Sirona care & health C.I.C.

Private and voluntary organisations · Community interest company

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First report 7 Jun 2017•Latest report 21 May 2018

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
2

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

  1. Addressed to Bristol Community Health C.I.C., now represented here by Sirona care & health C.I.C..

    Avon

    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

  2. Addressed to Bristol Community Health C.I.C., now represented here by Sirona care & health C.I.C..

    Avon

    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
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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