4 Dec 2024 Kayleigh Ann MELHUISH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Failure by healthcare staff to check and update ACCT care plan support actions during reviews View source Ligature point where the Residential Unit 3 privacy screen meets the wall View source Failure to complete or review ACCT care plans and support actions at every review View source Lack of understanding of when and how constant supervision can be used View source Lack of mandatory neurodiversity training for prison staff View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kayleigh Ann MELHUISH · 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
Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by neglect.
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 Eastwood Park Prison and Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare staff to check and update ACCT care plan support actions during reviews
Wider context from the report “2. Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated ; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.
” 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 Eastwood Park Prison and Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Ligature point where the Residential Unit 3 privacy screen meets the wall
Wider context from the report “3. To HMP Eastwood: the ligature point in Residential Unit 3 where the privacy screen meets the wall .
” 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 Eastwood Park Prison and Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or review ACCT care plans and support actions at every review
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews ;
c. Little or no understanding of when constant supervision can be used and how is it used;
” 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 Eastwood Park Prison and Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of when and how constant supervision can be used
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used ;
” 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 Eastwood Park Prison and Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory neurodiversity training for prison staff
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory ;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used;
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations