PFD report

Thomas Daniel RUGGIERO · Prevention of Future Deaths report

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Issued 24 Mar 2026•Kent and Medway

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 raised1

  1. Failure to secure attendance of the mental health team at required ACCT reviews
    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.7

  1. Action

    Revise mental-health staffing rotas to provide skilled practitioners during peak ACCT review periods.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  2. Action

    Run a daily multidisciplinary safety huddle to review ACCT patients, prioritise reviews, escalate risks, allocate actions and share information.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  3. Action

    Audit healthcare attendance at ACCT reviews and oversee compliance through clinical governance, PSIRF, risk-register and executive assurance arrangements.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.

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 secure attendance of the mental health team at required ACCT reviews

Wider context from the report

“(1) There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews. In this case, there were numerous instances that this was not met. While I heard evidence of some improvement, it was accepted that there were ongoing issues with securing the attendance of the mental health team (where required) at ACCT reviews. I was insufficiently reassured that the matter has been addressed and I consider that there is ongoing risk to particularly vulnerable prisoners for whom the ACCT processes should act as a safety-net and protective factor. ”

Is this part of a recurring concern?

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

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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

Revise mental-health staffing rotas to provide skilled practitioners during peak ACCT review periods.

Verbatim wording from the response

“In December 2024, a review of the mental health staffing model at HMP Swaleside was undertaken to strengthen the service's capacity to consistently attend and contribute to ACCT reviews. This review identified gaps in aligning staff availability with periods of higher ACCT demand. In response, revised rota arrangements were introduced, ensuring that appropriately skilled mental health practitioners are available during peak activity times, particularly during core ACCT review periods. This adjustment has improved responsiveness, reduced delays in attendance, and supported more consistent multidisciplinary input into risk management planning.”

Source location

Response from Oxleas NHS FT
Page 2 · response
Published 26 March 2026

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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

Run a daily multidisciplinary safety huddle to review ACCT patients, prioritise reviews, escalate risks, allocate actions and share information.

Verbatim wording from the response

“In January 2025, a structured daily safety huddle was introduced at HMP Swaleside, providing a formal mechanism for real-time oversight and coordination of high-risk patients. The huddle is held each morning and is attended by key members of the multidisciplinary team, including mental health, primary care, substance misuse, and operational leads where required. During the huddle, the team reviews all patients subject to ACCT, as well as any other individuals identified as presenting an elevated or emerging risk. The daily huddle includes:”

Source location

Response from Oxleas NHS FT
Page 2 · response
Published 26 March 2026

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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

Audit healthcare attendance at ACCT reviews and oversee compliance through clinical governance, PSIRF, risk-register and executive assurance arrangements.

Verbatim wording from the response

“Healthcare attendance at ACCT reviews is now subject to routine audit, with results reviewed through local clinical governance forums and within the Trust's Patient Safety Incident Response Framework (PSIRF) oversight structures. This is overseen by the head of healthcare and compliance is actively monitored, with any identified gaps followed up through targeted action plans. This area has also been incorporated into the Trust's risk register, with appropriate executive oversight in place.”

Source location

Response from Oxleas NHS FT
Page 3 · response
Published 26 March 2026

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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 an escalation and contingency process for missed healthcare attendance, including senior notification, alternative staffing, documentation and risk mitigation.

Verbatim wording from the response

“A formalised escalation and contingency process has been introduced to address occasions where healthcare attendance cannot be secured. This requires immediate notification to senior clinical leads, consideration of alternative appropriately qualified staff where feasible, and clear documentation of the rationale for non-attendance, alongside any mitigating actions taken to manage risk.”

Source location

Response from Oxleas NHS FT
Page 2 · response
Published 26 March 2026

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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

Circulate and embed the Kent ACCT Standard Operating Procedure through local induction and mandatory training, including exceptional non-attendance requirements.

Verbatim wording from the response

“In June 2025 the Kent ACCT Standard Operating Procedure was circulated and sets out clear guidance to all healthcare staff to reinforce expectations regarding attendance at ACCT reviews. This includes clarification of when mental health team involvement is required and the actions that must be taken if attendance cannot be achieved. The Standard Operating Procedure reiterates that a telephone or written contribution must be provided in exceptional circumstances when healthcare staff cannot attend. This updated guidance has been embedded within local induction processes and incorporated into mandatory training to support consistent understanding and application.”

Source location

Response from Oxleas NHS FT
Page 2 · response
Published 26 March 2026

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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

Strengthen forward planning for high-risk ACCT cases and monitor healthcare representation through daily operational meetings.

Verbatim wording from the response

“Multi-disciplinary working between healthcare and prison staff has been further strengthened through improved communication arrangements, particularly in relation to the scheduling of ACCT reviews. A daily tracker is circulated each evening by the prison safety team, clearly identifying individuals due for ACCT review the following day, which is then reinforced and actioned through the daily huddles. Any discrepancies are promptly identified and escalated to ensure timely resolution. Enhanced forward planning is now in place for high-risk individuals, and mental health representation at case reviews is actively monitored and supported through daily operational meetings.”

Source location

Response from Oxleas NHS FT
Page 3 · response
Published 26 March 2026

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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

Disseminate learning across offender healthcare through reflective practice sessions reinforcing healthcare input in ACCT processes.

Verbatim wording from the response

“Finally, learning from this case has been disseminated across the Offender healthcare directorate. Reflective practice sessions have been undertaken with clinical teams to reinforce the importance of healthcare input within ACCT processes. Ongoing monitoring arrangements are in place to ensure that these improvements are embedded and sustained overtime.”

Source location

Response from Oxleas NHS FT
Page 3 · response
Published 26 March 2026

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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