case management documentation
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 3
1. Action
  Deliver Case Management training to managers who chair ACCT case reviews.
  Stated by National Offender Management Service Equality, Rights and Decency GroupStatus at response
2. Action
  Operate a case-review booking system to improve case-manager continuity and multidisciplinary team attendance.
  Stated by National Offender Management Service Equality, Rights and Decency GroupStated completed
3. Action
  Implement a designated case-manager system for each offender supported through the ACCT process while the ACCT remains open.
  Stated by National Offender Management Service Equality, Rights and Decency GroupStated in progress
Respondent positions 1
1. Position
  Existing prison governance and monitoring processes are considered sufficient to deliver action on HMIP, PPO and Regulation 28 recommendations.
  Stated by National Offender Management Service Equality, Rights and Decency GroupExisting arrangements considered sufficient
AI-generated summary

Ian Keith Brown · 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

Ian Keith Brown, who had mental illness and was on remand at HMP Woodhill, was found in his cell with a belt ligature around his neck on 19 July 2015 and was pronounced dead at 14:00 hours. Concerns were raised that recommendations to improve suicide and self-harm prevention, including ACCT case management and a prison-wide strategy, had not been implemented sufficiently, while suicides and self-harm at HMP Woodhill continued to rise.

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 maintain adequate ACCT case management documentation
Wider context from the report
“(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour. (2) Deaths at the prison from suicide and self harm continue to rise. (3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored. (4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise. ”
Source location
Ian Keith Brown · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver Case Management training to managers who chair ACCT case reviews.

Verbatim wording from the response
“An early example of the improvement that is being driven by the taskforce is in the management of the ACCT process. The establishment has now delivered Case Management”

Source location
2016-0200-Response-by-NOMS
Page 1 · response
Published 26 May 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate a case-review booking system to improve case-manager continuity and multidisciplinary team attendance.

Verbatim wording from the response
“training to 90% of managers who chair ACCT case reviews. A new case review booking system is in place to improve the continuity of case manager attendance and to ensure that all members of the multi-disciplinary team are able to plan their attendance at review meetings. The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open. This approach will bring further improvement in the quality and consistency of case reviews and care plans.”

Source location
2016-0200-Response-by-NOMS
Page 2 · response
Published 26 May 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a designated case-manager system for each offender supported through the ACCT process while the ACCT remains open.

Verbatim wording from the response
“training to 90% of managers who chair ACCT case reviews. A new case review booking system is in place to improve the continuity of case manager attendance and to ensure that all members of the multi-disciplinary team are able to plan their attendance at review meetings. The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open. This approach will bring further improvement in the quality and consistency of case reviews and care plans.”

Source location
2016-0200-Response-by-NOMS
Page 2 · response
Published 26 May 2016
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing prison governance and monitoring processes are considered sufficient to deliver action on HMIP, PPO and Regulation 28 recommendations.

Verbatim wording from the response
“I hope this provides you with assurance that the Governor of HMP Woodhill, and the Deputy Director of Custody for High Security Prisons, have put in place processes and governance that will achieve successful action in response to the recommendations from HMIP and the PPO, and the matters of concern raised in your Regulation 28 reports, and that this will bring the necessary improvements in safety at the prison.”

Source location
2016-0200-Response-by-NOMS
Page 2 · response
Published 26 May 2016
Open published response
5 May2016
Leicester City and South Leicestershire
Concerns raised1
1. Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ahmedreza Fathi · 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

Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records
Wider context from the report
“1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison. ”
Source location
Ahmedreza Fathi · Prevention of Future Deaths report
Page 5 · concerns
Open source report
14 Dec2015
Milton Keynes
Concerns raised2
1. Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
2. Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 13
1. Action
  Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Train reception-screening staff, including agency staff where used, to apply the strengthened screening tool.
  Stated by Central and North West London NHS Foundation TrustStated in progress
3. Action
  Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.
  Stated by Central and North West London NHS Foundation TrustStated completed
1. Action
  Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Provide daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.
  Stated by Central and North West London NHS Foundation TrustStated in progress
4. Action
  Provide ongoing support for prison ACCT training and prison-led ACCT management.
  Stated by Central and North West London NHS Foundation TrustStated in progress
5. Action
  Check daily information-sharing and review ACCT records at each planned review meeting.
  Stated by Central and North West London NHS Foundation TrustStated completed
6. Action
  Audit and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.
  Stated by Central and North West London NHS Foundation TrustStated completed
7. Action
  Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.
  Stated by HM Prison and Probation ServiceStated in progress
8. Action
  Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.
  Stated by HM Prison and Probation ServiceStated in progress
9. Action
  Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.
  Stated by HM Prison and Probation ServiceStated in progress
10. Action
  Maintain a dedicated mental health team member on the First Night Centre to interview new prisoners and update identified risk factors.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 3
1. Position
  NOMS holds policy responsibility for suicide prevention and self-harm management.
  Stated by Central and North West London NHS Foundation TrustRedirects responsibility
1. Position
  The prison leads the ACCT process and is responsible for regularly assessing prisoners’ risk.
  Stated by Central and North West London NHS Foundation TrustRedirects responsibility
2. Position
  No nationally recognised best-practice risk-assessment tool exists beyond the processes specified in Prison Service Instructions.
  Stated by Central and North West London NHS Foundation TrustDisputes the concern
AI-generated summary

Daniel Brendan Byrne · 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

Daniel Brendan Byrne died at Milton Keynes Hospital on 27 February 2015 after being resuscitated following a suicide attempt by hanging in his cell at Woodhill Prison the previous day. The principal concerns were inadequate assessment of the risk of self-harm and suicide by healthcare staff and prison officers, failure to refer him for an urgent mental health assessment, and an inadequate first ACCT case review.

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 healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
Wider context from the report
“In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says: “ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT. There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare. Consideration should also be given to the introduction of a formal risk assessment tool. ”
Source location
Daniel Brendan Byrne · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners
Wider context from the report
“In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says: “ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT. There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare. Consideration should also be given to the introduction of a formal risk assessment tool. ”
Source location
Daniel Brendan Byrne · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.

Verbatim wording from the response
“While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.”

Source location
Daniel-Byrne-Response
Page 2 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train reception-screening staff, including agency staff where used, to apply the strengthened screening tool.

Verbatim wording from the response
“While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.”

Source location
Daniel-Byrne-Response
Page 2 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.

Verbatim wording from the response
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.”

Source location
Daniel-Byrne-Response
Page 2 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.

Verbatim wording from the response
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.”

Source location
Daniel-Byrne-Response
Page 2 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.

Verbatim wording from the response
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.”

Source location
Daniel-Byrne-Response
Page 2 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.

Verbatim wording from the response
“We have gone further and in the last year CNWL has been developing a new on-line e-learning training package, developed by our mental health staff, which will better equip staff in assessing the risk of self-harm and suicide. We have been concerned to raise the awareness of all staff but particularly those undertaking reception screening about both the risk of suicide and appropriate risk management processes. This package has been trialled across the Trust’s Offender Care services and all CNWL staff in HMP Woodhill will have completed this training by the end of February 2016. Once its effectiveness has been audited, the tool will be shared with NOMS and NHS England for use in prison healthcare services outside of the Trust.”

Source location
Daniel-Byrne-Response
Page 3 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide ongoing support for prison ACCT training and prison-led ACCT management.

Verbatim wording from the response
“We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.”

Source location
Daniel-Byrne-Response
Page 3 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Check daily information-sharing and review ACCT records at each planned review meeting.

Verbatim wording from the response
“We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.”

Source location
Daniel-Byrne-Response
Page 3 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.

Verbatim wording from the response
“We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.”

Source location
Daniel-Byrne-Response
Page 3 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.

Verbatim wording from the response
“You have identified that the PPO has made repeat recommendations and that there is need for a comprehensive review of the safer custody procedures.”

Source location
Daniel-Byrne-Response2
Page 1 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.

Verbatim wording from the response
“In response to the recent deaths in custody at HMP Woodhill, reviews of all aspects of safer custody, and of healthcare services have been commissioned. These reviews are being conducted by staff who are not based in the prison, and the results will inform future developments.”

