10 Feb 2021 Jason O’Rourke · Prevention of Future Deaths report Inner South London
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Concerns raised 2
Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff View source Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway 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
Jason O’Rourke · 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
Jason O’Rourke died by suicide in his cell at HMP Belmarsh after hanging himself with a bedsheet ligature between 7.28 pm on 1 April 2019 and 9.33 am on 2 April 2019. The jury identified possible contributing factors including inadequate follow-up of his mental health, insufficient sharing and understanding of information about his mental health and self-harm history, and inadequate safety intervention meetings. The report also raised concerns about unclear self-harm and suicide risk assessments on arrival and the lack of robust auditing of nightly roll checks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff
Wider context from the report “(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified.
The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.
It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”
Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.
” Source location Jason O’Rourke · 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 Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway
Wider context from the report “(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified .
The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.
It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”
Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.
” Source location Jason O’Rourke · 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 Implement a revised immediate-needs form with clearer guidance for identifying, communicating and documenting suicide or self-harm risks.
Verbatim wording from the response “Following evidence heard at the inquest you have raised concerns in relation to the ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh. This is a locally produced document created in line with the Prison Service Instruction (PSI) 07/2015 Early days in Custody. You will be aware that the early days in custody is a period in which risk of self-harm or suicide is heightened and the wellbeing of prisoners in our care is the primary concern of staff throughout the reception and first night process. Following the inquest a review of the form has taken place, and a new version is now in use.” Source location 2021-0032-Response-from-HMPPS-Redacted
Open published response
Concerns raised 1
Failure to reassess altered self-harm risk View source
This report raised 19 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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Andrew Patrick Jones · 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
Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.
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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 reassess altered self-harm risk
Wider context from the report “The Senior Officer, and the senior prison management accepted that there had been a substantial alteration in risk with every protective factor now being converted into a risk factor. Furthermore, it was accepted that there was a failure to warn the receiving wing of the alteration in risk and that there was a further failure to reassess the alteration in risk .
” Source location Andrew Patrick Jones · Prevention of Future Deaths report
Open source report
6 Mar 2020 Carl John Newman · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 2
Lack of ready access to prison staff training records View source Failure to ensure current ACCT and safer custody process training for prison staff View source
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
Carl John Newman · 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 John Newman, aged 23, died by suicide after fashioning a ligature around his neck in a prison cell toilet area on 6 October 2017. The report identified concerns about delayed completion of a Day Two Assessment and prison staff’s access to, and records of, current ACCT and SASH 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 Lack of ready access to prison staff training records
Wider context from the report “During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training. As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience.
What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes?
” Source location Carl John Newman · 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 ensure current ACCT and safer custody process training for prison staff
Wider context from the report “During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training . As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience.
What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes ?
” Source location Carl John Newman · Prevention of Future Deaths 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 Issue a staff information notice promoting myLearning access and reminding staff about refresher-training requirements.
Verbatim wording from the response “As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.” Source location 2020-0056-Response-from-Director-General-of-Prisons
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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 a comprehensive guide explaining how staff can use myLearning to access personal training records.
Verbatim wording from the response “As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.” Source location 2020-0056-Response-from-Director-General-of-Prisons
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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 local training coordination to assist staff and ensure attendance at required refresher training.
Verbatim wording from the response “As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.” Source location 2020-0056-Response-from-Director-General-of-Prisons
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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 Update ACCT-related training packages and refresh the broader safety-training approach to reduce duplication and align content.
Verbatim wording from the response “As you know, we intend to roll out a new version of the ACCT case management system soon, and we will be taking this opportunity to update the related training packages, and to refresh our approach to safety training more broadly. This will allow us to reduce duplication between courses whilst ensuring that the content is consistent and makes appropriate links between related issues. As we develop this new set of training materials we will ensure that expectations as to which staff should attend which courses, and the frequency of refresher training, are clear.” Source location 2020-0056-Response-from-Director-General-of-Prisons
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The myLearning database provides outcomes equivalent to certificates with expiry dates for recording and monitoring staff training.
Verbatim wording from the response “on successful completion of the training, their record is updated to reflect their attendance (and pass/fail outcome for some courses). Both the learner themselves and the local training department have access to this record. Training departments are also able to run a report to see who has attended and/or passed a particular course, and when. We consider that this electronic system achieves the same outcomes as the system of certificates with expiry dates that you mention in your letter.” Source location 2020-0056-Response-from-Director-General-of-Prisons
Open published response
21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
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Concerns raised 5
Failure of SystmOne search functions to extract key mental health risk information View source Failure to identify documented suicide and deliberate self-harm risk information View source SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information View source
Failure to maintain accurate and usable summary and active-problem risk information View source Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment View source See 2 more concerns
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
Andrew Goldstraw · 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
Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent 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 of SystmOne search functions to extract key mental health risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it .
