7 Apr 2026 Matilda Rose Davis · Prevention of Future Deaths report Warwickshire
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Concerns raised 1
Lack of mandatory suicide prevention training for frontline practitioners and staff 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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Matilda Rose Davis · 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
Matilda was found deceased at her home shortly after an urgent safeguarding visit concerning her mental health and the welfare of her children. The inquest identified concerns that suicide prevention training was not mandatory for frontline practitioners, that she was not asked directly about suicidal ideation, and that she was not signposted to crisis support services.
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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 mandatory suicide prevention training for frontline practitioners and staff
Wider context from the report “Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services . The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation.
In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context. It was also noted that she was not signposted to crisis support services at that time.
The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts.
” Source location Matilda Rose Davis · 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 Deliver mandatory Tier 1 suicide prevention awareness training to all Children and Families frontline staff within three months.
Verbatim wording from the response “Tier 1 – Universal awareness (mandatory)
This tier establishes a baseline for all staff. It focuses on:” Source location Response from Warwickshire County Council
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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 Commission Tier 2 practitioner suicide prevention training through a formal competitive procurement process.
Verbatim wording from the response “Due to the scale of investment, commissioning of Tier 2 training will be subject to a formal procurement tender process in line with organisational requirements. As such options will be finalised following a competitive tendering exercise. In person and online options will be considered with the preference to be for frontline staff who hold cases to have in person training. Commencing Autumn 2026.” Source location Response from Warwickshire County Council
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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 phased, mandatory Tier 2 practitioner training to identified Children and Families staff, with refreshers and ongoing training for new starters.
Verbatim wording from the response “Tier 2 – Practitioner response (mandatory)
This tier is designed for staff working directly with individuals at risk, including social workers, family practitioners, and personal advisors.
The focus is on developing applied skills and confidence in:” Source location Response from Warwickshire County Council
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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 Tier 2 practitioner training will be phased over three years because financial considerations and workforce capacity constrain faster implementation.
Verbatim wording from the response “Tier 2 Delivery Model and Timescale
Delivery of Tier 2 training will follow a phased three-year implementation model, reflecting both financial considerations and workforce capacity.” Source location Response from Warwickshire County Council
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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 Mandatory completion of universal suicide-awareness training across the Council remains subject to further corporate agreement.
Verbatim wording from the response “Delivery will be through the updated 2024 e-learning programme, ensuring content is aligned with current best practice in suicide prevention, supported by a single, accessible intranet resource hub which signposts to additional resources and pathways for support (including Dear Life). A refreshed and regularly reviewed suicide prevention intranet page will act as the central resource hub, building on the existing WCC Suicide Prevention page and ensuring consistent access to guidance and training materials, as well as signposting resources.” Source location Response from Warwickshire County Council
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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 Tier 2 training commissioning and delivery options cannot be finalised until a competitive procurement tender is completed.
Verbatim wording from the response “Due to the scale of investment, commissioning of Tier 2 training will be subject to a formal procurement tender process in line with organisational requirements. As such options will be finalised following a competitive tendering exercise. In person and online options will be considered with the preference to be for frontline staff who hold cases to have in person training. Commencing Autumn 2026.” Source location Response from Warwickshire County Council
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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 Expansion of suicide-prevention training to wider workforce groups is subject to funding agreement.
Verbatim wording from the response “Following initial rollout, delivery will transition into a business-as-usual model permitting funding, including:” Source location Response from Warwickshire County Council
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9 Feb 2026 Gareth Chumber-Kelly · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to provide suicide and self-harm risk management training to prison officers View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Gareth Chumber-Kelly · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.