Source location
Daniel-Byrne-Response2
Page 1 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.

Verbatim wording from the response
“You may be interested to know that in order to address the issues with reception screening that were identified in the case of Daniel Byrne a new tool is being introduced.”

Source location
Daniel-Byrne-Response2
Page 2 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain a dedicated mental health team member on the First Night Centre to interview new prisoners and update identified risk factors.

Verbatim wording from the response
“6. A dedicated mental health team member is now in place on the FNC Monday to Friday with plans to extend across weekends. All new prisoners will be interviewed by a member of this team. They will review the contents of the ECRA prior to prisoner interview and will also sign for the documents enclosed being present and having been read.”

Source location
Daniel-Byrne-Response2
Page 3 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NOMS holds policy responsibility for suicide prevention and self-harm management.

Verbatim wording from the response
“You stated that “there needs to be a review of the healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare”. In addition, that “consideration should be given to the introduction of a formal risk assessment tool”. We note that you raised similar concerns in Regulation 28 reports in 2014 and have considered the NOMS responses of 12 June and 31 October 2014. We note that the Equality, Rights and Decency Group of NOMS has policy responsibility for suicide prevention and self-harm management and will not repeat the description of the policy frameworks set out in the responses. We do however operate under the national frameworks set out in Prison Service Instructions (PSI) 74/2011 Early Days in”

Source location
Daniel-Byrne-Response
Page 1 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The prison leads the ACCT process and is responsible for regularly assessing prisoners’ risk.

Verbatim wording from the response
“It was also recognised that whilst those with complex Mental Health needs are ‘managed well’ there is very little resource available for those inmates who are primarily being supported by GPs. This will be picked up in the benchmarking exercise. There were a number of other recommendations including the need to regularly review and focus on the ACCT process recognising the importance of the prison risk assessing regularly and the quality and organisation of the process.”

Source location
Daniel-Byrne-Response
Page 3 · response
Published 14 December 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No nationally recognised best-practice risk-assessment tool exists beyond the processes specified in Prison Service Instructions.

Verbatim wording from the response
“While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.”

Source location
Daniel-Byrne-Response
Page 2 · response
Published 14 December 2015
Open published response
18 Sep2015
Worcestershire
Concerns raised1
1. Failure to follow mandatory ACCT procedures for prisoners at risk of self-harm
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.
Actions described in response 1
1. Action
  Review the ACCT process to inform changes to PSI 64/2011.
  Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Hewell Prison and HM Prison and Probation ServiceStated in progress
Respondent positions 1
1. Position
  ACCT procedures do not require automatic opening whenever risk may be indicated; staff must assess risk, consult appropriately and record their decision.
  Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Hewell Prison and HM Prison and Probation ServiceDisputes the concern
AI-generated summary

Liam SMITH · 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

Liam Smith was admitted to HMP Hewell on 7 August 2014 and died after taking a combination of prescribed and illicitly obtained medication in his cell. The concerns included possible failures to follow mandatory ACCT procedures, inadequate dissemination and recording of medical information, and limited healthcare interaction with high-risk drug users, potentially resulting in warning signs being missed.

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 follow mandatory ACCT procedures for prisoners at risk of self-harm
Wider context from the report
“(1) Evidence suggested that Mr Smith was at risk of inadvertant self harm and that therefore in accordance with PSI64/2011 ACCT procedures should have been opened in respect of him. Witnesses confirmed their understanding of that mandatory requirement but indicated that they would use their clinical judgement in deciding whether or not to open an ACCT. It is of concern that staff may therefore may therefore not be following mandatory PSI instructions and that prisoners are not receiving appropriate protection by way of the ACCT process. ”
Source location
Liam SMITH · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the ACCT process to inform changes to PSI 64/2011.

Verbatim wording from the response
“A review of the ACCT process is currently ongoing, which will inform changes to the current policy in PSI 64/2011.”

Source location
2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
ACCT procedures do not require automatic opening whenever risk may be indicated; staff must assess risk, consult appropriately and record their decision.