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Source location Andrew Goldstraw · 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 identify documented suicide and deliberate self-harm risk information
Wider context from the report “A. The computer system used by CNWL is known as SystmOne. Healthcare staff working on Reception when Mr Goldstraw first arrived at the prison had access to his previous medical notes and history (around 240 pages in all) stored on SystmOne. The records contained numerous references to suicidal ideation and previous attempts at deliberate self-harm. Mr Goldstraw had attempted to take his own life on several previous occasions, the most recent of which was only three months prior to his arrival at the prison. However, despite a proliferation of entries making reference to his mental health history the mental health nurse who had access to SystmOne was seemingly unaware of the relevant entries . Had he been, he said he would have opened an ACCT.
” Source location Andrew Goldstraw · 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 SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT . Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Source location Andrew Goldstraw · 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 maintain accurate and usable summary and active-problem risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment . It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm . The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Source location Andrew Goldstraw · 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 Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment
Wider context from the report “G. There also appeared to be a lack of training in relation to the effective use of SystmOne . In particular, it was not clear whether any steps had been taken to ensure that the staff who were working at the prison at the time of Mr Goldstraw's death had been retrained or had their competencies assessed in light of the failures identified. There is a real concern that some staff are still failing adequately to carry out assessments of a prisoners risk of suicide / deliberate self-harm.
H. The Head of Healthcare at HM Prison, Winchester has indicated that she intends to provide (in conjunction with the Prison Governor) a joint learning bulletin to all staff, stressing the importance of sharing information, most notably in reception and during the early days in custody. However, this does not address the technical shortcomings of SystmOne which present a matter of considerable concern, even if healthcare staff undertake all reasonable steps to ascertain a prisoner's previous mental health history as part of the prison induction process.
” Source location Andrew Goldstraw · 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 Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Verbatim wording from the response “The Trust has sent out guidance to all offender care sites in relation to the search function. Whilst this is a function owned by SystmOne CNWL has given staff directions on how to best utilise this function. For instance, when trying to get a history of suicide attempts rather than searching suicide the clinician should search ‘suic’ which will bring up results for suicide, suicidal, suicidal thoughts.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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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 Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Verbatim wording from the response “We will also remind staff that other organisations use SystmOne and that they may not enter data in an easy to view way. Staff have been advised to use search functionality to find data that may have not been entered properly by staff from other organisations.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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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 Require reception-screening staff to complete modified training and confirm competence through induction sign-off and supervision.
Verbatim wording from the response “The Trust has modified its staff training to ensure this type of issue does not re-occur in the future. All staff are required to complete this training as part of their induction and to sign that they have completed the training and are competent to undertake reception screening. For existing staff this training and compliance issues will be discussed through management supervisions.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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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 reception-screening nurses with a guide explaining how to register patients and access previous medical records.
Verbatim wording from the response “A reception guide has been developed for all CNWL nursing staff undertaking reception screening. This includes clear guidance on how a staff member is able to access previous medical records when registering a patient within the prison. A patient must be registered with the prison by the nurse in the reception and then the records saved prior to the nursing staff having access to all the medical records. This is clearly outlined in the reception guidance document.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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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 Distribute guidance and a standard process for reviewing, entering and linking diagnoses and problems in SystmOne.
Verbatim wording from the response “The usefulness of the “Problem section” is reliant on the information added to it by whichever establishment the patient is in. However, CNWL offender care have sent out a memo to all staff to inform them how to review problems which are on the SystmOne record. In addition, since this inquest, CNWL Offender Care have sent out the SystmOne guidance section in how to input diagnosis data and link it to consultations in a standard way across the service. This is referred to as “creating a problem”. To ensure this memo is acted upon, Offender Care will undertake a review of the use of problem section in conjunction with their annual medical records audit. This audit generates site specific action plans highlighting areas for improvement.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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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 Review use of SystmOne’s problem section through the annual medical-records audit and assign improvement actions where required.
Verbatim wording from the response “The usefulness of the “Problem section” is reliant on the information added to it by whichever establishment the patient is in. However, CNWL offender care have sent out a memo to all staff to inform them how to review problems which are on the SystmOne record. In addition, since this inquest, CNWL Offender Care have sent out the SystmOne guidance section in how to input diagnosis data and link it to consultations in a standard way across the service. This is referred to as “creating a problem”. To ensure this memo is acted upon, Offender Care will undertake a review of the use of problem section in conjunction with their annual medical records audit. This audit generates site specific action plans highlighting areas for improvement.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
Verbatim wording from the response “Additionally, Offender Care is carrying out quarterly review of risk assessments. Mental Health risk assessments have been developed across CNWL offender care services and have been uploaded onto SystmOne. These risk assessments include a patient’s risk of harm to themselves and to others. These risk assessments should be updated whenever there is a recognised change in a patients risk and should form the basis of a care plan. Both risk assessments and the care plans they help formulate are audited every three months and also form part of the annual medical records audit to provide assurances that risks are being appropriately identified.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all staff during induction to use SystmOne’s problem functionality and audit its use through quarterly care-quality meetings.