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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 provide suicide and self-harm risk management training to prison officers
Wider context from the report “(2) The court heard evidence that 2 prisoners had died by ligature suspension (on 17.6.2021 and 1.3.22) prior to Mr Chumber-Kelly’s death, and that since then a further 5 prisoners have died by ligature suspension (one of which was Mr Chumber-Kelly). The Governor of HMP Pentonville told the court that Suicide and Self harm training for prison staff had been suspended during Covid and had never been re-started notwithstanding that 38% of prisoners arriving at HMP Pentonville said they felt suicidal and notwithstanding that 7 prisoners have died by ligature suspension since June 2021. The failure to train prison officers in the risks and management of suicide and self-harm creates a risk of future deaths .
” Source location Gareth Chumber-Kelly · 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 Reintroduce the Pentonville Speed School and deliver self-harm and suicide-prevention training to officers.
Verbatim wording from the response “With regards to your training concerns, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention to officers. Additionally, all band 4 staff at HMP Pentonville have now received the Assessment, Care and Teamwork (ACCT) case review training, which equips them with the skills to be able to provide prisoners at risk of suicide with holistic and person-centred support in their role as ACCT case coordinators.” Source location Response from HMPPS
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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 ACCT case-review training to all band 4 staff.
Verbatim wording from the response “With regards to your training concerns, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention to officers. Additionally, all band 4 staff at HMP Pentonville have now received the Assessment, Care and Teamwork (ACCT) case review training, which equips them with the skills to be able to provide prisoners at risk of suicide with holistic and person-centred support in their role as ACCT case coordinators.” Source location Response from HMPPS
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23 May 2025 Shaun Michael Bass · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Lack of specific seller guidance and training on deliberate suicide or self-harm misuse of the substance View source
This report raised 4 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
Shaun Michael Bass · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Shaun Michael Bass, aged 23, was found collapsed and unresponsive at his residence on 23 February 2020 after ingesting a fatal quantity of sodium nitrate/nitrite. The report identified concerns about gaps in continuity of mental healthcare, a missed mental health assessment review, inadequate responses to family concerns, and the availability and online promotion of reportable poisons for self-harm.
Read the report on judiciary.uk
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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 specific seller guidance and training on deliberate suicide or self-harm misuse of the substance
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly ████████ acquired by members of the public, particularly over ‘on-line marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life.
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm.
” Source location Shaun Michael Bass · Prevention of Future Deaths report
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23 May 2025 Andrew Alexander Roger BROWN · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Lack of specific guidance and suggested training for sellers about one-off online purchases for self-harm View source
This report raised 8 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
Home Office
Engage online platforms and retailers to encourage voluntary removal of pure-form substances and vigilance for purchases linked to self-harm or suicide.
View source
Home Office
Improve supplier awareness of suspicious-activity reporting obligations and promote safer sales practices, including declaration-of-use forms.
View source
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AI-generated summary
Andrew Alexander Roger BROWN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Alexander Roger BROWN was found collapsed and unresponsive at his residence on 9 August 2023 and was pronounced dead after paramedics attended. The cause of death was toxicity from a self-administered poison, although his intentions remained unclear. Concerns included gaps in guidance for online sellers and the public regarding suspicious purchases and the potential use of the poison for suicide or self-harm, as well as access to websites providing information about obtaining and administering poisons.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specific guidance and suggested training for sellers about one-off online purchases for self-harm
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly ████████ acquired by members of the public, particularly over ‘on-line marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life.
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm.
” Source location Andrew Alexander Roger BROWN · 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 Engage online platforms and retailers to encourage voluntary removal of pure-form substances and vigilance for purchases linked to self-harm or suicide.
Verbatim wording from the response “The substances in question are not routinely individually highlighted within government issued guidance in relation to their potential misuse for self-harm or suicide. This is to avoid bringing widespread attention to them. However, my officials have engaged with selected online platforms and retailers individually to encourage them to voluntarily remove the sale of these substances to members of the public in their pure form and be vigilant for the possibility of purchase for self-harm or suicide. For all substances within scope of the Poisons Act, the Homeland Security Group works to improve retailer awareness of their legal obligation to report suspicious activity and to inform retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances.” Source location Response from the Home Office
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 Improve supplier awareness of suspicious-activity reporting obligations and promote safer sales practices, including declaration-of-use forms.
Verbatim wording from the response “The substances in question are not routinely individually highlighted within government issued guidance in relation to their potential misuse for self-harm or suicide. This is to avoid bringing widespread attention to them. However, my officials have engaged with selected online platforms and retailers individually to encourage them to voluntarily remove the sale of these substances to members of the public in their pure form and be vigilant for the possibility of purchase for self-harm or suicide. For all substances within scope of the Poisons Act, the Homeland Security Group works to improve retailer awareness of their legal obligation to report suspicious activity and to inform retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual substances are not routinely highlighted in guidance because doing so could draw widespread attention; existing general controls and targeted engagement are relied upon.
Verbatim wording from the response “The substances in question are not routinely individually highlighted within government issued guidance in relation to their potential misuse for self-harm or suicide. This is to avoid bringing widespread attention to them. However, my officials have engaged with selected online platforms and retailers individually to encourage them to voluntarily remove the sale of these substances to members of the public in their pure form and be vigilant for the possibility of purchase for self-harm or suicide. For all substances within scope of the Poisons Act, the Homeland Security Group works to improve retailer awareness of their legal obligation to report suspicious activity and to inform retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances.” Source location Response from the Home Office
Open published response
23 May 2025 Samuel David Dickenson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Lack of specific seller guidance and training on one-off online purchases for self-harm View source
This report raised 6 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
Samuel David Dickenson · 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
Samuel David Dickenson died after ingesting a substance acquired over the internet and was confirmed dead in hospital on 11 March 2020. The concerns relate to gaps in guidance and oversight of online sales of reportable poisons, including the failure to identify or address purchases intended for suicide or self-harm, and the availability of online information promoting access to poisons and methods of administration.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specific seller guidance and training on one-off online purchases for self-harm
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly Sodium Nitrate/Nitrite acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life.
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm.
” Source location Samuel David Dickenson · Prevention of Future Deaths report
Open source report
29 Nov 2024 Charlie Anthony OWEN · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Lack of mandatory suicide prevention training for army welfare officers and welfare NCOs View source
This report raised 6 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. 3
Ministry of Defence
Establish a working group to review all aspects of mental-health and wellbeing training, including suicide prevention, risk understanding and Vulnerability Risk Management.
View source
Ministry of Defence
Publish recommendations from the mental-health and wellbeing training review.
View source
Ministry of Defence
Update training policy using the published recommendations.
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AI-generated summary
Charlie Anthony OWEN · 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
Charlie Anthony Owen was found deceased in his room at Combermere Barracks on 11 September 2023, after previously making and aborting two attempts to end his life in the context of relationship breakdown. The inquest identified concerns about inadequate sharing of risk-management information, insufficient consideration of welfare checks and protective factors on his return to barracks, and gaps in Army training and Vulnerability Risk Management processes.
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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 mandatory suicide prevention training for army welfare officers and welfare NCOs
Wider context from the report “I heard that suicide prevention training is not mandatory for army welfare officers/welfare NCOs . This gives rise to a concern that those specifically tasked to deal with people who are most likely to pose a risk of suicide or self harm are not best equipped to identify this and assist the individual .
” Source location Charlie Anthony OWEN · 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 Establish a working group to review all aspects of mental-health and wellbeing training, including suicide prevention, risk understanding and Vulnerability Risk Management.
Verbatim wording from the response “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.” Source location Response from Ministry of Defence
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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 Publish recommendations from the mental-health and wellbeing training review.
Verbatim wording from the response “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.” Source location Response from Ministry of Defence
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 Update training policy using the published recommendations.
