PFD report

Michelle Barnes · Prevention of Future Deaths report

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Issued 24 Dec 2016•County Durham and Darlington

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to specify and plan the support to be offered by staff
  2. Failure to open an ACCT for a person likely to be upset
    Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Remind ACCT case managers to open and accurately record ACCT documents and use multidisciplinary reviews when prisoners are at risk.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
  2. Action

    Issue guidance and provide refresher training on delivering difficult news to prisoners with children or babies.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 24 October 2016.
  3. Action

    Hold multidisciplinary pregnancy pathway meetings, develop post-birth care plans, and allocate a continuity-of-care coordinator for each pregnant prisoner.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    ACCT is intended for identified suicide or self-harm risk, while general distress is addressed through other existing support mechanisms.

    Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to specify and plan the support to be offered by staff

Wider context from the report

“After the prisoner made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those officers, chose not to open an ACCT, notwithstanding she described Michelle as being very upset and crying but instead made an entry in the wing observation book that staff were to “offer support”. It should have been clear to all that Michelle was likely to be upset upon receiving such news. Nothing was documented to indicate or to explain what “support” could or should be offered by staff. There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to open an ACCT for a person likely to be upset

Wider context from the report

“After the prisoner made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those officers, chose not to open an ACCT, notwithstanding she described Michelle as being very upset and crying but instead made an entry in the wing observation book that staff were to “offer support”. It should have been clear to all that Michelle was likely to be upset upon receiving such news. Nothing was documented to indicate or to explain what “support” could or should be offered by staff. There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence. ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Remind ACCT case managers to open and accurately record ACCT documents and use multidisciplinary reviews when prisoners are at risk.

Verbatim wording from the response

“ACCT case managers at Low Newton were reminded in November 2016 of the importance of opening an ACCT document when a prisoner is at risk of suicide or self-harm, and the importance of recording this accurately and clearly, and making sure there is a multi-disciplinary approach to ACCT reviews.”

Source location

Michelle-Barnes-R
Page 2 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue guidance and provide refresher training on delivering difficult news to prisoners with children or babies.

Verbatim wording from the response

“It is fully recognised that thorough consideration must be given to how distressing news is given to prisoners in such situations, and appropriate action has been taken to ensure that this is appropriately undertaken in the future. Guidance was issued to Low Newton staff in December 2016 about the procedures for delivering difficult news to prisoners with children or babies. Where the mother is pre-natal it instructs staff who are informed of potentially upsetting news to refer this to the pregnancy pathway to ensure that the appropriate staff member, who is known to the prisoner and best placed to deliver the news, is involved. The decision on the timing and delivery of the message will initially be made by the Duty Governor. Annual Refresher Safer Custody training provided to staff includes the new guidelines on delivering difficult news to mothers of babies or young children.”

Source location

Michelle-Barnes-R
Page 2 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Hold multidisciplinary pregnancy pathway meetings, develop post-birth care plans, and allocate a continuity-of-care coordinator for each pregnant prisoner.

Verbatim wording from the response

“The needs of pregnant women are considered at the weekly, multi-disciplinary pregnancy pathway meetings. Attendees are responsible for drawing up and reviewing a care plan for each pregnant woman, detailing what will happen after the birth and how the mother will be supported emotionally and practically, particularly if their baby is removed from their care. The care plan will take into account input from a number of professions, ensuring the most appropriate care plan is put into place for mother and baby. A lead co-ordinator, already familiar with the prisoner, is allocated to support the prisoner throughout the pregnancy, providing continuity of care and ensuring an understanding of their individual circumstances.”

Source location

Michelle-Barnes-R
Page 2 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue and disseminate national guidance on multidisciplinary working and ACCT to support continuity of care.

Verbatim wording from the response

“In order to improve joined-up working to manage and support prisoners at risk of suicide or self-harm, new guidance around multi-disciplinary working and ACCT was issued by NOMS in October 2016 and disseminated to all prisons. The guidance aims to ensure that professionals carefully consider a prisoner’s needs and that they are provided with continuity of care, even when support will be delivered by different individuals or providers.”

Source location

Michelle-Barnes-R
Page 3 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

ACCT is intended for identified suicide or self-harm risk, while general distress is addressed through other existing support mechanisms.

Verbatim wording from the response

“You express concern that safer custody practices do not consider prisoners in a holistic manner. As you are aware, prisoners considered at risk of suicide and self-harm are managed through the ACCT process. The review of ACCT process undertaken in 2015, found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. It is recognised that when used effectively ACCT is a holistic tool, bringing together multi-disciplinary teams to contribute to the management of an individual’s risk, which may include mental health concerns, substance abuse and a range of other factors. The other support mechanisms described above also form part of the holistic approach, alongside everyday interaction, support and challenge by staff.”

