16 Sep 2013 Reggie Johns · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 7 Failure to provide the ACCT document to the nurse during interview View source Failure to involve appropriately qualified healthcare personnel in reviews View source Lack of formal record keeping of communication between prisons View source Failure to hold required multidisciplinary review meetings View source Failure to record the nurse's professional view in the ACCT document View source Failure to ensure officers remain engaged throughout the review View source Failure to communicate constant watch status to relevant prison staff View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Reggie Johns · 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
Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.
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. The report was sent to Bristol Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the ACCT document to the nurse during interview
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bristol Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to involve appropriately qualified healthcare personnel in reviews
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare .
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review .
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bristol Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of formal record keeping of communication between prisons
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff . Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bristol Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to hold required multidisciplinary review meetings
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate .
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed .
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bristol Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record the nurse's professional view in the ACCT document
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view .
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bristol Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers remain engaged throughout the review
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bristol Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate constant watch status to relevant prison staff
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status .
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Issue a Governor’s Order reminding staff of their responsibilities for sharing and recording information about prisoners at risk of harm.
Verbatim wording from the response “Since Mr Johns' death, HMP Bristol has introduced a system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm. In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments. These conversations are recorded on Prison-NOMIS and the enclosed Governor's Order has been issued to remind staff of their responsibilities in this area.” Source location 2013-0202-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue Operational Orders requiring ACCT reviews to be multidisciplinary and obtain views from all appropriate departments.
Verbatim wording from the response “Since Mr Johns' death, the enclosed Operational Orders have been issued entitled ‘Chairing ACCT Reviews’ and ‘ACCT Reviews’ which provide guidance for selecting appropriate ACCT case managers, and confirm that it is the case manager's responsibility to ensure that each review is multi-disciplinary with views from all appropriate departments being taken into consideration.” Source location 2013-0202-Response-by-NOMS
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 Produce joint guidance for discipline and healthcare staff on working together and appropriately sharing information about prisoners in their care.
Verbatim wording from the response “I am aware that you are now in receipt of Worcestershire Health and Care NHS Trust’s response to your report, which confirms that ACCT documents are now made available to nursing staff in reception in all cases when a prisoner arrives at HMP Hewell on an open ACCT. In addition to that response, I have enclosed a copy of a joint document which has been produced by HMP Hewell and Worcestershire Primary Care Trust which provides guidance to discipline and healthcare staff about the importance of working together and sharing information appropriately about the prisoners in their care.” Source location 2013-0202-Response-by-NOMS
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations