Hewell Prison

Justice · Prison or young offender institution

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First report 16 Sep 2013•Latest report 27 Jan 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
7

Naming this recipient

Published responses
29%

Found for named reports

Concerns addressed
10

Across all linked responses

Stated actions
13

Described in responses

Concerns and recipient responses

Statements from Hewell Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Worcestershire

    AI-generated summary

    Andrew Paul SHIRLEY · 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 Paul Shirley, a 25-year-old prisoner at HMP Hewell, was found unresponsive in his cell on 23 March 2021, suspended by a ligature, and was pronounced dead at the scene. The inquest found that healthcare and mental healthcare staff failed to sufficiently identify, manage, and share information about his risk of suicide and self-harm, and that these failures probably caused or contributed to his death. Concerns were also raised about staff training on suicide and self-harm risk and the Initial Segregation Health Screen process.

    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff completion of ACCT v.6 and SASH model 3 training

    Wider context from the report

    “(1) I heard evidence that v.6 of the ACCT document had been in place at prisons throughout England and Wales since June 2021, and that training relevant thereto consists of: (i) ACCT v.6 training; and (ii) SASH (suicide and self-harm) model 3 training. However, I also heard that, as at 20.1.23 (over 18 months after the introduction of the latest ACCT document), 280 out of 400 members of staff at the prison (70%) were yet to have completed that training. It is of considerable concern that such a high percentage of staff at the prison may not be in a position to recognise the risk which a prisoner presents of suicide and/or self-harm, and therefore to take appropriate steps to reduce that risk; ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training for Duty Governors in completing the Initial Segregation Health Screen algorithm document

    Wider context from the report

    “(2) I also heard evidence that, despite the introduction of a new Initial Segregation Health Screen algorithm document for prisoners in the Segregation Unit, Duty Governors at the prison had not yet received any training about the steps they should take in order to complete that document appropriately. ”
    Open source report

  2. Worcestershire

    AI-generated summary

    Gary McDonald · 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

    Gary McDonald was found deceased in his cell at HMP Hewell after spending nearly four months on remand awaiting trial; the inquest concluded that he died as a result of suicide. The principal concern was that, despite prison healthcare receiving records showing a history of depression and two previous overdoses, including one seven months earlier, there was no system to follow up discrepancies between a prisoner's disclosed mental health history and community GP records.

    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely follow up discrepancies between disclosed mental health history and community GP records

    Wider context from the report

    “5) I am concerned that there is currently no system in place at HMP Hewell to follow up with a prisoner any discrepancy between the mental health history which he has disclosed on arrival at the prison, and that revealed in his community GP records. Experience suggests that a prisoner with a recorded history of mental health issues, particularly one which includes a recent episode of attempted suicide or self-harm through overdose, may be at his most vulnerable during his first days and weeks at a prison, and having been reluctant to disclose such issues for any number of reasons ( e.g. fear, embarrassment ), may be reassured to be told that healthcare staff at the prison are aware of that history and can provide confidential support. In my view, without routine follow-up in such cases, there remains a significant risk that a prisoner’s recent significant history of suicide or self-harm may be overlooked in those important early days and weeks in prison, and that such prisoners will therefore be at an increased risk of further episodes of attempted suicide during that period. ”
    Open source report

  3. Worcestershire

    AI-generated summary

    Colin BLACKBURN · 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

    Colin Blackburn died at HMP Hewell on 6 July 2019 after spending 15 days on remand and having been found with a ligature around his neck on three prior occasions. Concerns included multiple accepted failings in the management of his ACCT suicide and self-harm risk, and uncertainty about the correct process for urgent mental-health referrals, particularly at weekends.

    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review the Care Map at ACCT Case Reviews

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to hold an ACCT Case Review immediately before transfer

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to hold an Initial ACCT Case Review within 24 hours of a concern

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out required ACCT observations

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct multidisciplinary ACCT Case Reviews

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to hold an ACCT Case Review after a ligature incident

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of ACCT Case Review participants to familiarise themselves with the ACCT document

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record triggers or warning signs on the ACCT inside cover

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of ACCT Case Manager involvement after prisoner transfer

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in holding scheduled ACCT Case Reviews

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document ligature incidents on the NOMIS record

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure prison staff understand their ACCT obligations

    Wider context from the report

    “I am not satisfied that sufficient action has yet been taken to ensure that all members of prison staff understand their obligations in respect of prisoners who are subject to the ACCT process. This is because: (i) there is no evidence yet that the changes described above have led to a change in how prison staff deal with ACCT documents; and (ii) I heard evidence during the inquest from a number of senior officers who, even now, found it difficult to comprehend that their involvement with Mr. Blackburn and his ACCT document fell short of an acceptable standard. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of timely urgent TAG referral handling at weekends

    Wider context from the report

    “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out. I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager. I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway. The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped. In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on internal post for urgent TAG referrals

    Wider context from the report

    “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out. I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager. I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway. The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped. In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in reaching and opening urgent TAG referrals

    Wider context from the report

    “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out. I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager. I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway. The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped. In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in assigning an ACCT Case Manager

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Uncertainty among prison staff about the urgent weekend TAG referral pathway

    Wider context from the report

    “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out. I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager. I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway. The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped. In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make timely entries on the ACCT Care Map

    Wider context from the report

    “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
    Open source report

  4. Worcestershire

    AI-generated summary

    Gareth Wycliffe WARBURTON · 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 Wycliffe Warburton had undergone a double lung transplant and was taking anti-rejection medication when he arrived at HMP Hewell. A prescription error resulted in him receiving half his usual dose, and he died after chronic rejection of his transplanted lungs. The report raised concerns about prescription systems, staffing and the handling of important health-related correspondence at the prison.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to pass important prisoner health and welfare letters to the prison healthcare team

    Wider context from the report

    “(1) Letters dated 16.10.17 and 27.11.17 from ████████ Mr. Warburton's treating clinician at the Queen Elizabeth Hospital, Birmingham to then Governor of HMP Hewell Gareth Sands, highlighting concern about the prescription error, asking for more information about the error, and seeking assurances that Mr. Warburton would continue to receive all required medication, were neither acknowledged nor answered by the Governor; (2) Furthermore, although such letters ought to have been passed on to the prison healthcare team, the evidence suggested that this was not done. Investigations carried out by current Governor Anthony Morrow failed to establish what had happened to these letters; (3) As to the suggestion that perhaps these letters were never received by the prison, it was apparent that the same letters had been sent to, and received by, members of Mr. Warburton's family; (4) Accordingly, I am satisfied that it is probable that these letters did reach the prison, but were not dealt with satisfactorily; (5) I am concerned that, as long as there is a risk that letters which seek or contain important information about a prisoner's health and welfare are not dealt with and go unanswered, there remains a risk to prisoners' lives at HMP Hewell. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to acknowledge and answer letters containing important information about prisoners' health and welfare

    Wider context from the report

    “(1) Letters dated 16.10.17 and 27.11.17 from ████████ Mr. Warburton's treating clinician at the Queen Elizabeth Hospital, Birmingham to then Governor of HMP Hewell Gareth Sands, highlighting concern about the prescription error, asking for more information about the error, and seeking assurances that Mr. Warburton would continue to receive all required medication, were neither acknowledged nor answered by the Governor; (2) Furthermore, although such letters ought to have been passed on to the prison healthcare team, the evidence suggested that this was not done. Investigations carried out by current Governor Anthony Morrow failed to establish what had happened to these letters; (3) As to the suggestion that perhaps these letters were never received by the prison, it was apparent that the same letters had been sent to, and received by, members of Mr. Warburton's family; (4) Accordingly, I am satisfied that it is probable that these letters did reach the prison, but were not dealt with satisfactorily; (5) I am concerned that, as long as there is a risk that letters which seek or contain important information about a prisoner's health and welfare are not dealt with and go unanswered, there remains a risk to prisoners' lives at HMP Hewell. ”
    Open source report

  5. Worcestershire

    AI-generated summary

    Kelvin Sean Speakman · 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

    Kelvin Sean Speakman was a serving prisoner at HMP Hewell with a long history of mental ill-health and extensive self-harm, including multiple attempts to hang himself. Following an incident of self-ligaturing, he suffered a hypoxic brain injury and died in hospital on 9 May 2016. The report identified shortcomings in the operation and documentation of the ACCT process, including inadequate healthcare input and inconsistent communication between staff.

    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to operate the ACCT process in accordance with national and local policies

    Wider context from the report

    “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate ACCT documentation

    Wider context from the report

    “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent or undocumented communication between staff involved in ACCT decisions

    Wider context from the report

    “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to rectify recurring ACCT process failings

    Wider context from the report

    “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Absence or unclear identification of health care department input to ACCT reviews

    Wider context from the report

    “(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
    Open source report

  6. Worcestershire

    AI-generated summary

    Liam SMITH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Liam Smith was admitted to HMP Hewell on 7 August 2014 and died after taking a combination of prescribed and illicitly obtained medication in his cell. The concerns included possible failures to follow mandatory ACCT procedures, inadequate dissemination and recording of medical information, and limited healthcare interaction with high-risk drug users, potentially resulting in warning signs being missed.

    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Limited healthcare staff interaction with prisoners at high risk from drug use

    Wider context from the report

    “(4) Evidence suggested only limited interaction between members of Healthcare Staff and prisoners who were deemed as "high risk drug users" with a concern that warning signs are missed ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure by healthcare staff to read relevant sections of System 1 notes

    Wider context from the report

    “(3) Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information with a result that staff may be unaware of that information. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to disseminate relevant medical risk information to staff involved in prisoner care

    Wider context from the report

    “(2) Evidence was given that certain medical information which arrived at the prison with Mr Smith was not disseminated to those in reception for those who had later dealings with him which meant that they were unaware of the potential risk of suicide or self harm. It was suggested by some witnesses that documentation "goes astray" and is only found much later. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow mandatory ACCT procedures for prisoners at risk of self-harm

    Wider context from the report

    “(1) Evidence suggested that Mr Smith was at risk of inadvertant self harm and that therefore in accordance with PSI64/2011 ACCT procedures should have been opened in respect of him. Witnesses confirmed their understanding of that mandatory requirement but indicated that they would use their clinical judgement in deciding whether or not to open an ACCT. It is of concern that staff may therefore may therefore not be following mandatory PSI instructions and that prisoners are not receiving appropriate protection by way of the ACCT process. ”
    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 Hewell Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the System 1 summary page to display relevant important information

    Wider context from the report

    “(3) Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information with a result that staff may be unaware of that information. ”
    Open source report

  7. Worcestershire

    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 Hewell 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 Hewell 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 Hewell 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 Hewell 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 Hewell 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 Hewell 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 Hewell 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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026