Verbatim wording from the response “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.” Source location Response from Ministry of Defence
Open published response
17 Jan 2024 Kane Christopher Boyce · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of understanding and training on key dates or anniversaries as self-harm risk factors View source
This report raised 9 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
Sodexo
Deliver the national ACCT, ACCT Assessor and Case Coordinator training packages using nationally trained Sodexo facilitators and HMPPS facilitators.
View source
Sodexo
Provide ACCT refresher training to all staff when operational management returns to Sodexo, unless they have completed it earlier.
View source
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AI-generated summary
Kane Christopher Boyce · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding and training on key dates or anniversaries as self-harm risk factors
Wider context from the report “4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI
A number of prison officers believed Kane’s birthday was incapable of amounting to a “key date or anniversary” for the purposes of PSI 64/2011 . It seems to me to common sense that a birthday, being the anniversary of one’s birth, could amount to a potential trigger date for heightened emotions when considering a prisoner’s risk of self harm and suicide. That is not to say it would be so for each and every prisoner, but perhaps something to be cognisant of when dealing with an emotional and intoxicated prisoner. I have seen no evidence that this is covered in Sodexo’s training for staff on the ACCT process , if indeed any series of training exists.
A number of prison officers gave evidence that an ACCT was not necessary because Kane had not said to anyone that he was going to harm himself (either fatally or otherwise). Serco’s Safer Prison Operating Policy (August 2022) is confusing on this point and seems to suggest at paragraph 3.4 that staff should only open an ACCT when a statement of self-harm has been verbalised. This is not consistent with the PSI. Sodexo have not offered for scrutiny any local policy, guidance or training material on the threshold for opening an ACCT, but even if such exists, it appears some staff continue to labour under the misapprehension that a prisoner must say they are thinking of harming themselves before an ACCT can be opened.
” Source location Kane Christopher Boyce · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the national ACCT, ACCT Assessor and Case Coordinator training packages using nationally trained Sodexo facilitators and HMPPS facilitators.
Verbatim wording from the response “Sodexo follow the national Prison Service Instruction 64/2011 which provides the framework underpinning any local policy. Sodexo deliver to staff the national training package issued by HMPPS for ACCT, version 6 and ACCT Assessor. To enable this Sodexo facilitators complete the national ACCT Train the Trainer course delivered by HMPPS facilitators. Relevant Sodexo staff also receive the national training package delivered directly by HMPPS facilitators on ACCT Case Coordinators.” Source location Response from Sodexo
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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 ACCT refresher training to all staff when operational management returns to Sodexo, unless they have completed it earlier.
Verbatim wording from the response “When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before.” Source location Response from Sodexo
Open published response
2 Dec 2022 Lewis Steven Johnson · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to train night patrol staff to respond effectively to ligature or other self-harm incidents View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Lewis Steven Johnson · 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
Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery position.
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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 night patrol staff to respond effectively to ligature or other self-harm incidents
Wider context from the report “(3) In the absence of healthcare staff being immediately available, the night patrol staff should be trained to respond effectively to ligature or other self-harm incidents .
” Source location Lewis Steven Johnson · 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 Update the emergency-response training video and distribute it to training centres and prisons for staff training.
Verbatim wording from the response “In respect of the EFAW training all prison officers receive during their entry level training, all first aid training certificates are valid for three years and although not mandatory, staff are encouraged to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures. The initial training for staff includes an HMPPS video which shows how to respond to an emergency situation where a prisoner has attempted suicide. This is currently being updated to reflect changes to policy and equipment available since the original video was produced. This video covers the use of prison issue ligature tools, emergency response codes, placing someone in the recovery position and considerations such as when to initiate first aid and the use of defibrillators.” Source location Response from HM Prison & Probation Service
Open published response
27 Jun 2022 Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Insufficient training and awareness of domestic abuse and suicide risk among front line police officers View source
This report raised 10 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. 1
Home Office
Provide up to £3.3 million to support further rollout of domestic abuse and related policing training.
View source
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AI-generated summary
Jessica Louise LAVERACK “Jessie” · 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
Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.
