Samaritans

Private and voluntary organisations · Registered charity

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First report 4 Oct 2016•Latest report 4 Oct 2016

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
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Central Hampshire

    AI-generated summary

    Haydn James Burton · 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

    Haydn James Burton, a prisoner at HMP Winchester, was found suspended from a ligature point in his cell on 15 July 2015 and died in hospital on 18 July 2015 from the delayed effects of ligature suspension. The concerns included inadequate implementation of ACCT plans and observations, uncertainty about confidentiality rules in the Prison Listener scheme, and limitations in recording and communicating information about closed ACCT plans.

    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 Samaritans; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement ACCT plans in accordance with national policy

    Wider context from the report

    “(1) The evidence in this case indicated that prison staff at Winchester Prison are not implementing ACCT plans in accordance with national policy notwithstanding the training they have received and in particular the observations conducted are inadequate. I therefore consider that the process and future training needs to be reviewed ”
    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 Samaritans; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate observations under ACCT plans

    Wider context from the report

    “(1) The evidence in this case indicated that prison staff at Winchester Prison are not implementing ACCT plans in accordance with national policy notwithstanding the training they have received and in particular the observations conducted are inadequate. I therefore consider that the process and future training needs to be reviewed ”
    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 Samaritans; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to train Listeners to pass information about imminent suicide risk to prison staff

    Wider context from the report

    “(2) The Prison Listener scheme rules as to prisoner confidentiality appeared to be confusing to the listener involved in this case. The HMP Winchester Listener Scheme Protocol dated October 2012 makes no reference to situations where an “at risk” prisoner admits to having made active plans for suicide and threatens to self harm in the future (as in this case). I consider the protocol for Listeners should make it another exception to the principle of confidentiality so that they can pass such information to prison staff and that Listeners should be trained to do so if they have reason to believe there is an imminent risk of suicide even if the prisoner is already subject to an ACCT. ”
    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 Samaritans; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make Case Notes for all ACCT plans

    Wider context from the report

    “(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously. The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it. The ACCT post-closure process should therefore be reviewed. I consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment. ”
    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 Samaritans; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the Listener Scheme protocol to specify an exception to confidentiality for imminent suicide risk

    Wider context from the report

    “(2) The Prison Listener scheme rules as to prisoner confidentiality appeared to be confusing to the listener involved in this case. The HMP Winchester Listener Scheme Protocol dated October 2012 makes no reference to situations where an “at risk” prisoner admits to having made active plans for suicide and threatens to self harm in the future (as in this case). I consider the protocol for Listeners should make it another exception to the principle of confidentiality so that they can pass such information to prison staff and that Listeners should be trained to do so if they have reason to believe there is an imminent risk of suicide even if the prisoner is already subject to an ACCT. ”
    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 Samaritans; that does not assign responsibility.

    PFD Monitor interpretation

    Limitations of the NOMIS database in recording details of closed ACCT plans

    Wider context from the report

    “(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously. The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it. The ACCT post-closure process should therefore be reviewed. I consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment. ”
    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