Concerns raised 2
Failure to complete SACU hourly prisoner checks consistently View source Lack of real-time detection of incomplete SACU prisoner checks View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
CHARLIE BRIAN TODD · 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
On 2 September 2019, Charlie Brian Todd, a prisoner at HMP Durham, was found hanging by a ligature in his cell in the Segregation & Care Unit and died despite resuscitation attempts. The report identifies concerns about staffing and supervision arrangements, including an incomplete record of hourly checks and no check of Mr Todd’s cell at 3pm, alongside the absence of a real-time system to alert staff to missed checks.
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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 complete SACU hourly prisoner checks consistently
Wider context from the report “During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis.
On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete . No check on Mr Todd’s cell took place at 3pm that day .
Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed .
Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance.
” Source location CHARLIE BRIAN TODD · 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 real-time detection of incomplete SACU prisoner checks
Wider context from the report “During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis.
On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day.
Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed.
Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU , as well there is no constant supervising officer present or other system there to ensure compliance .
” Source location CHARLIE BRIAN TODD · 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 Provide an additional officer and administration staff member to support SACU operations.
Verbatim wording from the response “I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU’s regime, and allow for the required checks to take place. The staffing of the SACU is in line with national benchmarking standards, and indeed the Governor has provided an additional officer resource, as well as an administration staff member in order to support the work of the SACU. HMP Durham have a weekly Regime Management Plan meeting which forecasts staffing levels for the following week to ensure that the regime across the prison is delivered and consistent.” Source location 2021-0318-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a “Know Your Job” sheet for staff temporarily assigned to SACU, setting out required duties.
Verbatim wording from the response “It is inevitable that at some points staff who are not normally based in the SACU will be required to work on the unit for a shift, and in order to support those staff in understanding the expectations of the unit a “Know Your Job” sheet will be provided to them, setting out the tasks they will be required to cover.” Source location 2021-0318-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Oversee daily and weekly SACU management checks and report recurring issues to the Head of Residence for action.
Verbatim wording from the response “Additionally, the SACU CM has been tasked with overseeing the daily and weekly management checks being carried out and will also provide an update to the Head of Residence, so that any reoccurring issues can be promptly addressed as appropriate with individual staff.” Source location 2021-0318-Response-from-HMPPS_Published
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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 Existing staffing, supervision and assurance arrangements are considered sufficient to deliver SACU regimes and required hourly checks safely.
Verbatim wording from the response “I can assure you that there is clear management oversight of the SACU. The day-to-day running of the unit is directed by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there. The CM reports to, and is supported by, the Head of Residence and Safety (a Governor grade) who forms part of the Governor’s Senior Management Team. The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check.” Source location 2021-0318-Response-from-HMPPS_Published
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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 A real-time system for confirming checks cannot be implemented because the required resources would be significant and prohibitive.
Verbatim wording from the response “Given the number of checks that take place throughout the prison on a daily basis, implementing a ‘real-time’ system to ensure these have been done would require significant and prohibitive resource. I believe that the robust assurance processes already in place, together with the improvements made will ensure that prisoners located in the SACU at HMP Durham, can be safely managed.” Source location 2021-0318-Response-from-HMPPS_Published
Open published response
Concerns raised 1
Failure to conduct welfare checks during first morning cell unlocks View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring 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
Brett Anthony Marrs · 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
Brett Anthony Marrs, a long-term drug user, was found collapsed in his prison cell after morning unlock on 4 September 2018. The inquest concluded that he died as a result of synthetic cannabinoid and morphine toxicity. Concerns included inadequate first-aid and resuscitation training for prison officers and failures to conduct welfare checks during morning cell unlocks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct welfare checks during first morning cell unlocks
Wider context from the report “2. CCTV footage viewed at the inquest showed a prison officer conducting a first morning cell unlock on C wing without conducting even the most basic of welfare checks and this despite clear notices from management drawing to the attention of staff the necessity of carrying out welfare checks, particularly at the time of the first morning unlock. Evidence was heard to the effect that this was not an isolated instance . Given that notices and reminders appear not to have achieved uniform observance , you are asked to consider how better compliance with welfare checks can be achieved.