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 training and awareness of domestic abuse and suicide risk among front line police officers
Wider context from the report “(5) There is a need to consider better training and awareness of both domestic abuse and risk of suicide for front line police officers.
” Source location Jessica Louise LAVERACK “Jessie” · 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 up to £3.3 million to support further rollout of domestic abuse and related policing training.
Verbatim wording from the response “In terms of training, the College of Policing has developed the Policing Education Qualifications Framework which is an important step in raising standards in policing, including in tackling violence against women and girls. Additionally, the College have developed a range of other training products, including the Domestic Abuse Matters programme. We committed up to £3.3m to support further rollout of the training.” Source location Response from Home Office (2)
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1 Dec 2021 Kaja Weronika SPIEWAK · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Failure to ensure proper training of frontline and control-room staff in dealing with vulnerable or suicidal persons View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Govia Thameslink Railway Limited Network Rail Infrastructure Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Govia Thameslink Railway Limited and Network Rail Infrastructure Limited
Brief every Network Rail and Govia Thameslink Railway control-room staff member on recognising, handling and sharing concern-for-welfare reports.
View source
Govia Thameslink Railway Limited
Employ a dedicated Suicide Prevention Manager to promote awareness, signpost support and develop staff training with the Samaritans.
View source
Govia Thameslink Railway Limited
Deliver the in-house online Suicide Prevention course to frontline colleagues and keep it available for knowledge refreshment.
View source
Govia Thameslink Railway Limited
Deliver suicide-prevention training through staff briefings and induction, including Mental Health Nurse input for new starters.
View source
Govia Thameslink Railway Limited
Audit the training programme’s impact and provide the results to the Office of Rail and Road.
View source
Govia Thameslink Railway Limited
Develop a training course for handling vulnerable people’s calls through telephones and station help points.
View source
Govia Thameslink Railway Limited
Assess control-room staff annually through a practical exercise on responding to help-point calls from suicidal people.
View source
Govia Thameslink Railway Limited
Strengthen guidance on non-emergency welfare concerns through training and staff briefings, reinforcing contact with British Transport Police.
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AI-generated summary
Kaja Weronika SPIEWAK · 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 7 April 2021, Kaja Weronika SPIEWAK was identified as vulnerable while travelling by train and was later declared deceased at 1.07pm after being at Southbourne Station. The report raised concerns about inadequate training, inappropriate control-room guidance, incomplete recording of actions, and failures to share welfare concerns with relevant agencies.
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 ensure proper training of frontline and control-room staff in dealing with vulnerable or suicidal persons
Wider context from the report “(1) I heard evidence from the Suicide Prevention Manager for Govia Thameslink Railway Ltd that training on dealing with vulnerable persons was not mandatory for frontline staff .
In fact only 583 out of 7,500 staff had attended a course run by the Samaritans entitled Managing Suicidal Contacts , 40% had completed some e-learning and an unknown number had completed an internal course. In addition refresher training on this issue was an aspiration only and had not been rolled out by Govia Thameslink Railway Ltd.
I also heard evidence that the Suicide Prevention Manager for Govia Thameslink Railway Ltd did not have any input into the training for their team based on the joint control room .
I am therefore concerned that those members of staff most likely to have contact with vulnerable or suicidal persons, as well as those responsible for assisting frontline staff, are not all properly trained to deal with the situation in the best possible way .
” Source location Kaja Weronika SPIEWAK · 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 Brief every Network Rail and Govia Thameslink Railway control-room staff member on recognising, handling and sharing concern-for-welfare reports.
Verbatim wording from the response “NR has worked with GTR to brief every member of control room staff, including those employed by both NR and GTR, with the ‘Concern for Welfare’ briefing, either in person or on MS teams. The briefings addressed the sequence of events that led to Kaja’s tragic death and highlighted the key learning and crucially the importance of all agencies including NR, GTR and notably the British Transport Police (BTP) sharing information relating to ‘Concern for Welfare’. A copy of this briefing is attached.” Source location 2022-0052-Response-from-Network-Rail_Published
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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 Employ a dedicated Suicide Prevention Manager to promote awareness, signpost support and develop staff training with the Samaritans.
