4 Jun 2021 Geoffrey Harrison HUTTON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 6 Failure of the ACCT Case Manager allocation and oversight system View source Lack of formal training for ACCT Case Manager allocation and duties View source Insufficient Safer Custody team capacity for Equality & Disability issues View source Failure of the social care referral system to make referrals to the relevant Local Authority View source Lack of training for identifying and making social care referrals View source Failure to ensure ACCT training for staff carrying out night observations View source See 3 more concerns
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Geoffrey Harrison HUTTON · 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
Geoffrey Harrison Hutton died by suicide in his cell at HMP Long Lartin on 8 February 2019 after hanging himself with a ligature made from a laundry-bag drawstring. He had significant hearing impairment, longstanding mental health and substance misuse issues, and was subject to an ACCT document. The substantive concerns included failures relating to social-care referral and support for his hearing and communication needs, ineffective ACCT case-manager oversight, and insufficient ACCT training for some staff carrying out observations.
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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the ACCT Case Manager allocation and oversight system
Wider context from the report “(2) There appears to be no effective system for allocating ACCT Case Managers at HMP Long Lartin . The officer (Officer A) who, when she opened the final ACCT document for Mr. Hutton, appointed herself as Case Manager for this ACCT, did so knowing that she would have no contact with him over the following two weeks. Officer A gave evidence that:
(a) this was common practice at the prison;
(b) officers were discouraged from not naming a Case Manager when they opened an ACCT, even if (as here ) it was opened at night;
(c) she was hoping that another officer might “take it over” from her.
As she predicted, she herself did indeed have no further contact with Mr. Hutton. Furthermore, this problem was not passed on or identified, and no other officer took over the Case Manager role. Therefore there was no effective oversight of an ACCT involving a potentially very vulnerable individual .
Of particular concern is that another appears to have filled in Officer A’s details in the “name” and “signature” boxes at the foot of the ACCT Caremap, and dated them 7.2.19 (the day before Mr. Hutton’s death ), thereby giving the impression that Officer A had reviewed and satisfied herself that the actions identified in the Caremap had been dealt with. In fact, the most important action on the Caremap, which required a social care referral, had not been completed.
This lack of effective oversight was not confined to Mr. Hutton’s final ACCT document. For his first ACCT document at HMP Long Lartin, only a month earlier, the named Case Manager had no involvement with it until the fourth ACCT Case Review, and made no entries on the Caremap ( which was signed off by a different officer ).
I heard evidence from a member of the current Senior Management Team at the prison that:
(a) there is currently no formal training for the allocation of, or fulfilment of the duties of the ACCT Case Manager role;
(b) this will be reviewed, and training will be organised.
The lack of an effective ACCT Case Manager, who is able to provide proper oversight of an ACCT , is an issue which was raised by me in a previous Report to Prevent Future Deaths which followed the death of another prisoner at HMP Long Lartin ( David KIRSCH – report dated 30.10.19 )
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of formal training for ACCT Case Manager allocation and duties
Wider context from the report “(2) There appears to be no effective system for allocating ACCT Case Managers at HMP Long Lartin. The officer (Officer A) who, when she opened the final ACCT document for Mr. Hutton, appointed herself as Case Manager for this ACCT, did so knowing that she would have no contact with him over the following two weeks. Officer A gave evidence that:
(a) this was common practice at the prison;
(b) officers were discouraged from not naming a Case Manager when they opened an ACCT, even if (as here ) it was opened at night;
(c) she was hoping that another officer might “take it over” from her.
As she predicted, she herself did indeed have no further contact with Mr. Hutton. Furthermore, this problem was not passed on or identified, and no other officer took over the Case Manager role. Therefore there was no effective oversight of an ACCT involving a potentially very vulnerable individual.
Of particular concern is that another appears to have filled in Officer A’s details in the “name” and “signature” boxes at the foot of the ACCT Caremap, and dated them 7.2.19 (the day before Mr. Hutton’s death ), thereby giving the impression that Officer A had reviewed and satisfied herself that the actions identified in the Caremap had been dealt with. In fact, the most important action on the Caremap, which required a social care referral, had not been completed.
This lack of effective oversight was not confined to Mr. Hutton’s final ACCT document. For his first ACCT document at HMP Long Lartin, only a month earlier, the named Case Manager had no involvement with it until the fourth ACCT Case Review, and made no entries on the Caremap ( which was signed off by a different officer ).
I heard evidence from a member of the current Senior Management Team at the prison that:
(a) there is currently no formal training for the allocation of, or fulfilment of the duties of the ACCT Case Manager role ;
(b) this will be reviewed, and training will be organised.
The lack of an effective ACCT Case Manager, who is able to provide proper oversight of an ACCT, is an issue which was raised by me in a previous Report to Prevent Future Deaths which followed the death of another prisoner at HMP Long Lartin ( David KIRSCH – report dated 30.10.19 )
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient Safer Custody team capacity for Equality & Disability issues
Wider context from the report “(1) No social care referral had been made for Mr. Hutton, despite the need for one having been identified soon after his arrival at HMP Long Lartin. This was because no effective system for making such referrals to the relevant Local Authority appeared to be in place at the prison at the time of these events. The Safer Custody team were responsible for making such referrals, but members of that team suggested in evidence that they had insufficient time to deal with such issues. The Safer Custody lead at the time of these events gave evidence as follows:
(a) a social care referral, on the correct form as per the prison’s Adult Safeguarding Policy, was never made;
(b) such a referral should have been made within days of Mr. Hutton’s arrival at the prison;
(c) he was unable to explain why the system had broken down, but agreed that officers within his team had then, and continue to have insufficient time to devote to Equality & Disability issues ;
(d) there is still no training in place to ensure that officers are able to identify the need for a social care referral, and know how to make such a referral.
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the social care referral system to make referrals to the relevant Local Authority
Wider context from the report “(1) No social care referral had been made for Mr. Hutton, despite the need for one having been identified soon after his arrival at HMP Long Lartin. This was because no effective system for making such referrals to the relevant Local Authority appeared to be in place at the prison at the time of these events. The Safer Custody team were responsible for making such referrals, but members of that team suggested in evidence that they had insufficient time to deal with such issues. The Safer Custody lead at the time of these events gave evidence as follows:
(a) a social care referral, on the correct form as per the prison’s Adult Safeguarding Policy, was never made;
(b) such a referral should have been made within days of Mr. Hutton’s arrival at the prison;
(c) he was unable to explain why the system had broken down, but agreed that officers within his team had then, and continue to have insufficient time to devote to Equality & Disability issues;
(d) there is still no training in place to ensure that officers are able to identify the need for a social care referral, and know how to make such a referral.
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of training for identifying and making social care referrals
Wider context from the report “(1) No social care referral had been made for Mr. Hutton, despite the need for one having been identified soon after his arrival at HMP Long Lartin. This was because no effective system for making such referrals to the relevant Local Authority appeared to be in place at the prison at the time of these events. The Safer Custody team were responsible for making such referrals, but members of that team suggested in evidence that they had insufficient time to deal with such issues. The Safer Custody lead at the time of these events gave evidence as follows:
(a) a social care referral, on the correct form as per the prison’s Adult Safeguarding Policy, was never made;
(b) such a referral should have been made within days of Mr. Hutton’s arrival at the prison;
(c) he was unable to explain why the system had broken down, but agreed that officers within his team had then, and continue to have insufficient time to devote to Equality & Disability issues;
(d) there is still no training in place to ensure that officers are able to identify the need for a social care referral, and know how to make such a referral .
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure ACCT training for staff carrying out night observations
Wider context from the report “(3) Not all prison staff who carry out ACCT observations on vulnerable prisoners at night have received ACCT training .
This issue became apparent when the Operational Support Grade member of staff ( OSG ) who found Mr. Hutton on the morning of his death gave evidence to the inquest. Not only had he not received any training about the ACCT procedure at the time of these events, that remains the case now.
I heard evidence from a member of the current Senior Management Team at the prison that OSGs are currently required to carry out ACCT observations at night, but that ACCT training for them is not mandatory and some have therefore not received such training .
