27 Feb 2019 Kelvin Sean Speakman · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to rectify recurring ACCT process failings View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Kelvin Sean Speakman · 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
Kelvin Sean Speakman was a serving prisoner at HMP Hewell with a long history of mental ill-health and extensive self-harm, including multiple attempts to hang himself. Following an incident of self-ligaturing, he suffered a hypoxic brain injury and died in hospital on 9 May 2016. The report identified shortcomings in the operation and documentation of the ACCT process, including inadequate healthcare input and inconsistent communication between staff.
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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 rectify recurring ACCT process failings
Wider context from the report “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate.
The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified.
Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition.
Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken.
This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports).
In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned".
However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again .
Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated .
I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices.
(2)
(3)
” Source location Kelvin Sean Speakman · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ACCT coaching sessions for case managers, focusing on information sharing and accurate, comprehensive recording.
Verbatim wording from the response “In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with prison senior managers to improve adherence to the ACCT process.
Verbatim wording from the response “In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out bi-monthly assurance checks of ACCT documentation.
Verbatim wording from the response “In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a senior leadership quality-assurance process with daily review of ACCT documents and associated healthcare attendance and action completion.
Verbatim wording from the response “Since January 2019, HMP Hewell has been operating a new quality assurance process. A member of the senior leadership team now carries out a daily review of all ACCT documents, making sure that they have been completed in accordance with instructions. They also check that healthcare staff attended first case reviews and that all necessary actions have been taken.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot and evaluate an updated ACCT case-management system.
Verbatim wording from the response “On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the final revised ACCT case-management system nationally after evaluation.
Verbatim wording from the response “On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out a quality-assurance tool alongside the updated ACCT document to assess compliance with the process.
Verbatim wording from the response “A new quality assurance tool is also being rolled out alongside the updated ACCT document, which assesses whether the process is being followed correctly.” Source location 2019-0074-Response-by-HM-Prison-and-Probation-Services
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Concerns raised 1
Lack of clarity in PSI64/2011 guidance on first case review of an ACCT assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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John Mayhew · 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 Mayhew died at HMP Durham on 15 January 2017 from self-inflicted hanging. He had a recent history of suicide attempts and made comments concerning potential self-harm or suicide after returning to custody, but the ACCT was closed at the initial case review without a care plan. The report raised concerns about the lack of involvement of the person who initiated the ACCT and the ambiguity of the relevant PSI 64/2011 attendance requirements.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity in PSI64/2011 guidance on first case review of an ACCT assessment
Wider context from the report “(1) Clarification is needed as to how to construe the part of PSI64/2011 dealing with first case review of an ACCT assessment, in particular the proviso in the words “whenever possible” as to which type of potential attendee it might apply.
(2) Consideration should be given to re-drafting this part of the PSI.
(3) Consideration might thereafter, be given, as to providing guidance on how this part of the PSI, if modified, should be applied in practice by all staff in all prisons.
” Source location John Mayhew · Prevention of Future Deaths report
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11 Jan 2018 John Martin Chapman · Prevention of Future Deaths report Lancashire
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Concerns raised 1
Failure to routinely share prisoner self-harm and well-being information with reception healthcare staff View source
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Each statement is shown once, even when linked to more than one concern.
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John Martin Chapman · Prevention of Future Deaths report
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Report summary
John Martin Chapman was transferred to HMP Wymott on 23 January 2014, and information about two previous self-harm or threatened self-harm incidents was not passed to the reception nurse. He was found hanging in his cell on 21 March 2014; the inquest concluded that he died as a result of accidental hanging. The report identified concerns about the lack of a formal mechanism for sharing relevant self-harm and welfare information between prison and healthcare staff during reception.
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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 routinely share prisoner self-harm and well-being information with reception healthcare staff
Wider context from the report “1. TO THE GOVERNOR HMP WYмott
Although evidence was heard to the effect that currently at reception at HMP Wymott the CNomis entries relating to a newly arrived prisoner are scrutinised by prison reception staff to ascertain whether there are any self-harm or welfare alerts, it did not appear that a direction exists to pass relevant information to the nurse carrying out the reception medical screen .