Verbatim wording from the response
“As you are aware, chapter 5 of Prison Service Instruction (PSI) 64/2011 sets out the policy on the Assessment, Care in Custody and Teamwork (ACCT) process. ACCT is a prisoner-centred, flexible care planning approach which is used in all prisons to manage a prisoner's risk or self-harm or suicide.”

Source location
2015-0382-Response-by-NOMS
Page 1 · response
Published 18 September 2015
Open published response
28 Apr2015
Leicester City and South Leicestershire
Concerns raised2
1. Over-reliance on others to make further enquiries about statements of depression and self-harm
2. Failure to consistently open ACCTs for prisoners presenting with self-harm or other risks
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 6
1. Action
  Reinforce reception procedures requiring an ACCT to open when a recent self-harm attempt is identified.
  Stated by Glen Parva Young Offender InstitutionStated completed
2. Action
  Brief existing staff and provide new staff with Safer Custody training on when to open an ACCT.
  Stated by Glen Parva Young Offender InstitutionStated planned
3. Action
  Establish a Safer Custody team to advise and support staff and monitor adherence to the Safer Prisons strategy.
  Stated by Glen Parva Young Offender InstitutionStated completed
1. Action
  Place every prisoner presenting a suicide or self-harm risk on an ACCT, regardless of the number already open.
  Stated by Glen Parva Young Offender InstitutionStated completed
2. Action
  Reallocate resources when ACCT numbers are particularly high to ensure they are managed appropriately.
  Stated by Glen Parva Young Offender InstitutionStated planned
3. Action
  Remind staff to open an ACCT whenever information indicates suicide or self-harm risk, even when the prisoner does not appear at risk.
  Stated by Glen Parva Young Offender InstitutionStated completed
AI-generated summary

Greg Revell · 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

Greg Revell was found hanging in his cell at HM YOI Glen Parva, and resuscitation was unsuccessful. The concerns included that a previous ligature self-harm attempt did not lead to an ACCT, uncertainty among prison officers about when to open an ACCT, insufficient consideration of recorded risk factors, and weaknesses in capturing healthcare information and obtaining a GP summary.

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
Over-reliance on others to make further enquiries about statements of depression and self-harm
Wider context from the report
“5. There was a culture of over-reliance on “others” being responsible for enquiring further into statements regarding depression and self harm made by Greg, rather than any focus on individual responsibility. ”
Source location
Greg Revell · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to consistently open ACCTs for prisoners presenting with self-harm or other risks
Wider context from the report
“1. Greg had been a prisoner at Glen Parva YOI earlier the same year, and on that occasion presented with a florid and undiagnosable ligature mark on his neck from an attempt at self harm shortly before his imprisonment. Notwithstanding this, he was not placed on an ACCT. 2. There was confusion amongst Prison Officers who gave evidence regarding when it was appropriate to open an ACCT. 3. There was suggestion that there would be “too many ACCTS” and they would be ineffective if all prisoners with risks were placed on an ACCT. ”
Source location
Greg Revell · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reinforce reception procedures requiring an ACCT to open when a recent self-harm attempt is identified.

Verbatim wording from the response
“(1) Greg had been in Glen Parva YOI earlier the same year, and on that occasion presented with a florid and distinguishable ligature mark on his neck from an attempt at self-harm shortly before his imprisonment. Notwithstanding this, he was not placed on an ACCT. It is accepted that Mr Revell should have been placed on an Assessment Care in Custody and Teamwork (ACCT) when he first came into HMYOI Glen Parva. Local policies and procedures have since been reinforced to ensure that an ACCT is opened on reception whenever there is evidence of a recent self-harm attempt.”

Source location
2015-0165-Response-by-NOMS
Page 1 · response
Published 28 April 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Brief existing staff and provide new staff with Safer Custody training on when to open an ACCT.

Verbatim wording from the response
“In accordance with PSI64/2011 Safer Custody, the local Safer Prisons strategy gives clear guidance to staff on when it is appropriate to open an ACCT. All existing staff have been briefed on the strategy, and new staff will receive ‘Introduction to Safer Custody’ training to ensure that they are confident about this process. A new Safer Custody team is now in place to”

Source location
2015-0165-Response-by-NOMS
Page 1 · response
Published 28 April 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a Safer Custody team to advise and support staff and monitor adherence to the Safer Prisons strategy.