It is of concern that those carrying out potentially critical observations on very vulnerable prisoners may not be aware of what the ACCT procedure involves , or what it may require of them if they have any concerns about a prisoner.
” Open source report
5 May 2021 Richard James Ormond · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to provide WMAS with critical patient-condition information promptly during emergencies View source Failure of prison and healthcare staff to recognize the need to update WMAS with critical patient-condition information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Richard James Ormond · 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
Richard James Ormond, who had a history of substance misuse while in prison, was found in his cell at HMP Long Lartin in a drug-related cardiac arrest and was declared deceased later that day at hospital. The inquest heard that critical information that he was not breathing and required CPR was not passed to the ambulance service for at least nine minutes, delaying the highest-category emergency response. Concern was raised that prison and healthcare staff might not recognise the need to provide such critical updates in similar circumstances.
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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide WMAS with critical patient-condition information promptly during emergencies
Wider context from the report “1) During the course of the inquest I heard evidence that:
(a) Pursuant to an agreement between HM Prison Service and West Midlands Ambulance Service (WMAS):
(i) When a Code Blue or Code Red emergency is phoned through to WMAS by a prison, and no answer can be given by the prison control room to the questions “is the patient conscious?” and “is the patient breathing?”, then without further information a Category 2 response will be generated (i.e. average attendance time of c.18 minutes );
(ii) Should further information be relayed to WMAS by the prison control room that the patient is either in cardiac arrest or peri-arrest, or not breathing, or fitting, or choking, or that CPR is being administered, WMAS will upgrade the response to Category 1 (i.e. average attendance time of 7 minutes).
(b) In Mr. Ormond’s case:
(i) It was immediately apparent to prison officers who found Mr. Ormond in his cell that he was unresponsive and required CPR. When healthcare staff responded to the Code Blue call which went out over the radio, and attended the cell a short time later, they found those officers already giving Mr. Ormond CPR;
(ii) The prison control room initially informed WMAS that this was a Code Blue emergency, but were unable to say whether Mr. Ormond was conscious or breathing. The call was therefore given a Category 2 status;
(iii) There was then a delay of at least 9 minutes before the prison control room provided WMAS with information that Mr. Ormond was not breathing and was requiring CPR , at which point WMAS upgraded the response to Category 1;
(iv) In a Safer Custody Learning Bulletin issued in December 2016 to all prison staff, entitled “The Importance of Immediate Emergency Response”, the instruction was given to “Ensure that information on the condition of the patient is passed to the control room as soon as possible so that the ambulance service can be updated.”
(v) The 9 minute delay referred to at (iii) above occurred despite prison officers and healthcare staff who first attended the scene having radios, and therefore being in a position to share the control room the information that Mr. Ormond was not breathing and required CPR.
2) The failure to provide WMAS with critical information about Mr. Ormond’s condition , which would have resulted in the call being given the highest category of emergency response, did not appear to have been recognized by either HM Prison Service or Practice Plus Group until this inquest hearing. In the circumstances, there is concern that members of the prison and healthcare staff at HMP Long Lartin will not recognize the need to update WMAS with critical information about a patient’s condition in similar circumstances.
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to recognize the need to update WMAS with critical patient-condition information
Wider context from the report “1) During the course of the inquest I heard evidence that:
(a) Pursuant to an agreement between HM Prison Service and West Midlands Ambulance Service (WMAS):
(i) When a Code Blue or Code Red emergency is phoned through to WMAS by a prison, and no answer can be given by the prison control room to the questions “is the patient conscious?” and “is the patient breathing?”, then without further information a Category 2 response will be generated (i.e. average attendance time of c.18 minutes );
(ii) Should further information be relayed to WMAS by the prison control room that the patient is either in cardiac arrest or peri-arrest, or not breathing, or fitting, or choking, or that CPR is being administered, WMAS will upgrade the response to Category 1 (i.e. average attendance time of 7 minutes).