” Source location Brett Anthony Marrs · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to detect unlawful segregation and deprivation of basic amenities View source
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring 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
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 detect unlawful segregation and deprivation of basic amenities
Wider context from the report “However, the message from the prison governor undertaking the adjudications that the adjudication would not occur that day and would be delayed to the following day did not reach the wing and was not conveyed to Andrew Jones. This is a breach of prison rules, did not detect that Andrew Jones was unlawfully segregated, failed to covey information to him and also failed to detect he did not even have the benefit of basic amenities such as a shower, a telephone call and fresh air .
” Source location Andrew Patrick Jones · Prevention of Future Deaths report
Open source report
21 Mar 2019 John Wright · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1
Lack of guidance for reducing observations of newly arrived prisoners from constant watch View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care UK HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Care UK
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
View source
Care UK
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
View source
Care UK
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
View source
HM Prison and Probation Service
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
View source
HM Prison and Probation Service
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
View source
HM Prison and Probation Service
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
View source
HM Prison and Probation Service
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
View source See 4 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.
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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 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 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
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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
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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
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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
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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
Open published response
Concerns raised 1
Lack of policy or guidance for additional checks of prisoners with repeated NPS use View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jerome Jason Omri 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
Jerome Jason Omri Jones was a serving prisoner who died in hospital after being found unresponsive in his cell, following suspected use of a synthetic cannabinoid and in the context of a congenital heart defect. The concerns included the absence of guidance for additional checks after repeated NPS use, no clear method for communicating his increased risk to healthcare or prison officers, and limited access by drug workers to relevant medical information.
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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 policy or guidance for additional checks of prisoners with repeated NPS use
Wider context from the report “(1)During the inquest evidence was heard that apart from some hourly checks by prison officers during the evening of the incident on 20/10/17 (the third known instance of NPS use by the deceased) no other specific checks were made on the deceased leading up to the date of his death . This was a prisoner who had 3 known instances of NPS use within a relatively short space of time. I heard evidence that the requirement for further checks would have had to come from the Healthcare team rather than from prison officers . I was told here is no policy or guidance to cover additional checks for a prisoner in a situation such as this.
” Source location Jerome Jason Omri JONES · 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 Launch an updated drug strategy at the establishment.
Verbatim wording from the response “I am grateful to you for bringing your concerns to my attention. I am aware that the Shropshire Community NHS Trust wrote to you on 31 August. In addition to the information in their response, an updated drug strategy has been launched at the” Source location 2018-0369-Response-by-HM-Prison-Probation-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify staff that healthcare determines when additional checks are needed and must communicate this to prison discipline staff.
Verbatim wording from the response “establishment. All staff were notified of this last month by way of a Notice to Staff which also reminded them that healthcare staff are responsible for determining when additional checks of prisoners at risk from repeated use of psychoactive substances are necessary, and that this must be communicated by them to all prison discipline staff.” Source location 2018-0369-Response-by-HM-Prison-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 Healthcare staff determine when additional checks of prisoners at risk from repeated psychoactive substance use are necessary.
Verbatim wording from the response “establishment. All staff were notified of this last month by way of a Notice to Staff which also reminded them that healthcare staff are responsible for determining when additional checks of prisoners at risk from repeated use of psychoactive substances are necessary, and that this must be communicated by them to all prison discipline staff.” Source location 2018-0369-Response-by-HM-Prison-Probation-Service
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18 Dec 2017 Stephen Mark SHAYLOR · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2
Reliance on continuous CCTV monitoring to detect prisoner self-harm View source Intermittent night welfare checks and ACCT observations View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Care UK
Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.