Verbatim wording from the response
“In accordance with PSI64/2011 Safer Custody, the local Safer Prisons strategy gives clear guidance to staff on when it is appropriate to open an ACCT. All existing staff have been briefed on the strategy, and new staff will receive ‘Introduction to Safer Custody’ training to ensure that they are confident about this process. A new Safer Custody team is now in place to”

Source location
2015-0165-Response-by-NOMS
Page 1 · response
Published 28 April 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Place every prisoner presenting a suicide or self-harm risk on an ACCT, regardless of the number already open.

Verbatim wording from the response
“All prisoners presenting with a risk of suicide or self-harm are placed on an ACCT, regardless of the number of ACCTs that are already open in the establishment. At times when there are particularly high numbers of ACCTs the Governor will ensure that resources are reallocated to ensure that they are managed appropriately.”

Source location
2015-0165-Response-by-NOMS
Page 2 · response
Published 28 April 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reallocate resources when ACCT numbers are particularly high to ensure they are managed appropriately.

Verbatim wording from the response
“All prisoners presenting with a risk of suicide or self-harm are placed on an ACCT, regardless of the number of ACCTs that are already open in the establishment. At times when there are particularly high numbers of ACCTs the Governor will ensure that resources are reallocated to ensure that they are managed appropriately.”

Source location
2015-0165-Response-by-NOMS
Page 2 · response
Published 28 April 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind staff to open an ACCT whenever information indicates suicide or self-harm risk, even when the prisoner does not appear at risk.

Verbatim wording from the response
“All staff have been reminded of the local policy which states that an ACCT must be opened whenever information is received to indicate that a prisoner is at risk, even if the prisoner himself does not present as being at risk. Case managers have also been reminded to take account of all the relevant information and to have regard to the dynamic and static risk factors for the individual when carrying out case reviews, and not simply to rely on their assessment of the prisoner’s presentation. This ensures that the level of risk is assessed on the basis of comprehensive information.”

Source location
2015-0165-Response-by-NOMS
Page 2 · response
Published 28 April 2015
Open published response
24 Mar2015
Peterborough
Concerns raised2
1. Failure to comprehensively assess suicide and self-harm risk using documented risk factors and information
2. Allowing cell door keys to be carried around the neck on tied shoelaces
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stuart Megginson BAUMBER · 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

Stuart Megginson BAUMBER died by hanging in his cell at HMP Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013, after being remanded in custody for arson. The jury found that occasions existed when the ACCT process should have been initiated and that inadequate understanding and training contributed to this not happening. The report also raised concerns about ligature points on cell doors, healthcare screening that did not mention section 136 detentions, and items available to prisoners that could facilitate suicide.

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 comprehensively assess suicide and self-harm risk using documented risk factors and information
Wider context from the report
“8. There appears to be on occasions an over reliance on assessment of current risk as emphasised in the QTLB of 2012 by considering demeanour and presentation at the reception stage. The PPO bulletin of March 2015 highlights deficiencies in this approach. There are known risk factors for suicide and self-harm and active identification of relevant risk factors from documentation and information (e.g. SASH forms and PERs and medical records and an EME report) should be fully considered and balanced against apparent mood so that there is a comprehensive risk assessment.. A pro forma document could record what factors and information have been considered and the reasons for the decision. ”
Source location
Stuart Megginson BAUMBER · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Allowing cell door keys to be carried around the neck on tied shoelaces
Wider context from the report
“12. Some prisoners at HMP Peterborough are allowed to carry their cell door key which is placed on shoelaces tied together and placed around the neck of the prisoner which clearly creates a self-made ligature for those who may be at risk. ”
Source location
Stuart Megginson BAUMBER · Prevention of Future Deaths report
Page 3 · concerns
Open source report
28 Dec2014
Mid Kent and Medway
Concerns raised1
1. Failure to seek advice before disciplinary action indicated increased self-harm risk
This report raised 27 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 1
1. Action
  Publish guidance reminding staff to present ACCT plans at adjudications so self-harm risks inform adjudication decisions.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Alex Kelly · 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

Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to seek advice before disciplinary action indicated increased self-harm risk
Wider context from the report
“Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
Source location
Alex Kelly · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish guidance reminding staff to present ACCT plans at adjudications so self-harm risks inform adjudication decisions.

