Recipient

Sirona care & health C.I.C.

First report 7 Jun 2017•Latest report 21 May 2018

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Community interest company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Sirona care & health C.I.C. linked to the concerns in each report. Select any concern, action or position to view the source wording.

21 May2018
Avon
Concerns raised4
1. Failure to make detoxification observations available to medication-administering staff at medication dispensing
2. Failure to assign handover responsibility to a registered nurse
3. Failure to include all prisoners/patients undergoing detoxification in handover
1. Failure to review shift records during handover
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

Michalla Jane SWEETING · 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

Michalla Jane Sweeting was a remand prisoner undergoing detoxification who was found unresponsive in her cell at 07.00hrs on 2nd June 2016. The medical cause of death was aspiration of gastric content in association with methadone toxicity. Concerns included inadequate response to reported over-sedation, unsatisfactory handover between shifts, inadequate clinical observations, and failures in communication and assessment.

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 Sirona care & health C.I.C.; that does not assign responsibility.
PFD Monitor interpretation
Failure to make detoxification observations available to medication-administering staff at medication dispensing
Wider context from the report
“2. Observations to prisoners/patients undergoing detoxification: they are taken at a time which is close to the time of dispensing medications so that the staff administering the medication have that information. Again this was raised by ████████ as being the best time to review the observations and was indeed reflected in the jury conclusion. ”
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 Sirona care & health C.I.C.; that does not assign responsibility.
PFD Monitor interpretation
Failure to assign handover responsibility to a registered nurse
Wider context from the report
“1. Handover: a. That the handover includes all prisoners/patients undergoing detoxification. b. That the handover is the responsibility of the registered nurse c. That it includes a review of the records for the shift by that registered nurse – this was raised by ████████ and was reflected in the jury conclusion. I therefore report this to you for your consideration in preventing future deaths ”
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 Sirona care & health C.I.C.; that does not assign responsibility.
PFD Monitor interpretation
Failure to include all prisoners/patients undergoing detoxification in handover
Wider context from the report
“1. Handover: a. That the handover includes all prisoners/patients undergoing detoxification. b. That the handover is the responsibility of the registered nurse c. That it includes a review of the records for the shift by that registered nurse – this was raised by ████████ and was reflected in the jury conclusion. I therefore report this to you for your consideration in preventing future deaths ”
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 Sirona care & health C.I.C.; that does not assign responsibility.
PFD Monitor interpretation
Failure to review shift records during handover
Wider context from the report
“1. Handover: a. That the handover includes all prisoners/patients undergoing detoxification. b. That the handover is the responsibility of the registered nurse c. That it includes a review of the records for the shift by that registered nurse – this was raised by ████████ and was reflected in the jury conclusion. I therefore report this to you for your consideration in preventing future deaths ”
Open source report
7 Jun2017
Avon
Concerns raised2
1. Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment
2. Inadequate training of healthcare/mental healthcare staff on the ACCT process
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

Callum Oliver 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

Callum Oliver SMITH was in the care of HMP Bristol when he was found hanging in his cell and died from hanging. The inquest concluded that his death was caused by suicide while he was suffering extreme anxiety and distress. Concerns included inadequate risk assessment and mental health assessment, poor communication and record-sharing, and repeated failures to open an ACCT due to training and staff-understanding issues.

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 Sirona care & health C.I.C.; that does not assign responsibility.
PFD Monitor interpretation
Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment
Wider context from the report
“1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011. 2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011. 3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide. 4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff. ”
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 Sirona care & health C.I.C.; that does not assign responsibility.
PFD Monitor interpretation
Inadequate training of healthcare/mental healthcare staff on the ACCT process
Wider context from the report
“1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011. 2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011. 3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide. 4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Failure to make detoxification observations available to medication-administering staff at medication dispensing

Failure to assign handover responsibility to a registered nurse

Failure to include all prisoners/patients undergoing detoxification in handover

Failure to review shift records during handover

Concerns raised2

Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment

Inadequate training of healthcare/mental healthcare staff on the ACCT process