Verbatim wording from the response “This functionality has the potential to be very helpful if used appropriately as, for instance, every episode of self-harm could be linked to a problem “Self-harm” meaning all episodes are collated in one place. CNWL has sent out guidance to all staff on how to manage problems on SystmOne. Training will be provided on “problems” for every member of staff during their induction. The use of problems on SystmOne will be audited through the Offender Care, Care Quality Meetings initially on a quarterly basis to review progress of this function.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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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 SystmOne training through induction and the Learning and Development Zone, including additional training identified through supervision.
Verbatim wording from the response “All staff are trained in SystmOne during their induction. SystmOne training is now available on the Trust’s Learning and Development Zone (LDZ) and all staff identified as requiring additional training (through six weekly supervision) will complete the SystmOne training on LDZ.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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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 Require annual Suicide and Self Harm and ACCT training, with successful testing before staff are signed off as compliant.
Verbatim wording from the response “All staff are now required to complete annual Suicide and Self Harm training and annual ACCT training. In these training packages, identification of suicide and deliberate self- harm risk are covered and all staff have to successfully pass a test which covers these areas to be signed off as compliant.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.
Verbatim wording from the response “SystmOne is the medical records system for all prisoners and this contract with TPP is managed by NHS England and not directly by CNWL. However, with internal training and audit we hope to be able to overcome a significant proportion of the limitations identified. We will also be raising the Coroner’s concerns and our work around with TPP so that they can consider them in any future developments of the system” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Verbatim wording from the response “Whilst the risk assessment template on SystmOne does ask pre-set questions the clinician is not reliant solely on the information disclosed during the assessment. When completing the risk assessment there is a section on the right hand side of the template with previous values that have been entered in relation to these questions. This allows the clinician to have an understanding of previous answers to these questions and gives them some context when considering a response to a question. For instance if a patient’s response contradicts a previous statement they have made the staff will be able to ascertain this and ask appropriate follow up. When the cursor is put in the box relating to risk incidents and triggers previous entries about this come up on the right hand section of the template.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The accuracy of SystmOne’s problem list depends on all providers updating records, not solely on CNWL.
Verbatim wording from the response “The Problem list is populated by staff who use SystmOne. CNWL are not the only provider who use SystmOne and therefore an accurate Problem list is dependent on” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
20 Dec 2019 Tomasz Nowosad · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 4
Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment View source Failure of prison staff to separately record self-harm and suicide risk information View source Observation regimes failing to account for predictable observation patterns View source
Failure to undertake holistic and updated self-harm or suicide risk assessment View source See 1 more concern
This report raised 17 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
Tomasz Nowosad · 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
Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.
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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 Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
Wider context from the report “5 1 The context of this case has to be seen in the light of the fact that in 2019 two self-inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above it is suggested that there has been a repeated theme in the majority of these cases that there was an over reliance and emphasis on the assumptions made by a prisoner that they “had no thoughts of self-harm or suicide” This is often simply recorded in ACCT reviews by ticking boxes on the review document . Whilst it is appropriate for this issue to be addressed whenever a prison is on an ACCT either by healthcare staff or at ACCT reviews because in many cases prisoners still go on to harm themselves or commit suicide It should not be regarded as definitive This was recognised and recorded in the latest PPO Investigation Report relating to a death that occurred on 5 April 2019
This was specifically referred to in paragraph 26 of the report which said “In previous investigation into self-inflicted deaths at Manchester, we identified weaknesses in the risk assessment of prisoners at risk of suicide and self-harm We found in particular that staff placed too much emphasis on prisoner’s presentation and did not give sufficient consideration to their risk factors”
” Source location Tomasz Nowosad · 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 of prison staff to separately record self-harm and suicide risk information
Wider context from the report “5 7 It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide
” Source location Tomasz Nowosad · 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 Observation regimes failing to account for predictable observation patterns
Wider context from the report “5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH staff
” Source location Tomasz Nowosad · 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 undertake holistic and updated self-harm or suicide risk assessment
Wider context from the report “5 2 PSI-64/2011 recognises that there are a number of potential triggers to self-harming behaviour or suicide All staff should be alert to the increased risk of self-harm or suicide posed by prisoners with these risk factors and should act appropriately to address any concerns, including opening an ACCT if necessary However, it is suggested that the list of factors is not exhaustive and everything needs to be considered in light of the overall picture This will usually involve discipline staff and health care staff It is suggested that thereafter, particularly if the prisoner is moved to the HCC, considering all the risk factors and the changing position taking into account the previous recorded history of the prisoner from both a health care and general prison service records This is especially so when ACCTs are being reviewed and a prisoner is being discharged from the ACCT or moved out of the limited number of safer cells available in the prison There has to be consideration of the overall or ‘big picture’ with regards to the risks that the prisoner poses
” Source location Tomasz Nowosad · 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 Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.
Verbatim wording from the response “A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020.” Source location 2019-0445-Response-from-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 Redevelop ACCT training and deliver it to new staff and as refresher training for existing staff.
Verbatim wording from the response “The associated training packages are currently being redeveloped and will be delivered to all new staff through POEL training and made available as refresher training for existing staff. A specific session on the risks and triggers for self-harm and suicide will form a major part of this training.” Source location 2019-0445-Response-from-HMPPS
Open published response
19 Nov 2019 Shaun William Dewey · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3
Failure to reflect remand prisoners’ higher risk of self-harm or suicide in national safer-custody guidance View source Failure to highlight remand prisoners’ higher risk of self-harm or suicide on the ACCT document View source Failure to highlight the higher risk of self-harm or suicide among remand prisoners to prison and healthcare staff 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
Shaun William Dewey · 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
Shaun William Dewey, a remand prisoner, was found hanging in his cell at HMP Bristol and died on 13 April 2018 after suspending himself from a ligature tied to the bed frame. The inquest identified anxiety, depression, separation from family, uncoordinated supervision, erratic medication use, and insufficient application of prison, healthcare and mental health systems as contributory factors. Concerns included whether remand prisoners’ higher risk of self-harm or suicide should be reflected in staff training, prisoner care, ACCT documentation and national guidance.
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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 reflect remand prisoners’ higher risk of self-harm or suicide in national safer-custody guidance
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Source location Shaun William Dewey · 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 Failure to highlight remand prisoners’ higher risk of self-harm or suicide on the ACCT document
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Source location Shaun William Dewey · 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 highlight the higher risk of self-harm or suicide among remand prisoners to prison and healthcare staff
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Source location Shaun William Dewey · 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 Disseminated guidance identifying remand status as a suicide and self-harm risk factor.
Verbatim wording from the response “As you rightly point out, whilst Prison Service Instruction (PSI) 64/2011 ‘Safer Custody’ contains lists of identified risks and triggers for suicide and self-harm that include factors that are relevant to many remand prisoners (such as early days in custody), it does not mention remand status itself. However, we frequently supplement the list in the PSI with additional information for staff, and this has included references to the increased risk posed by remand prisoners. For instance, the April 2014 Prison and Probation Ombudsman learning bulletin, from which you have quoted in your report, was disseminated widely within prisons, and more recent guidance issued by our prison safety team and made available to staff on the HMPPS intranet includes remand status as a risk factor for suicide. Training based on this more recent guidance has also been provided to staff in a number of prisons.” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
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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 Replace the existing safer-custody instruction with a policy framework and update risk and trigger lists using evidence on remand-status risks.
Verbatim wording from the response “During 2020 we will be replacing PSI 64/2011 with a policy framework on prison safety, and as part of this process the lists of risks and triggers will be reviewed and updated. We will ensure that the evidence about the risks posed by remand status, which you have drawn to my attention, is used to inform that work. The new policy framework will include a new version of the Assessment, Care in Custody and Teamwork (ACCT) process designed to make the system easier to operate and improve the quality of care offered to prisoners. The new version of the form and associated guidance were piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
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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 Develop and include a revised ACCT process in the new prison-safety policy framework, incorporating evaluation feedback before national rollout.
Verbatim wording from the response “During 2020 we will be replacing PSI 64/2011 with a policy framework on prison safety, and as part of this process the lists of risks and triggers will be reviewed and updated. We will ensure that the evidence about the risks posed by remand status, which you have drawn to my attention, is used to inform that work. The new policy framework will include a new version of the Assessment, Care in Custody and Teamwork (ACCT) process designed to make the system easier to operate and improve the quality of care offered to prisoners. The new version of the form and associated guidance were piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
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 Provided staff training based on guidance recognising remand status as a suicide and self-harm risk factor.
Verbatim wording from the response “As you rightly point out, whilst Prison Service Instruction (PSI) 64/2011 ‘Safer Custody’ contains lists of identified risks and triggers for suicide and self-harm that include factors that are relevant to many remand prisoners (such as early days in custody), it does not mention remand status itself. However, we frequently supplement the list in the PSI with additional information for staff, and this has included references to the increased risk posed by remand prisoners. For instance, the April 2014 Prison and Probation Ombudsman learning bulletin, from which you have quoted in your report, was disseminated widely within prisons, and more recent guidance issued by our prison safety team and made available to staff on the HMPPS intranet includes remand status as a risk factor for suicide. Training based on this more recent guidance has also been provided to staff in a number of prisons.” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Open published response
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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 Revise suicide and self-harm prevention training and update its risk-and-trigger recognition module to reflect the new policy framework and ACCT changes.
Verbatim wording from the response “evaluation report and expect to make some further changes before the national rollout. I will ensure that your point about the need to bring attention to the risks associated with remand status is considered as we do so. We will also be revising the Introduction to Suicide and Self Harm Prevention training (a course that is undertaken by all staff with prisoner contact) to reflect and support the new policy framework and changes to ACCT. Again, we will use this opportunity to ensure that the module on recognising risks and triggers is reviewed and updated.” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Open published response
30 Oct 2019 David John KIRSCH · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4
Failure to allocate a Case Manager to oversee ACCT documents View source Failure to notify the designated Case Manager about ACCT documents View source Lack of prison officer knowledge of ACCT reasons and monitoring issues View source
Failure to conduct direct assessment of suicide and self-harm risk during ACCT reviews View source See 1 more concern
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
David John KIRSCH · 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
David John Kirsch was found deceased in his cell on 19 March 2018 after inflicting a large wound to his neck with the lid of a tin. The principal concerns were the lack of allocated case-manager oversight for his ACCT document, deficiencies in recording and addressing risks, failure to escalate the case, and inadequate staff knowledge and assessment of his suicide risk.
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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 allocate a Case Manager to oversee ACCT documents
Wider context from the report “(1) No Case Manager had been allocated to oversee Mr. Kirsch's ACCT document . This lack of oversight resulted in a number of deficiencies in the ACCT process, including:
(a) 11 different people chairing the 13 ACCT reviews which took place in the 6 weeks between Mr. Kirsch's return from hospital on 5.2.18 and his death on 19.3.18;
(b) Inadequate completion of the Caremap within the ACCT document, which ought to have highlighted the issues behind Mr. Kirsch's concerning behaviour and suicide attempts in January 2018, and identified actions to be taken to try to address those issues. In this case, evidence was heard that:
(i) When he had first started his sentence in 2008, Mr. Kirsch had told people that he would not live to complete it;
(ii) In August 2017 he had had two notable episodes of bizarre behaviour which, it was thought, may have been down to having taken the psychoactive substance Spice on those occasions;
(iii) Evidence from staff who had witnessed the suicide attempts in January 2018 indicated that they thought he may have taken Spice on those occasions;
(iv) Throughout 2017 and early 2018 he had been rather obsessed with a complaint he had made about an entry on his NOMIS record, and that in the days leading up to his death he had reported that this had been keeping him up at night;
(v) He was concerned that his daughter, who had become an adult relatively recently, had not tried to make contact with him;
(vi) He was worried about visits from his family, and how he was going to tell them what he had done in January 2018;
(vii) He had been involved in a fight on 13.3.18 with another prisoner (something out of character for him), which had resulted in his transfer to another wing, away from a fellow prisoner who was an important part of his support network;
(viii) He had recently sought out a member of the healthcare team in tears, because he was worried that he had not been able to get across his version of events in the adjudication hearing held after the fight incident;
(ix) On the afternoon of his death, two fellow prisoners had expressed concerns to a Supervising Officer that Mr. Kirsch was "looking particularly down" and was not himself. This conversation was passed on to the Supervising Officer on Mr. Kirsch's wing who spoke to him. In that conversation, Mr. Kirsch made a concerning comment about having bitten someone, and denied (untruthfully) that he had had any involvement with the mental health team at the prison. These concerns and conversations were not recorded anywhere in the main body of the ACCT document.
Save for the fact of the fight on 13.3.18 and of his resulting transfer to another wing, none of these matters was noted in the Caremap on Mr. Kirsch's ACCT document, and so no actions were identified to try to address them.
(c) The ACCT document was opened on 20.1.18. Between then and 5.2.18 Mr. Kirsch had been receiving treatment for his injuries in hospital, and had been on constant bedwatch there. When he returned to the prison on 5.2.18, no entries were made to the Caremap at all for the first four weeks thereafter.
” Source location David John KIRSCH · 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 Failure to notify the designated Case Manager about ACCT documents
Wider context from the report “(2) The person whose name had been entered as Case Manager on the ACCT document ████████ confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it . More worryingly, another unknown person appears to have signed off the first page of the Caremap using ████████ initials.