(b) In Mr. Ormond’s case:
(i) It was immediately apparent to prison officers who found Mr. Ormond in his cell that he was unresponsive and required CPR. When healthcare staff responded to the Code Blue call which went out over the radio, and attended the cell a short time later, they found those officers already giving Mr. Ormond CPR;
(ii) The prison control room initially informed WMAS that this was a Code Blue emergency, but were unable to say whether Mr. Ormond was conscious or breathing. The call was therefore given a Category 2 status;
(iii) There was then a delay of at least 9 minutes before the prison control room provided WMAS with information that Mr. Ormond was not breathing and was requiring CPR, at which point WMAS upgraded the response to Category 1;
(iv) In a Safer Custody Learning Bulletin issued in December 2016 to all prison staff, entitled “The Importance of Immediate Emergency Response”, the instruction was given to “Ensure that information on the condition of the patient is passed to the control room as soon as possible so that the ambulance service can be updated.”
(v) The 9 minute delay referred to at (iii) above occurred despite prison officers and healthcare staff who first attended the scene having radios, and therefore being in a position to share the control room the information that Mr. Ormond was not breathing and required CPR.
2) The failure to provide WMAS with critical information about Mr. Ormond’s condition, which would have resulted in the call being given the highest category of emergency response, did not appear to have been recognized by either HM Prison Service or Practice Plus Group until this inquest hearing . In the circumstances, there is concern that members of the prison and healthcare staff at HMP Long Lartin will not recognize the need to update WMAS with critical information about a patient’s condition in similar circumstances.
” Open source report
30 Oct 2019 David John KIRSCH · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 7 Failure to allocate a Case Manager to oversee ACCT documents View source Inadequate completion of Caremaps in ACCT documents View source Failure to ensure accountable sign-off of ACCT Caremaps View source Failure to notify the designated Case Manager about ACCT documents View source Failure to escalate open ACCT documents in accordance with policy View source Lack of prison officer knowledge of ACCT reasons and monitoring issues View source Failure to conduct direct assessment of suicide and self-harm risk during ACCT reviews View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David John KIRSCH · 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
David John Kirsch was found deceased in his cell on 19 March 2018 after inflicting a large wound to his neck with the lid of a tin. The principal concerns were the lack of allocated case-manager oversight for his ACCT document, deficiencies in recording and addressing risks, failure to escalate the case, and inadequate staff knowledge and assessment of his suicide risk.
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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate a Case Manager to oversee ACCT documents
Wider context from the report “(1) No Case Manager had been allocated to oversee Mr. Kirsch's ACCT document . This lack of oversight resulted in a number of deficiencies in the ACCT process, including:
(a) 11 different people chairing the 13 ACCT reviews which took place in the 6 weeks between Mr. Kirsch's return from hospital on 5.2.18 and his death on 19.3.18;
(b) Inadequate completion of the Caremap within the ACCT document, which ought to have highlighted the issues behind Mr. Kirsch's concerning behaviour and suicide attempts in January 2018, and identified actions to be taken to try to address those issues. In this case, evidence was heard that:
(i) When he had first started his sentence in 2008, Mr. Kirsch had told people that he would not live to complete it;
(ii) In August 2017 he had had two notable episodes of bizarre behaviour which, it was thought, may have been down to having taken the psychoactive substance Spice on those occasions;
(iii) Evidence from staff who had witnessed the suicide attempts in January 2018 indicated that they thought he may have taken Spice on those occasions;
(iv) Throughout 2017 and early 2018 he had been rather obsessed with a complaint he had made about an entry on his NOMIS record, and that in the days leading up to his death he had reported that this had been keeping him up at night;
(v) He was concerned that his daughter, who had become an adult relatively recently, had not tried to make contact with him;
(vi) He was worried about visits from his family, and how he was going to tell them what he had done in January 2018;
(vii) He had been involved in a fight on 13.3.18 with another prisoner (something out of character for him), which had resulted in his transfer to another wing, away from a fellow prisoner who was an important part of his support network;
(viii) He had recently sought out a member of the healthcare team in tears, because he was worried that he had not been able to get across his version of events in the adjudication hearing held after the fight incident;
(ix) On the afternoon of his death, two fellow prisoners had expressed concerns to a Supervising Officer that Mr. Kirsch was "looking particularly down" and was not himself. This conversation was passed on to the Supervising Officer on Mr. Kirsch's wing who spoke to him. In that conversation, Mr. Kirsch made a concerning comment about having bitten someone, and denied (untruthfully) that he had had any involvement with the mental health team at the prison. These concerns and conversations were not recorded anywhere in the main body of the ACCT document.