2. TO THE GOVERNOR AND HEAD OF HEALTHCARE
There does not appear to be a mechanism at reception whereby information relevant to the self-harm or well-being of a prisoner is routinely shared by prison staff with medical staff carrying out a reception medical screen including alerts on the CNomis system . As a result, there appears to be a danger that significant alerts concerning a prisoner might not come to the attention of the reception nurse to enable the nurse to take appropriate action and make relevant entries within the medical records.
Those in authority, giving evidence on behalf of the prison and healthcare on the subject of reception practice, saw merit in there being a formal procedure agreed between prison discipline staff on the one hand and healthcare staff on the other, for the sharing of information relevant to a prisoner’s well-being, and for this to be accomplished promptly .
” Source location John Martin Chapman · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide reception staff with PSI 07/2015, require them to read and comply with it, and monitor completion through performance records.
Verbatim wording from the response “Every member of staff in reception at HMP Preston has been provided with a copy of the PSI and set an objective to read and comply with it in their Staff Performance and Development Record. Line managers will monitor the achievement of this objective. Copies of the PSI are also available in the reception area.” Source location 2018-0007-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 Routinely pass PER forms to the reception nurse and require documentation in SystemOne that each form was received and considered.
Verbatim wording from the response “As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st.
As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored.
Thank you once again for bringing your concern to my attention.” Source location 2018-0007-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 Explore incorporating a PER-form receipt check into the existing reception health-screen template.
Verbatim wording from the response “As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st.
As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored.
Thank you once again for bringing your concern to my attention.” Source location 2018-0007-Response
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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 CNomis is not managed by healthcare, and reception nurses are not routinely granted access to it.
Verbatim wording from the response “As a result there appears to be a danger that significant alerts concerning a prisoner might not come to the attention of the reception nurse”
It is, of course, recognised that it is important to share relevant information and the reception nurse would expect prison officers always to communicate any significant information regarding risk or welfare of which they were aware – whether this be contained in a PER document, on CNomis, or otherwise. As you were made aware during the inquest, it was not the practice, at the time, for the PER document to be passed by prison officers to the reception nurse and, regards CNomis, this is not a system managed by healthcare and nurses are not routinely granted access to it.” Source location 2018-0007-Response
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18 Dec 2017 Stephen Mark SHAYLOR · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Reliance on continuous CCTV monitoring to detect prisoner self-harm View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Stephen Mark SHAYLOR · Prevention of Future Deaths report
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Report summary
Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.
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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 Reliance on continuous CCTV monitoring to detect prisoner self-harm
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming .
” Source location Stephen Mark SHAYLOR · Prevention of Future Deaths report
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19 Oct 2017 Sean Patrick Plumstead · Prevention of Future Deaths report Central Hampshire
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Concerns raised 3
Failure to provide ACCT training to all relevant prison staff View source Failure to maintain adequate suicide and self-harm awareness training coverage View source Failure to train all prisoner-facing Carillion staff in self-harm and suicide prevention View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Sean Patrick Plumstead · Prevention of Future Deaths report
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Report summary
Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.
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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 ACCT training to all relevant prison staff
Wider context from the report “1. ACCT Training
I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017.
In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training ; at the date the evidence was given 61% of staff had received ACCT training ; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training .
Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows:
• As at September 2016 77.29% of forward- facing prison service staff
• As at September 2016 64.27% of all prison service staff
• As at September 2017 72% of forward- facing prison service staff
• As at September 2017 57% of prison service staff were “in date” with such training.
The evidence was that the current aim is to achieve the 80% target by mid 2018.
It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing. This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact.
” Source location Sean Patrick Plumstead · 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 maintain adequate suicide and self-harm awareness training coverage
Wider context from the report “1. ACCT Training
I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017.
In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training; at the date the evidence was given 61% of staff had received ACCT training; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training.
Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows:
• As at September 2016 77.29% of forward- facing prison service staff
• As at September 2016 64.27% of all prison service staff
• As at September 2017 72% of forward- facing prison service staff
• As at September 2017 57% of prison service staff were “in date” with such training.
The evidence was that the current aim is to achieve the 80% target by mid 2018.
It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing . This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact.
” Source location Sean Patrick Plumstead · 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 train all prisoner-facing Carillion staff in self-harm and suicide prevention
Wider context from the report “2. Training of All Prisoner-facing Staff
The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention .
It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future. Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff. There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records.
I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with.
I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities.
” Source location Sean Patrick Plumstead · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver SASH suicide and self-harm prevention training to new prisoner-facing staff and roll out refresher training to existing staff.
Verbatim wording from the response “The Introduction to Safer Custody course to which this refers was replaced by the Introduction to Suicide and Self-Harm Prevention course, known as SASH, in May 2017. Like its predecessor courses, the SASH course is being delivered to all new prison officers as part of their entry level training, and to all new staff in other prisoner-facing roles. It has also been developed in modular form so that it can be delivered as refresher training to existing staff.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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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 Train additional staff as SASH trainers to increase capacity for course delivery.
Verbatim wording from the response “The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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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 Provide HMPPS’s Suicide Prevention Learning Tool through the intranet.
Verbatim wording from the response “You may also be interested to know that HMPPS has worked with Samaritans to develop a Suicide Prevention Learning Tool that is now available on the HMPPS” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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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 Requested HMPPS issue a formal instruction identifying prisoner-facing staff required to complete SASH training.
Verbatim wording from the response “4. We have proposed to them that they provide us with a formal instruction under the contractual arrangements for our staff to undergo SASH training and confirm which categories of staff should undergo training. Our client has confirmed this week that it considers all Carillion prisoner facing staff should be required to undergo training.” Source location 2017-0316-Response-by-Carillion
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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 prisoner-facing Carillion staff and maintain training records for all staff, including directly employed and contracted staff.
Verbatim wording from the response “I can confirm that a number of Carillion staff in prisoner-facing roles at HMP Winchester have been trained, and that records of training delivered to all staff, including those who are not directly employed, are now held. These records do not, however, include information about the internal training programmes of other employers.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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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 Issue a Service Manager’s Instruction notifying contractors of suicide and self-harm prevention training requirements and contractual obligations.
Verbatim wording from the response “I accept that the requirement for prisoner-facing staff to undertake suicide and self-harm prevention training was not specifically brought to the attention of Carillion when their contract began, and I can confirm that a Service Manager’s Instruction will be issued imminently to ensure that Carillion, and our other contractors, are made aware of the requirement and their contractual obligation to comply with it. Both HMPPS and Carillion are committed to ensuring that all relevant staff are trained as soon as possible.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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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 Refresher-training figures do not mean prisoner-facing staff have never been trained or are deployed unable to recognise suicide and self-harm risk.
Verbatim wording from the response “Crucially, this does not mean that untrained staff who are unable to recognise prisoners at risk are being deployed in the prison. The training targets relate to the completion of the local refresher training. So, whilst the figures that you quote show a temporary reduction in the proportion of staff who are “in date” in terms of the local requirement to have undertaken such training within the last three years, this does not mean that there are staff in prisoner-facing roles who have never been trained. Moreover, the refresher training that the staff are now undertaking is much more extensive, and contains more detailed information about risk, than the ACCT training that was previously available. For this reason I am confident that the changes that have been made to the training programme will have the effect of improving staff awareness and capacity to identify and address risk.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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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 Refresher-training completion was delayed because the longer course, resourcing challenges and limited availability of qualified trainers constrained delivery.
Verbatim wording from the response “The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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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 Carillion disputes that its HMPPS contracts require Carillion staff to undergo self-harm and suicide prevention training.
Verbatim wording from the response “CARILLION’S CONTRACTS WITH HMPPS
I wish to clarify an apparent misunderstanding about our contractual obligations that you appear to be under following evidence that you heard during the inquest.
By contract, Carillion provides a range of hard and soft facilities management services to HMPPS in public prisons throughout the country. However, having carefully reviewed our contracts with HMPPS, and contrary to the view that you formed during the inquest, there is in fact no contractual requirement upon Carillion and its staff to undergo SASH training, either as a business requirement, key deliverable or at all.
Accordingly, prior to the inquest touching the death of Mr Plumstead, Carillion was unaware of the requirement for its staff to undergo SASH training.” Source location 2017-0316-Response-by-Carillion
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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 HMPPS is responsible for training all prison-facing staff, including Carillion staff, in self-harm and suicide prevention.