” Source location David John KIRSCH · 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 Lack of prison officer knowledge of ACCT reasons and monitoring issues
Wider context from the report “(4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document being opened, and of the issues set out therein which needed to be monitored . By way of example:
(a) the Supervising Officer on Mr. Kirsch's wing who had the conversation with him described at 1(b)(ix) above, was not aware that DK had attempted suicide twice in January 2018 , and had not realised that Mr. Kirsch was being untruthful about his involvement with the mental health team;
(b) another Supervising Officer who had conducted an earlier ACCT review on 8.2.18 also conceded in evidence that at the time he conducted the review he had "probably not" had any idea about the two suicide attempts the previous month .
” Source location David John KIRSCH · 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 conduct direct assessment of suicide and self-harm risk during ACCT reviews
Wider context from the report “(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self-harm . When asked how he had proposed to assess Mr. Kirsch's level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation .
” Source location David John KIRSCH · 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 Introduce revised national ACCT case-manager training covering case management, Caremaps and information sharing.
Verbatim wording from the response “Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.” Source location 2019-0362-Response-from-NOMS_Redacted
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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 prison-wide access to an online log identifying all open ACCT documents and their assigned case managers through daily briefings.
Verbatim wording from the response “An online log of all open ACCT documents, complete with details of the assigned case manager, is now accessible to all staff at the prison. This forms part of the daily briefing document shared with all staff. This prompts case managers to take ownership of their cases, as well as avoiding any confusion about who has been assigned each case.” Source location 2019-0362-Response-from-NOMS_Redacted
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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 Convene weekly multidisciplinary safety meetings to discuss complex cases and cases approaching six weeks for escalation or enhanced care planning.
Verbatim wording from the response “At Long Lartin, a weekly multi-disciplinary safety intervention meeting is convened where cases that are complex and/or require a higher level of input are now discussed. This provides an opportunity to discuss cases approaching the six-week point in order to identify a more senior member of staff to take over as case manager and/or to devise an enhanced care plan as appropriate.” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate guidance on case management, Caremaps and information sharing to existing Long Lartin ACCT case managers.
Verbatim wording from the response “Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.” Source location 2019-0362-Response-from-NOMS_Redacted
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 Introduction to Suicide and Self Harm Prevention training to HMPPS staff with prisoner contact and offer it to partner and contractor staff.
Verbatim wording from the response “Introduction to Suicide and Self Harm Prevention (SASH) training is being delivered to all HMPPS staff with prisoner contact, and is also offered to staff of partners and contractors. The course is made up of six modules, including ‘Recognising Risks and Triggers’, ‘Opening ACCT Documents’, and ‘An Introduction to Mental Health Awareness’.” Source location 2019-0362-Response-from-NOMS_Redacted
Open published response
23 Jun 2019 Marcus William George McGuire · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to provide an embedded single case manager for each ACCT 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
Marcus William George McGuire · 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
Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.
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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 provide an embedded single case manager for each ACCT
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points .
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager .
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager... ”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management ”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” Source location Marcus William George McGuire · 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 Train additional single case managers to reduce caseloads and improve attendance at prisoners’ case reviews.
Verbatim wording from the response “In accordance with Prison Service Instruction (PSI) 64/2011, HMP Birmingham operates a single case manager model, and consistency of case management continues to improve. There are ongoing operational challenges in delivering this model in every case but, since the inspection to which you refer, the prison has trained additional case managers and this means that each individual has a lower caseload and is more frequently able to attend their prisoners' case reviews.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor compliance with the single case manager model daily and review it at monthly Safer Custody meetings.
Verbatim wording from the response “Compliance with the single case manager model is being monitored daily, and is reviewed at the monthly Safer Custody meetings. All case managers have been given additional briefing about the importance of consistent delivery of it, and the safety team for the West Midlands Prison Group is providing support and additional assurance measures to ensure that the process is embedded.” Source location 2019-0209-Response-by-HM-Prison-and-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 Brief all case managers on the importance of consistently delivering the single case manager model.
Verbatim wording from the response “Compliance with the single case manager model is being monitored daily, and is reviewed at the monthly Safer Custody meetings. All case managers have been given additional briefing about the importance of consistent delivery of it, and the safety team for the West Midlands Prison Group is providing support and additional assurance measures to ensure that the process is embedded.” Source location 2019-0209-Response-by-HM-Prison-and-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 Provide safety-team support and additional assurance measures to embed the single case manager process.
Verbatim wording from the response “Compliance with the single case manager model is being monitored daily, and is reviewed at the monthly Safer Custody meetings. All case managers have been given additional briefing about the importance of consistent delivery of it, and the safety team for the West Midlands Prison Group is providing support and additional assurance measures to ensure that the process is embedded.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
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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 Decisions on actions at HMP Birmingham are outside G4S’s remit because HMPPS now operates and manages the prison.