Verbatim wording from the response
“The third concern that you have addressed to the Governor of HMYOI Cookham Wood relates to what you describe as a conflict between regimes, in the sense that the ACCT process and behaviour improvement plan were not sufficiently joined up with the adjudications process.”

Source location
2014-0555-Response-by-Ministry-of-Justice
Page 5 · response
Published 28 December 2014
Open published response
29 Aug2014
Milton Keynes
Concerns raised2
1. Failure to complete formal self-harm or suicide risk assessments on prison admission
2. Unavailability of a formal self-harm or suicide risk assessment tool in prisons
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Continue improving risk identification, assessment and management processes.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Remind reception and first-night staff to gather relevant information and consider relevant risk factors.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Improve the healthcare staff risk-assessment process.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Train healthcare staff to use the improved risk-assessment process.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 1
1. Position
  Existing processes, including limited screening tools, are considered sufficient without a formal risk-assessment tool across the prison estate.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
AI-generated summary

Stephen Philip Owen Farrar · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stephen Philip Owen Farrar was found hanging in his cell at HMP Woodhill on 12 December 2013 and was pronounced dead later that evening. The report raised concerns that no formal self-harm or suicide risk assessment had been completed on admission despite his previous self-harm history and past mental health problems, and that no formal risk assessment tool was available in prisons.

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 complete formal self-harm or suicide risk assessments on prison admission
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression. Almost any risk assessment tool would have identified him as high risk. (2) I was told that there is no formal risk assessment tool available in any of our prisons. ”
Source location
Stephen Philip Owen Farrar · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of a formal self-harm or suicide risk assessment tool in prisons
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression. Almost any risk assessment tool would have identified him as high risk. (2) I was told that there is no formal risk assessment tool available in any of our prisons. ”
Source location
Stephen Philip Owen Farrar · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue improving risk identification, assessment and management processes.

Verbatim wording from the response
“In response to your renewed expression of concern, I would like to assure you that reducing the number of self-inflicted deaths in prisons remains a priority for NOMS, and that we continue to work to improve our risk identification, assessment and management processes. In response to the recent rise in the number of deaths, additional dedicated resources are being provided for safer custody work in a number of prisons, and we have put in place additional staff at regional level to support staff in prisons and to share good practice. A learning and knowledge management team at headquarters provides further support to prisons in learning from deaths in custody and for safer custody work more generally.”

Source location
2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind reception and first-night staff to gather relevant information and consider relevant risk factors.

Verbatim wording from the response
“Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.”

Source location
2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Improve the healthcare staff risk-assessment process.

Verbatim wording from the response
“Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.”

Source location
2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train healthcare staff to use the improved risk-assessment process.

Verbatim wording from the response
“Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.”

Source location
2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing processes, including limited screening tools, are considered sufficient without a formal risk-assessment tool across the prison estate.

Verbatim wording from the response
“I note that you raised similar concerns in a Regulation 28 Report following an inquest held in February 2014 into a death at HMP Woodhill in May 2013, and that you received a detailed response to that report from my colleague ████████ on 12 June 2014. I will not repeat the description of the policy framework given there. In summary there is a comprehensive set of systems for identifying and assessing prisoners at risk that includes some specific tools, such as a healthcare reception screening tool that has been made available to all prison establishments, but, of necessity, such tools form only a small part of the very broad set of processes involved in this complex task.”

Source location
2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure of suicide risk guidance to include irrational behaviour indicative of psychosis

Failure to open an ACCT document when behaviour indicates a need for additional monitoring

Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance

Concerns raised1

Failure to properly observe ACCT procedures

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.7

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

Concerns raised1

Failure to maintain adequate ACCT case management documentation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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

Concerns raised1

Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records

Concerns raised2

Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners

Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners

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.13

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 7

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 13

Respondent positions 3