View source
Care UK
Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
View source
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AI-generated summary
Stephen Mark SHAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen 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
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 Intermittent night welfare checks and ACCT observations
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
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 Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.
Verbatim wording from the response “Night welfare checks are carried out by Health Care Assistants (HCAs). At the start of the night shift, the nurse and HCA will print off the relevant welfare check list which will show all new additions made that day, as well as those prisoners who are already on the list. HCAs will then use that list and the printed template to assist them in conducting checks overnight. A copy of the template used was provided under cover of my first letter.” Source location 2017-0380-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 Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
Verbatim wording from the response “3. The ACCT process is a prison process and is operated and owned by HMPPS using prison documentation. To that extent, the overview and monitoring of the ACCT process does not sit with the healthcare team. However, any member of staff working at the prison can open an ACCT if they identify risks. Healthcare staff from the SMS, primary health or mental health team will attend ACCT reviews and record this on SystmOne. Therefore, these health care staff are responsible for contributing their knowledge regarding any risk factors which may include issues pertaining to substance misuse or detox. In my previous letter I had intended to underline that the use of the night welfare check has never been intended to replace ACCT documentation. This is simply because there are many prisoners suffering from substance withdrawal who would not require an ACCT; i.e.” Source location 2017-0380-Response-by-Care-UK
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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 HMPPS owns and operates the ACCT process; healthcare staff contribute risk information but do not oversee or monitor it.
Verbatim wording from the response “3. The ACCT process is a prison process and is operated and owned by HMPPS using prison documentation. To that extent, the overview and monitoring of the ACCT process does not sit with the healthcare team. However, any member of staff working at the prison can open an ACCT if they identify risks. Healthcare staff from the SMS, primary health or mental health team will attend ACCT reviews and record this on SystmOne. Therefore, these health care staff are responsible for contributing their knowledge regarding any risk factors which may include issues pertaining to substance misuse or detox. In my previous letter I had intended to underline that the use of the night welfare check has never been intended to replace ACCT documentation. This is simply because there are many prisoners suffering from substance withdrawal who would not require an ACCT; i.e.” Source location 2017-0380-Response-by-Care-UK
Open published response
Concerns raised 1
Lack of meaningful pastoral interaction with a dedicated custodial officer View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring 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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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of meaningful pastoral interaction with a dedicated custodial officer
Wider context from the report “(2) The use of personal (or ‘custodial’) officers was identified as an important aspect of risk management. The jury identified the absence of interaction with a custodial officer in the current case to have been a missed opportunity to further identify and consider the risk of suicide/self harm. Again this has been addressed locally. The lack of meaningful interaction with a dedicated member of staff in a pastoral capacity , particularly for those in prison for the first time , gives rise to a concern that deaths may occur in other cases nationally.
” Source location Peter Lawrence · Prevention of Future Deaths report
Open source report
Concerns raised 3
Failure to maintain visual observation when the observation panel is blocked View source Delays in responding when a prisoner is unobserved View source Failure to complete scheduled observations View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
National Offender Management Service Equality, Rights and Decency Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
National Offender Management Service Equality, Rights and Decency Group
Revise and disseminate the contingency plan, train staff to intervene quickly when observation panels are blocked, and permit individual staff to open cells during immediate danger.
View source
National Offender Management Service Equality, Rights and Decency Group
Introduce the Safer Custody toolkit with guidance on ACCT procedures, emergency response, and communication with hard-to-engage prisoners.
View source
National Offender Management Service Equality, Rights and Decency Group
Implement unpredictable ACCT observations, remind staff of requirements, and monitor compliance through management checks and document quality assurance.
View source
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AI-generated summary
Michael 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
Michael Williams died by hanging in his locked prison cell on 15 September 2015 while subject to four observations per hour and after he had threatened to take his life, appeared tearful and anxious, and blocked the observation panel. The concerns included missed and predictable observations, the lack of an explanation for missed checks, and an approximately one-hour delay before the cell was opened after he became unobserved.