Save for the fact of the fight on 13.3.18 and of his resulting transfer to another wing, none of these matters was noted in the Caremap on Mr. Kirsch's ACCT document, and so no actions were identified to try to address them.
(c) The ACCT document was opened on 20.1.18. Between then and 5.2.18 Mr. Kirsch had been receiving treatment for his injuries in hospital, and had been on constant bedwatch there. When he returned to the prison on 5.2.18, no entries were made to the Caremap at all for the first four weeks thereafter.
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate completion of Caremaps in ACCT documents
Wider context from the report “(1) No Case Manager had been allocated to oversee Mr. Kirsch's ACCT document. This lack of oversight resulted in a number of deficiencies in the ACCT process, including:
(a) 11 different people chairing the 13 ACCT reviews which took place in the 6 weeks between Mr. Kirsch's return from hospital on 5.2.18 and his death on 19.3.18;
(b) Inadequate completion of the Caremap within the ACCT document , which ought to have highlighted the issues behind Mr. Kirsch's concerning behaviour and suicide attempts in January 2018, and identified actions to be taken to try to address those issues. In this case, evidence was heard that:
(i) When he had first started his sentence in 2008, Mr. Kirsch had told people that he would not live to complete it;
(ii) In August 2017 he had had two notable episodes of bizarre behaviour which, it was thought, may have been down to having taken the psychoactive substance Spice on those occasions;
(iii) Evidence from staff who had witnessed the suicide attempts in January 2018 indicated that they thought he may have taken Spice on those occasions;
(iv) Throughout 2017 and early 2018 he had been rather obsessed with a complaint he had made about an entry on his NOMIS record, and that in the days leading up to his death he had reported that this had been keeping him up at night;
(v) He was concerned that his daughter, who had become an adult relatively recently, had not tried to make contact with him;
(vi) He was worried about visits from his family, and how he was going to tell them what he had done in January 2018;
(vii) He had been involved in a fight on 13.3.18 with another prisoner (something out of character for him), which had resulted in his transfer to another wing, away from a fellow prisoner who was an important part of his support network;
(viii) He had recently sought out a member of the healthcare team in tears, because he was worried that he had not been able to get across his version of events in the adjudication hearing held after the fight incident;
(ix) On the afternoon of his death, two fellow prisoners had expressed concerns to a Supervising Officer that Mr. Kirsch was "looking particularly down" and was not himself. This conversation was passed on to the Supervising Officer on Mr. Kirsch's wing who spoke to him. In that conversation, Mr. Kirsch made a concerning comment about having bitten someone, and denied (untruthfully) that he had had any involvement with the mental health team at the prison. These concerns and conversations were not recorded anywhere in the main body of the ACCT document.
Save for the fact of the fight on 13.3.18 and of his resulting transfer to another wing, none of these matters was noted in the Caremap on Mr. Kirsch's ACCT document, and so no actions were identified to try to address them .
(c) The ACCT document was opened on 20.1.18. Between then and 5.2.18 Mr. Kirsch had been receiving treatment for his injuries in hospital, and had been on constant bedwatch there. When he returned to the prison on 5.2.18, no entries were made to the Caremap at all for the first four weeks thereafter .
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accountable sign-off of ACCT Caremaps
Wider context from the report “(2) The person whose name had been entered as Case Manager on the ACCT document ████████ confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it. More worryingly, another unknown person appears to have signed off the first page of the Caremap using ████████ initials .
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the designated Case Manager about ACCT documents
Wider context from the report “(2) The person whose name had been entered as Case Manager on the ACCT document ████████ confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it . More worryingly, another unknown person appears to have signed off the first page of the Caremap using ████████ initials.
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate open ACCT documents in accordance with policy
Wider context from the report “(3) Despite the ACCT document having been open for more than 6 weeks, it was not escalated to a more senior member of staff, as per prison policy .