Verbatim wording from the response “HM Area Coroner will be aware that HMP Birmingham is now operated and managed by HMPPS, ████████ being the current governing Governor. Any decisions in terms of actions to be taken at HMP Birmingham are not therefore within the remit of G4S.” Source location 2019-0209-Response-by-G4S
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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 arrangements mitigate risks when the designated case manager cannot conduct a review, including substitute reviews and case transfers.
Verbatim wording from the response “harm or other notable event, and the person concerned is not on duty. When this occurs, another case manager thoroughly reviews the ACCT documentation and, wherever possible, speaks to members of staff who know the prisoner to enable them to understand the relevant risks prior to chairing the review. Similarly, if the case manager is going to be absent for an extended period then the case is transferred to a different case manager.” Source location 2019-0209-Response-by-HM-Prison-and-Probation-Service
Open published response
16 May 2019 Daniel Davey · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1
Inadequate advance notification and information sharing for ACCT reviews View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Davey · 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 Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.
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 Inadequate advance notification and information sharing for ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive . It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer . For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” Source location Daniel Davey · 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 Develop escalation procedures with Care UK and the prison for occasions when healthcare cannot attend an ACCT review.
Verbatim wording from the response “The Local Operating Procedure identifies there is an expectation that the staff attending the ACCT record this on SystmOne and future reviews are diarised for attendance.
We will actively contribute to quality assurance checks of compliance with this Local Operating Policy including those done as part of the PROTECT audits and are committed to improving our service delivery in response to any actions identified within these checks. In addition we will work with Care UK and the prison in the development of procedures for escalation should healthcare, for any reason, be unable to attend an ACCT review.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
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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 Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Verbatim wording from the response “Response:
As was stated at the inquest, our prescriber’s always record on the prescription form whether the medication they are prescribing should be held in possession. We have reminded our staff to ensure when they are reviewing any medication that they, where necessary, include an update of the ‘Medication In possession risk assessment’ which goes onto SystmOne, which in turn will feed into the ACCT. This ensures that both dispensing staff and prison staff are aware of any changes and respond accordingly, this will include the removal of any medicines currently being held.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the new ACCT case-management process, including dedicated case managers, review booking oversight and daily healthcare attendance allocation.
Verbatim wording from the response “In June 2019, a new way of operating the ACCT case management system was implemented at Bullingdon, with a specific case manager being allocated to each ACCT case. This system allows ACCT reviews to be booked by the case managers on a spreadsheet that is overseen by the safer custody department. Reviews can be organised earlier through this booking system, giving healthcare better capability to ensure attendance at all reviews, and each day an identified member of healthcare staff is responsible for attending each review or allocating an attendee to go in their place. If there are any issues with healthcare attendance, case managers are asked to inform the safer custody department and remedial action is taken.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
21 Mar 2019 John Wright · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2
Failure of the pre-arrival process to ensure receipt of high-risk self-harm or suicide information View source Lack of guidance for reducing observations of newly arrived prisoners from constant watch 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.
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. 11
Action
Implement a reception communication process using direct telephone alerts, secure email, acknowledgement and routine inbox checks for incoming patient risk information.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Provide NHS email accounts to all reception staff, including agency staff, to securely access incoming risk information.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Remind escort contractors to alert reception staff when constant supervision preceded a prisoner’s arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Remind reception staff to share and record risk information on prisoner passports, and audit passport recording and use.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 15 August 2019. View source
Action
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source
Action
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 August 2019. View source See 8 more actions
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AI-generated summary
John Wright · 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
John Wright, aged 32, died at Bullingdon Prison on 15 December 2017 after being found partially suspended by an electrical cable in his cell. He had expressed suicidal thoughts and had previously been kept on constant watch, but observations were reduced to twice hourly during reception. The concerns relate to the receipt and sharing of information about heightened suicide risk and the guidance and decision-making processes for reducing observation levels.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the pre-arrival process to ensure receipt of high-risk self-harm or suicide information
Wider context from the report “The first concern which I raise applies to both the prison and healthcare and relates to the receipt of information by the prison and/or healthcare about a heightened risk of self-harm/suicide for a prisoner who has yet to arrive at prison. I heard evidence that it is not uncommon for outside agencies to pass on concerns, and, for example, copies of relevant mental health assessments, in anticipation of the prisoner arriving at the prison in a state of heightened risk requiring help and assessment. I also heard evidence that the software system operated by healthcare (System One) does not enable healthcare staff to make entries prior to the prisoner being received at reception and a prison officer opening a record on the computer and allocating a prisoner number . This being the case, I understand that the practice has been to email or print a hard copy of the document and take it to reception . In this case, a mental health nurse who was part of the secondary mental health team received a report about heightened risk and telephoned the nurse in reception to pass on details. The secondary mental health nurse said in evidence she would normally take a hard copy of the mental health assessment that she received and place it in a tray in reception. There was an alternative of emailing, but this was not considered the best way to bring it to the attention of the relevant healthcare staff in reception.