Verbatim wording from the response “We are accordingly grateful for having had this issue drawn to our attention and immediately upon receipt of your Regulation 28 report set about investigating the matter and how we might work with HMPPS on it, the obligation to train all prison facing staff, being theirs.” Source location 2017-0316-Response-by-Carillion
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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 Carillion cannot provide self-harm and suicide prevention training because it is highly specialist and specific to custodial settings.
Verbatim wording from the response “2. We have identified that SASH training is highly specialist and specific to a custodial setting and as such is not job specific in terms of the training we would ordinarily expect our staff to undertake within facilities management. Accordingly, it is not training that we are able to provide to our staff as employers.” Source location 2017-0316-Response-by-Carillion
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13 Sep 2017 Sam MOLYNEUX · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to place prisoners at risk of suicide or self-harm on an 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Sam MOLYNEUX · 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
Sam Molyneux, a prisoner at HMP Liverpool, was found hanging from a ligature in his cell on 1 April 2016 and was pronounced dead at 22:55. The inquest identified a failure to open an ACCT, concerns about the response to assaults and possible bullying, and a delay in accessing him because the cell door could be barricaded.
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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 place prisoners at risk of suicide or self-harm on an ACCT
Wider context from the report “During the course of the inquest it became apparent that in old prisons not all wings have been adapted to have anti-barricade doors. In this case Mr Molyneux had barricaded his door and this delayed prison staff gaining access to him during a Code Blue Situation. He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death . Local directions in the Prison during the inquest have addressed this situation in HMP Liverpool at Walton. That said HM Prison and Probation service might wish to consider amending “Management of Prisoners at risk of harm to self, to others and from others (Safer Custody)” to include consideration of where reasonably practicable avoiding locating prisoners behind a door which is not designed to circumvent barricading.
” Source location Sam MOLYNEUX · Prevention of Future Deaths report
Open source report
7 Jun 2017 Callum Oliver SMITH · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment 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
Callum Oliver SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Callum Oliver SMITH was in the care of HMP Bristol when he was found hanging in his cell and died from hanging. The inquest concluded that his death was caused by suicide while he was suffering extreme anxiety and distress. Concerns included inadequate risk assessment and mental health assessment, poor communication and record-sharing, and repeated failures to open an ACCT due to training and staff-understanding issues.
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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 healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment
Wider context from the report “1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011.
2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011.
3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide.
4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff.
” Source location Callum Oliver SMITH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the rolling SASH programme, mandate existing healthcare staff attendance, and provide new starters with training within six months.
Verbatim wording from the response “All healthcare staff will therefore revisit the PSI through Suicide and Self Harm (SASH) training and local training/meetings.” Source location 2017-0185-Response-by-Prison-Health-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate an ACCT overview into the induction process for new staff, including documented acknowledgement of understanding.
Verbatim wording from the response “ACCT overview to be incorporated into new staff induction process.” Source location 2017-0185-Response-by-Prison-Health-Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce SASH requirements through monthly team meetings using bite-sized ACCT-opening scenarios and discussion.
Verbatim wording from the response “SASH training requirements to be at reinforced monthly team meetings.” Source location 2017-0185-Response-by-Prison-Health-Services
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28 Mar 2017 John WILLIAMS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to accurately record self-harm or suicide assessments View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
John WILLIAMS · 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 Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately record self-harm or suicide assessments
Wider context from the report “1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had .
It appears she may benefit from additional training and/or supervision.
” Source location John WILLIAMS · Prevention of Future Deaths report
Open source report
4 Oct 2016 Haydn James Burton · Prevention of Future Deaths report Central Hampshire
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Concerns raised 2
Failure to train Listeners to pass information about imminent suicide risk to prison staff View source Failure to make Case Notes for all ACCT plans 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
Haydn James Burton · 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
Haydn James Burton, a prisoner at HMP Winchester, was found suspended from a ligature point in his cell on 15 July 2015 and died in hospital on 18 July 2015 from the delayed effects of ligature suspension. The concerns included inadequate implementation of ACCT plans and observations, uncertainty about confidentiality rules in the Prison Listener scheme, and limitations in recording and communicating information about closed ACCT plans.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to train Listeners to pass information about imminent suicide risk to prison staff
Wider context from the report “(2) The Prison Listener scheme rules as to prisoner confidentiality appeared to be confusing to the listener involved in this case. The HMP Winchester Listener Scheme Protocol dated October 2012 makes no reference to situations where an “at risk” prisoner admits to having made active plans for suicide and threatens to self harm in the future (as in this case). I consider the protocol for Listeners should make it another exception to the principle of confidentiality so that they can pass such information to prison staff and that Listeners should be trained to do so if they have reason to believe there is an imminent risk of suicide even if the prisoner is already subject to an ACCT .