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer knowledge of ACCT reasons and monitoring issues
Wider context from the report “(4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document being opened, and of the issues set out therein which needed to be monitored . By way of example:
(a) the Supervising Officer on Mr. Kirsch's wing who had the conversation with him described at 1(b)(ix) above, was not aware that DK had attempted suicide twice in January 2018 , and had not realised that Mr. Kirsch was being untruthful about his involvement with the mental health team;
(b) another Supervising Officer who had conducted an earlier ACCT review on 8.2.18 also conceded in evidence that at the time he conducted the review he had "probably not" had any idea about the two suicide attempts the previous month .
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct direct assessment of suicide and self-harm risk during ACCT reviews
Wider context from the report “(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self-harm . When asked how he had proposed to assess Mr. Kirsch's level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation .
” Open source report
12 Dec 2017 Sidonio Eugenio TEIXEIRA · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 6 Lack of ongoing audit View source Ineffective reporting View source Inadequacy of intelligence View source Inappropriateness of analysis View source Failure to share lessons with appropriate staff View source Inadequate training of analysts View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sidonio Eugenio TEIXEIRA · 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
Sidonio Eugenio TEIXEIRA was murdered in prison by another prisoner. Inquest concerns included the adequacy of intelligence, reporting, analysis and analyst training, ongoing audit, and the sharing of lessons from a critical internal report with appropriate 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing audit
Wider context from the report “(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit .
These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff.
(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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Ineffective reporting
Wider context from the report “(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting , the appropriateness of analysis, the training of analysts and the need for ongoing audit.
These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff.
(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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of intelligence
Wider context from the report “(1) : issues arose in the course of the inquest regarding the adequacy of intelligence , the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit.
These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff.
(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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Inappropriateness of analysis
Wider context from the report “(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis , the training of analysts and the need for ongoing audit.
These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff.
(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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to share lessons with appropriate staff
Wider context from the report “(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit.
These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff .
(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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of analysts
Wider context from the report “(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit.
These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff.
(2)
(3)
” Open source report
15 Oct 2014 Severyn Witold Glowinski · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Lack of knowledge among Senior Custodial Managers of segregation transfer requirements View source Failure to ensure accurate documentation for review and authorisation of further segregation detention View source Delays in commencing risk assessments for proposed relocation from segregation View source Failure to communicate plans for the management and potential relocation of segregated individuals View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Severyn Witold Glowinski · 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
Severyn Witold Glowinski, a serving prisoner diagnosed with paranoid schizophrenia, was transferred to segregation and remained there for a little under a fortnight. He was found hanging in his cell on the evening of 3 July 2013 while subject to an open ACCT for self-harm. Concerns included poor communication about his care plan, inaccurate paperwork copied from another prisoner’s file, and a lack of awareness of requirements concerning the segregation of prisoners on an open ACCT.
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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge among Senior Custodial Managers of segregation transfer requirements
Wider context from the report “(3) The Senior Custodial Managers in the wing were unaware of the requirements of prison service orders which meant that an individual on an open ACCT should not be transferred to segregation unless there were exceptional reasons for doing so.
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate documentation for review and authorisation of further segregation detention
Wider context from the report “(2) The documents to review and authorise his further detention in the Segregation Unit were completed by the way of "cutting and pasting" from other prisoner's files. It was clear that the information on Mr Glowinski's paperwork was incorrect and had been transposed from another prisoner.
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing risk assessments for proposed relocation from segregation
Wider context from the report “(1) There appeared to be no communication between the Residential Wing and the Segregation Unit as to the plan for Mr Glowinski. It appeared that the Segregation staff were unaware that the wing staff wanted to have him risk assessed for a move to another location and in fact the risk assessment was not commenced until the day before his death .
” 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 Long Lartin Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate plans for the management and potential relocation of segregated individuals
Wider context from the report “(1) There appeared to be no communication between the Residential Wing and the Segregation Unit as to the plan for Mr Glowinski. It appeared that the Segregation staff were unaware that the wing staff wanted to have him risk assessed for a move to another location and in fact the risk assessment was not commenced until the day before his death.
” 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