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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 visual observation when the observation panel is blocked
Wider context from the report “Mr Williams should have been observed 4x every hour during the evening of 15th September 2015. Several of these checks were missed, and after he blocked the observation panel, he could only be heard, not seen .
a) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour, and were therefore predictable. This is not best practice and should be discouraged.
b) There was no explanation for the missed observations.
c) Mr Williams was unobserved for approximately 1 hour before the cell door was opened, and he was found deceased. The jury found this was inappropriate delay and I agree with them. Clear guidance and training should be provided, and regularly repeated, to assist the Prison Officers in managing such situations in a timely way.
” Source location Michael Williams · 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 Delays in responding when a prisoner is unobserved
Wider context from the report “Mr Williams should have been observed 4x every hour during the evening of 15th September 2015. Several of these checks were missed, and after he blocked the observation panel, he could only be heard, not seen.
a) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour, and were therefore predictable. This is not best practice and should be discouraged.
b) There was no explanation for the missed observations.
c) Mr Williams was unobserved for approximately 1 hour before the cell door was opened , and he was found deceased. The jury found this was inappropriate delay and I agree with them. Clear guidance and training should be provided, and regularly repeated, to assist the Prison Officers in managing such situations in a timely way.
” Source location Michael Williams · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete scheduled observations
Wider context from the report “Mr Williams should have been observed 4x every hour during the evening of 15th September 2015. Several of these checks were missed , and after he blocked the observation panel, he could only be heard, not seen.
a) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour, and were therefore predictable. This is not best practice and should be discouraged.
b) There was no explanation for the missed observations.
c) Mr Williams was unobserved for approximately 1 hour before the cell door was opened, and he was found deceased. The jury found this was inappropriate delay and I agree with them. Clear guidance and training should be provided, and regularly repeated, to assist the Prison Officers in managing such situations in a timely way.
” Source location Michael Williams · 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 Revise and disseminate the contingency plan, train staff to intervene quickly when observation panels are blocked, and permit individual staff to open cells during immediate danger.
Verbatim wording from the response “(3) Mr Williams was unobserved for approximately 1 hour before the cell door was opened and he was found deceased. The jury found this was an inappropriate delay and I agree with them. Clear guidance and training should be provided and regularly repeated to assist the prison Officers in managing such situation in a timely way.
The contingency plan at HMP Leicester was revised in April 2016, and the amended plan has been brought to the attention of staff through training and briefings. Staff have been made aware that they must intervene quickly if the observation panel has been blocked and a prisoner is refusing to engage. In particular, where there appears to be an immediate danger to life, cells can be opened by an individual member of staff.” Source location 2016-0245-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 Introduce the Safer Custody toolkit with guidance on ACCT procedures, emergency response, and communication with hard-to-engage prisoners.
Verbatim wording from the response “(2) There was no explanation for the missed observations.
In a notice to staff dated 24 March 2016, all staff were reminded of the importance of ACCT observations. The new Safer Custody toolkit that will be introduced in August 2016 provides clear instructions to staff regarding ACCT procedures and the importance of conducting ACCT observations.” Source location 2016-0245-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 unpredictable ACCT observations, remind staff of requirements, and monitor compliance through management checks and document quality assurance.
Verbatim wording from the response “(1) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour and therefore predictable. This is not best practice and should be discouraged.
Prison Service Instruction 64/2011 Safer Custody sets out very clearly the requirement for observations to be conducted at unpredictable times, for example four times an hour, as opposed to every 15 minutes.