Verbatim wording from the response “GTR is the only Train Operating Company in UK Rail to employ a dedicated Suicide Prevention Manager. They play an active role in promoting awareness of the issues of vulnerable people coming on to our Network, signposting support channels to rail users and Staff through organised events to such as ‘Small Talk Saves Lives’, ‘Brew Monday’ and ‘Affirmation Art’ campaigns. They also work closely with the Samaritans to develop training courses for staff to help them feel more confident approaching a vulnerable person and giving them the tools and knowledge to make a safe intervention. These initiatives together have, since having a dedicated Suicide Prevention Manager, doubled the number of interventions made by staff, with 456 recorded in the last year.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the in-house online Suicide Prevention course to frontline colleagues and keep it available for knowledge refreshment.
Verbatim wording from the response “We recognised the importance for everyone to have the skills to identify someone who is vulnerable and have the confidence to make an intervention, so have developed, in-house, the ‘Suicide Prevention’ course. It is based on the content of the Samaritans MSC course, designed with interactive learning cemented with quizzes and is delivered via an e-learning platform, meaning that it can reach more people. So far 3045 GTR colleagues have completed this course and being online, it remains accessible to all, on any device, so that knowledge can be refreshed at any time.
This number accounts for 70% of our Customer facing, frontline teams completing this course.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver suicide-prevention training through staff briefings and induction, including Mental Health Nurse input for new starters.
Verbatim wording from the response “It is our intent that all GTR colleagues benefit from this programme, so in addition to being included as part of an individuals’ briefing cycle, this course is delivered to all new starters in the ‘Caring for the Vulnerable’ session of the company induction. This gives the opportunity to enhance it further, with a session delivered by a Mental Health Nurse to help prepare people, new to Rail, should find themselves in a situation with someone in crisis in a precarious position. So far 860 new people have benefited from this course.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the training programme’s impact and provide the results to the Office of Rail and Road.
Verbatim wording from the response “We at GTR are confident that this approach gives us the best and quickest penetration to enable those members of staff, most likely to have contact with vulnerable or suicidal persons, to make a safe intervention. However, we want to test both the breadth and depth of understanding of this important subject, amongst those in this cohort. GTR will conduct audit to assess the impact of its programme, the results of which will be used to identify improvements which could be made and will be made available to the rail regulator, the Office of Rail and Road (ORR), by the end of April.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a training course for handling vulnerable people’s calls through telephones and station help points.
Verbatim wording from the response “On occasion the control room might take a call, via a station call point, from a member of the public or the vulnerable person themselves. GTR’s suicide Prevention Manager is working with the Samaritans to develop a training course specific to dealing with vulnerable people over the phone and help points. Learning will be underpinned with a practical assessment for GTR control room staff, which is done annually, on how they would deal with a help point call from a suicidal person.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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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 Assess control-room staff annually through a practical exercise on responding to help-point calls from suicidal people.
Verbatim wording from the response “On occasion the control room might take a call, via a station call point, from a member of the public or the vulnerable person themselves. GTR’s suicide Prevention Manager is working with the Samaritans to develop a training course specific to dealing with vulnerable people over the phone and help points. Learning will be underpinned with a practical assessment for GTR control room staff, which is done annually, on how they would deal with a help point call from a suicidal person.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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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 Strengthen guidance on non-emergency welfare concerns through training and staff briefings, reinforcing contact with British Transport Police.
Verbatim wording from the response “threshold. I agree that this ambiguity needs to be eradicated. The output from the Operational Deployment Days will be used to strengthen guidance to aid better decisions in respect to non-emergency concerns for welfare.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.