Source location

Michelle-Barnes-R
Page 3 · response
Published 24 October 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Introduce and update the pregnancy pathway to guide pregnancy, birth, hospital escort and mental health support arrangements.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
  2. 2

    Review continuity of mental-health provision across the women’s estate and produce prison-specific action plans under senior oversight.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 24 October 2016.
  3. 3

    Review birthing-plan arrangements across the female prison estate.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
  4. 4

    Review systems so local-authority contributions are considered at the outset of Mother and Baby Unit applications.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
  5. 5

    Update the local suicide and self-harm policy to address safer-custody risks for pregnant prisoners before and after delivery.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
  6. 6

    Introduce a weekly complex-case risk register for multidisciplinary discussion of patients with complex mental or physical needs.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
  7. 7

    Invite physical and mental health staff to daily senior management meetings, and record attendees and minutes.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing birthing plan arrangements across the female estate are considered appropriate and are being implemented appropriately.

    Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce and update the pregnancy pathway to guide pregnancy, birth, hospital escort and mental health support arrangements.

Verbatim wording from the response

“As you will be aware from the inquest, the birthing plan arrangements at Low Newton have now been replaced by the pregnancy pathway which was introduced in May 2016, and updated in October to include mental health provision. This pathway provides clear guidance to staff on a range of issues, including how to support a prisoner during her pregnancy, the parameters of contact between the mother and her baby and who can be present at the birth. It also provides clear guidance to staff escorting women to hospital for the purpose of giving birth.”

Source location

Michelle-Barnes-R
Page 1 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review continuity of mental-health provision across the women’s estate and produce prison-specific action plans under senior oversight.

Verbatim wording from the response

“I have been copied to the response from the Tees, Esk and Wear Valley NHS Foundation Trust concerning the continuity of mental health care when healthcare staff are absent so I will not repeat that information here. However, I can confirm that there is currently a review of continuity of mental health provision across the women’s estate. Work is ongoing to produce an action plan for each prison which will identify further progress required, the delivery of which will be overseen by the Deputy Director of Custody for the women’s estate. A Safer Custody summit meeting for the women’s estate is taking place on 1 February 2017, at which mental health provision will be one of the topics discussed.”

Source location

Michelle-Barnes-R
Page 3 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review birthing-plan arrangements across the female prison estate.

Verbatim wording from the response

“In response to your concern that birthing arrangements in other establishments are appropriate, I can confirm NOMS conducted a review of birthing plan arrangements across the female estate and is confident that these are being implemented appropriately.”

Source location

Michelle-Barnes-R
Page 2 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review systems so local-authority contributions are considered at the outset of Mother and Baby Unit applications.

Verbatim wording from the response

“Systems have also been reviewed to ensure that contributions from the local authority are carefully considered at the outset when reviewing applications to the Mother and Baby Unit to ensure appropriate decision making. The care plan further supports pregnant women by assisting them to access legal advice where they are contesting local authority decisions regarding care proceedings.”

Source location

Michelle-Barnes-R
Page 2 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the local suicide and self-harm policy to address safer-custody risks for pregnant prisoners before and after delivery.

Verbatim wording from the response

“Additionally, in November 2016 Low Newton updated its local policy on suicide and self-harm to take into consideration and place additional emphasis on safer custody issues surrounding pregnant prisoners, before and post-delivery, taking into account the potential risks associated with their baby being taken into care.”

Source location

Michelle-Barnes-R
Page 2 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce a weekly complex-case risk register for multidisciplinary discussion of patients with complex mental or physical needs.

Verbatim wording from the response

“In May 2016, Low Newton introduced a ‘complex case risk register’ to ensure that patients with complex mental or physical needs were discussed on a weekly basis by members of the multi-disciplinary team. This is comprised of staff from Tees, Esk and Wear Valleys NHS Foundation Trust, G4S, and DART as well as operational staff.”

Source location

Michelle-Barnes-R
Page 4 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Invite physical and mental health staff to daily senior management meetings, and record attendees and minutes.

Verbatim wording from the response

“I would like reassure you that in response to the matters raised in your report, the Governing Governor has taken action to ensure that both physical and mental health staff are invited to attend the daily senior management meetings. Since November 2016, these meetings have been minuted, with attendees recorded. Additionally, the prison’s Healthcare Governance Board is held bi-monthly and attended by representatives from dentistry, GP, mental health, nursing and pharmacy services as well as physical healthcare.”

Source location

Michelle-Barnes-R
Page 1 · response
Published 24 October 2016

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing birthing plan arrangements across the female estate are considered appropriate and are being implemented appropriately.

Verbatim wording from the response

“In response to your concern that birthing arrangements in other establishments are appropriate, I can confirm NOMS conducted a review of birthing plan arrangements across the female estate and is confident that these are being implemented appropriately.”

Source location

Michelle-Barnes-R
Page 2 · response
Published 24 October 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026