All relevant staff at HMP Leicester have been reminded of this, and management checks are now in place to ensure that staff are correctly undertaking observations. All ACCT documents are quality assured and monitored by the Head of Safer Custody.” Source location 2016-0245-Response-by-NOMS
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25 Nov 2015 Dean Ronald Edmund BOLAND · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Failure to monitor prisoners overnight View source Inadequate overnight security officer capacity for B wing View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
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AI-generated summary
Dean Ronald Edmund BOLAND · 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
Dean Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to monitor prisoners overnight
Wider context from the report “5. Prisoners on B wing are not viewed or monitored at all overnight unless they are on an ACCT . This gives them a considerable period of time to smoke and use drugs knowing there will be no supervision or observation from prison officers .
” Source location Dean Ronald Edmund BOLAND · 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 Inadequate overnight security officer capacity for B wing
Wider context from the report “6. The prison deploy a security officer to B wing at night (172 prisoners) .This person is unable to interact with prisoners and is only there to answer call bells . This seems inadequate given that this group of prisoners are at high risk of drug use particularly at night when there are no cell checks.
” Source location Dean Ronald Edmund BOLAND · Prevention of Future Deaths report
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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 No additional night staff are planned because current deployment exceeds contractual requirements and provides access to senior and clinical staff.
Verbatim wording from the response “Prisoners on B Wing are not viewed or monitored overnight unless they are on an ACCT giving them a considerable period of time to smoke and use drugs
Across the prison service there is no routine night time monitoring for prisoners other than those subject to the Assessment, Care in Custody and Teamwork (ACCT) case management process and those who are segregated or located on an inpatient ward. It is important that during night state the reduced numbers of staff are deployed to supervise those most vulnerable or at risk.” Source location 2015-0468-Response-by-NOMS
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24 Jul 2015 Carl David Roy SMITH · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Carl David Roy 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
Carl David Roy SMITH was found unconscious and without signs of life in his cell at HMP Exeter on 22 November 2012, after being held on remand and receiving medication for seizures and detoxification. His death was concluded to be drug-related, involving methadone toxicity and illicitly obtained methadone. The report identified insufficient custodial and welfare checks and deficient information sharing about those checks for a prisoner on an ACCT and Methadone Stabilisation Programme.
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 Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme
Wider context from the report “The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient.
” Source location Carl David Roy 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 Review patients on drug treatment programmes jointly with prison staff, agree observation arrangements, and share caseload information.
Verbatim wording from the response “5.5. Concern 1 - To review the systems for Information Sharing reference those on drug treatments stabilisation programmes for Substance Misuse IDTS with Prison Officers so that all Prison Officers are aware of Prisoners concerned.” Source location 2015-0298-Response-by-Dorset-Health-Care-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 Introduce a robust system for monitoring patients arriving at HMP Exeter who require night welfare checks.
Verbatim wording from the response “6.1. In addition to the Coroners Ruling noted in this report the Trust has introduced a robust system for the monitoring of patients arriving at HMP Exeter and requiring Night Welfare Checks (see appendix 5). This guidance was developed jointly with Public Health England (NTA), HMP Exeter National Offender Management Service and will be approved by NHS England at the Devon Prison Partnership Board in October 2015.” Source location 2015-0298-Response-by-Dorset-Health-Care-NHS-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 The action plan addressed identified care issues, with ongoing compliance audit and executive review providing sufficient assurance.
Verbatim wording from the response “5.1. The Trust recognises that there were failings in relation to Mr Smith’s care, and agrees with both the PPO and HM Coroners view that these issues are of concern. In order to ensure that these issues do not reoccur within the Trust services, an action plan was put into place at the time of receipt of the PPO report into Mr Smith’s death, as the Trust was not the provider at the time of Mr Smith’s death. This action plan assured the Trust that actions taken by the provider at the time of Mr Smith’s death addressed the issues outlined.” Source location 2015-0298-Response-by-Dorset-Health-Care-NHS-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 NOMS at HMP Exeter is responsible for training and auditing operation of the ACCT document system.
Verbatim wording from the response “5.7. Concern 3- To review training and audit the operation of the ACCT document system so that it is made as robust as possible.” Source location 2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.