” Source location Haydn James Burton · 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 make Case Notes for all ACCT plans
Wider context from the report “(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously. The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it . The ACCT post-closure process should therefore be reviewed. I consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment.
” Source location Haydn James Burton · 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 Operate additional management assurance and quality checks of ACCT documentation, care, case management, Caremap actions and NOMS records, with monthly trend review and follow-up.
Verbatim wording from the response “The Governor has recently introduced additional management assurance checks to ensure that staff are completing ACCT documents correctly and to the required standard, and that the appropriate level of care is given any person who requires additional support provided during the ACCT process. These assurance checks are completed by Orderly Officers, Duty Governors and the Safer Custody Team. The results are collated and will be discussed at the monthly Safer Custody meeting where trends will be identified and appropriate actions taken. In addition quality assurance checks will consider the role of ACCT Case Managers to confirm compliance, and identify any development needs. ACCT Caremap actions are checked by the Safer Custody Supervising Officer and Custodial Manager who ensure that appropriate actions have been identified and taken forward.” Source location 2016-0346-Response-by-NOMS
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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 and embed a post-closure ACCT process requiring daily notification, plan circulation, interview updates, core-record filing and NOMS recording of ACCT openings and closures.
Verbatim wording from the response “PSI 64/2011 requires staff to ensure that “The closure must be recorded within the case notes section of NOMS giving a brief summary of the relevant issues” (italics indicate a mandatory requirement). The Governor at Winchester has introduced a process whereby Wing Supervising Officers are informed each day of any ACCT post closure reviews which are due to be held, and provided with copies of the relevant ACCT plans. When the post closure interview has taken place, the ACCT is updated and returned to the Safer Prisons team to be filed within the prisoner’s core record. All Case Managers have been reminded of the importance of ensuring that the NOMS case notes are updated following an ACCT case review, and are using the ACCT alerts on NOMS to record the dates of an ACCT being opened and closed.” Source location 2016-0346-Response-by-NOMS
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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 Winchester will not add an exception to Listener confidentiality because national confidentiality arrangements are considered necessary to preserve prisoners’ trust.
Verbatim wording from the response “As the Samaritans have set out in their separate response to your report, the principle of total confidentiality is central to their work, and applies equally to the work of Listeners. This is reflected in the national partnership agreement between NOMS and the Samaritans that governs the operation of the Listener scheme, and the NOMS safer custody policy set out in PSI 64/2011. In the light of this it is not appropriate for Winchester to adopt a different policy on this point. Without the assurance of confidentiality, prisoners may not feel able to approach Listeners and talk freely in an atmosphere of total trust. Any change to this approach may lead to a reduction in the number of prisoners accepting this vital source of support and sharing their concerns.” Source location 2016-0346-Response-by-NOMS
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Concerns raised 3
Failure to communicate less obvious suicide and self-harm risk factors View source Failure to comprehensively record suicide and self-harm risk observations View source Failure to identify less obvious suicide and self-harm risk factors at initial screening 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Peter Lawrence · 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
Peter Lawrence was remanded into custody at HMP Peterborough and, on 02.02.15, was found in a prison workshop toilet cubicle having stabbed himself with a chisel; he was taken to hospital where death was confirmed. The concerns related to identifying and recording suicide or self-harm risks during the initial screening of first-time prisoners, and to the absence of meaningful interaction with a custodial officer who could help identify and manage such risks.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate less obvious suicide and self-harm risk factors
Wider context from the report “(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors, particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference. HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial ;
” Source location Peter Lawrence · 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 comprehensively record suicide and self-harm risk observations
Wider context from the report “(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors, particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference . HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial;
” Source location Peter Lawrence · 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 less obvious suicide and self-harm risk factors at initial screening
Wider context from the report “(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors , particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference. HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial;
” Source location Peter Lawrence · Prevention of Future Deaths report
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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.
