Recurring concern

Unreliable ACDT suicide and self-harm risk-management processes

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First reported 13 Feb 2019•Latest report 28 Aug 2019

Definition

What this concern includes

Includes failures of the explicitly named ACDT process, including staff understanding and participation, care documentation, monitoring, review, notification, information sharing and implementation of associated risk-management requirements.

Not included

Excludes failures confined to the distinct ACCT process unless the assertion explicitly identifies ACDT.
Excludes generic prison healthcare, staff training or information-sharing deficiencies not directly tied to ACDT operation.
Excludes Rule 35 procedures or Home Office notification failures where ACDT placement is not the relevant process.
Excludes general custody observation, clinical treatment or suicide-prevention concerns without an identified ACDT control failure.

Reports: 2
Individual concerns: 5
Date range: 2019–2019
Stated actions: 3

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Home Office2

Central and North West London NHS Foundation Trust1

Langley Health Centre1

Mitie1

Mitie Care And Custody Limited1

Recipient name withheld1

the Hillingdon Hospitals NHS Foundation Trust1

Wife of the deceased1

Concerns and responses across reports

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

28 Aug2019
London (West)
Concerns raised4
1. Lack of authority to require healthcare staff participation in the ACDT process
2. Failure of the Consultant Forensic Psychiatrist to read ACDT documents
3. Failure of healthcare staff to understand and participate in the ACDT process
1. Unclear healthcare staff roles in the ACDT process
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Amir Siman-Tov · 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

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

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 authority to require healthcare staff participation in the ACDT process
Wider context from the report
“4. The Centre Manager gave evidence that he recognised the importance of the ACDT process in keeping detainee’s safe and he actively encouraged as wide participation in the process as possible. He stated that he was only able to direct the custody staff and it was not in his power to direct that healthcare staff participated. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of the Consultant Forensic Psychiatrist to read ACDT documents
Wider context from the report
“3. The Consultant Forensic Psychiatrist did not read the ACDT documents. This puts detainees at risk. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of healthcare staff to understand and participate in the ACDT process
Wider context from the report
“1. A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the documents as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process. This puts detainees at risk. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unclear healthcare staff roles in the ACDT process
Wider context from the report
“2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process. This puts detainees at risk. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Feb2019
Dorset
Concerns raised1
1. Lack of a formal procedure for informing the Home Office when detainees are placed on ACDT
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop provisions to identify and flag detainees subject to ACDT monitoring or Rule 35 reporting.
  Stated by Home OfficeStated in progress
2. Action
  Remind IRC staff of ACDT information-sharing guidance and responsibilities through communications to all IRC parties.
  Stated by Home OfficeStated planned
3. Action
  Use pilot learning to improve suicide and self-harm prevention guidance and procedures and clarify ACDT information-sharing responsibilities.
  Stated by Home OfficeStated planned
Respondent positions 1
1. Position
  Existing processes ensure Home Office officials and case workers are notified when ACDT monitoring begins for a detained individual.
  Stated by Home OfficeExisting arrangements considered sufficient
AI-generated summary

Branko Zdravkovic · 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

Branko Zdravkovic, who was detained at the Immigration Removal Centre, The Verne, was found suspended by a ligature in a toilet cubicle and died on 9 April 2017. The inquest concluded that his death was suicide, with the medical cause recorded as ligature suspension. Concerns were raised that staff were instructed to use ACDT procedures instead of making Rule 35 reports, and that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT.

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 a formal procedure for informing the Home Office when detainees are placed on ACDT
Wider context from the report
“The Inquest heard evidence from a Doctor and Psychiatrist and Healthcare staff working at the IRC that they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies. There was also evidence from several witnesses that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT. In the case of a suicidal detainee, the ACDT procedure is necessary and desirable, but it cannot replace the statutory duty to make a report under Rule 35. Rule 35 imposes a requirement to speedily review whether someone should be released because of concerns recorded by the medical practitioner. Without that information being provided the state cannot carry out its obligations under Article 2 ECHR. ”
Source location
Branko Zdravkovic · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop provisions to identify and flag detainees subject to ACDT monitoring or Rule 35 reporting.

Verbatim wording from the response
“The Home Office is making provisions to better identify and flag individuals in IRCs and foreign national offenders in prisons who are subject to ACDT/ACCT¹ monitoring, and those about whom a Rule 35 report has been submitted. This will ensure an early review of suitability for detention and the assessment of adult at risk factors, and will improve information sharing.”

Source location
2019-0047-Response-by-Home-Office
Page 2 · response
Published 24 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Remind IRC staff of ACDT information-sharing guidance and responsibilities through communications to all IRC parties.

Verbatim wording from the response
“There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.”

Source location
2019-0047-Response-by-Home-Office
Page 3 · response
Published 24 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use pilot learning to improve suicide and self-harm prevention guidance and procedures and clarify ACDT information-sharing responsibilities.

Verbatim wording from the response
“The Home Office will use the learning from the pilot to improve suicide and self-harm prevention guidance and procedures and to clarify the information sharing responsibilities in relation to those detainees assessed as being at risk of self harm and/or suicide.”

Source location
2019-0047-Response-by-Home-Office
Page 4 · response
Published 24 May 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing processes ensure Home Office officials and case workers are notified when ACDT monitoring begins for a detained individual.

Verbatim wording from the response
“There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.”

Source location
2019-0047-Response-by-Home-Office
Page 3 · response
Published 24 May 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised4

Lack of authority to require healthcare staff participation in the ACDT process

Failure of the Consultant Forensic Psychiatrist to read ACDT documents

Failure of healthcare staff to understand and participate in the ACDT process

Unclear healthcare staff roles in the ACDT process

Concerns raised1

Lack of a formal procedure for informing the Home Office when detainees are placed on ACDT

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

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

Actions described in response 3

Respondent positions 1