Of course, information about an incoming prisoner, who is assessed at high risk of suicide, is precisely the sort of important information which should not be allowed to fall through any gaps. It is high priority. An outside person or agency has considered it necessary to bring the matter to the attention of the prison or health care.
I understand that Care UK have set up a generic email address for healthcare staff in reception which may assist. Clearly, this still relies on healthcare staff checking to see if any such emails have been received . I appreciate that it is very busy in reception in the late afternoon/early evening.
” Source location John Wright · 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 Lack of guidance for reducing observations of newly arrived prisoners from constant watch
Wider context from the report “The second matter I wish to raise, also to the prison and healthcare, is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case, Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact that there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment will not have taken place yet, there should in my view be some guidance to staff when reducing observations from constant watch .
I note that the Prison and Probation Ombudsman stated at the beginning of her report that ……. ‘Mr Wright had been under constant watch by police and court staff because he said he wanted to take his life at the earliest opportunity. Although prison staff started suicide and self-harm prevention procedures when Mr Wright arrived at Bullingdon, they reduced the level of observations from constant to twice an hour. In my view, this decision was misjudged and taken far too quickly, without a proper assessment of Mr Wright’s risk.’
I appreciate there is a great deal of responsibility on prison and healthcare staff when making assessments. Much depends on how they assess the prisoner in front of them. It may be appropriate to reduce a newly arrived prisoner from constant cell watch to less frequent observations on occasions. The concern which I raise relates to such decisions being made in reception and I enquire if there should be some guidance available to assist staff in their decision-making process? For example, should such a decision be postponed until a further assessment has been carried out the following day?
I realise that this issue is not straightforward and there are significant resource implications in keeping a prisoner under constant watch.
” Source location John Wright · 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 a reception communication process using direct telephone alerts, secure email, acknowledgement and routine inbox checks for incoming patient risk information.
Verbatim wording from the response “A new process flow has been developed in partnership with the Liaison and Diversion team which specifies how to contact and share risk and special care needs information of patients from Police Custody (Via Court) to HMP Bullingdon Healthcare in Reception. The new process provides a direct telephone number to the Reception nurse from 08.00 to 20.45 Monday to Friday and 08.00-17.00 on Saturdays. The process flow now advises if there is no answer via telephone, the Reception nurse should be contacted via the prison communications room who will contact the nurse via their prison radio. Outside of these times detailed above, the prison communications team can contact the senior nurse on duty.” Source location 2019-0175-Response-by-CARE-UK
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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 NHS email accounts to all reception staff, including agency staff, to securely access incoming risk information.
Verbatim wording from the response “All staff, including agency staff, who work in Reception have been provided with an nhs.net email account to securely access the risk information in the email. In agreement with the Liaison and Diversion service this new system went live on 25th April 2019. The requirement of a prompt made via telephone which is clearly outlined in the new process flowchart, will provide assurance to Liaison and Diversion services that their information has been effectively communicated and received by Reception staff. A copy of the process is attached.” Source location 2019-0175-Response-by-CARE-UK
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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 Remind escort contractors to alert reception staff when constant supervision preceded a prisoner’s arrival.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-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 Remind reception staff to share and record risk information on prisoner passports, and audit passport recording and use.
Verbatim wording from the response “All staff working in reception have been reminded of the importance of sharing risk information and ensuring that it is recorded on the prisoner passport. The first night custodial manager conducts regular audits of the prisoner passports to ensure that relevant information is being recorded, and that the document is being seen and used by staff working in reception.” Source location 2019-0175-Response-by-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 Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
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 Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
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 internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Verbatim wording from the response “Staff meetings are held every two weeks to continue to improve and share knowledge and lessons learned regarding the management of prisoners in custody. Currently HMPPS are providing specialist HMPPS training for both healthcare and discipline staff; “Understanding Risk: Why is Risk Risky?” and “Defensible Decision Making”, both of which seek to reinforce rational and appropriate decisions when applying the ACCT process and understanding suicide risk. Care UK are providing ASIST - Applied Suicide Intervention Skills Training, which is an internationally accredited and licensed 2-day course to all patient-facing staff to increase their confidence in identifying suicide risk. This improved learning, supported by SASH training will better inform decision making in all cases, including those cases where removal from constant watch is being considered.” Source location 2019-0175-Response-by-CARE-UK
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 a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-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 Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-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 Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-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 Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
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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.
