Samuel William Gale · Prevention of Future Deaths report

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Issued 23 Oct 2015•South Yorkshire (Eastern)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
2

Of 2 recipients

Stated actions
6

Described in responses

Recipients and published responses

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. Lack of a formalised objective risk assessment process throughout the prison estate
  2. Failure to consult relevant healthcare, chaplaincy, unit management or ACCT review officers before closing an ACCT
    Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Serco Home Affairs

    Move to a nominated-case-manager model to improve continuity and enable more frequent reviews by the same manager.

  2. Serco Home Affairs

    Restrict ACCT closure authority to manager-grade staff.

  3. Serco Home Affairs

    Limit Case Manager roles to manager-grade staff.

  4. Serco Home Affairs

    Require ACCT closure reviews to involve at least two people and completion of all CAREMAP actions.

  5. NHS England

    Review national templates, including first-night screening and risk assessment, with the relevant information and clinical reference organisations.

  6. NHS England

    Deploy and roll out the new Health & Justice Information System to all sites, including any new national templates, with full functionality planned by July 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Serco Home Affairs

    Staff sickness, annual leave and lost days make limiting ACCT closure to the primarily responsible person impractical.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. Serco Home Affairs

    Limiting ACCT closure to the primarily responsible person may reduce scrutiny and support in ways detrimental to prisoner wellbeing.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Lack of a formalised objective risk assessment process throughout the prison estate

Wider context from the report

“(2) The importance of an objective risk assessment has been recognised by the Trust which now uses a mandatory risk assessment from on System One. It is understood that NHS England is in the process of procuring a new version of System One, and is invited to consider whether this procurement exercise provided an opportunity for formalising the risk assessment process throughout the prison estate nationally. ”

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 consult relevant healthcare, chaplaincy, unit management or ACCT review officers before closing an ACCT

Wider context from the report

“i) The ACCT was closed by a person who had previous dealings with Samuel without reference to healthcare, the chaplaincy or a unit manager or any officer who had carried out an ACCT review. ii) The Deputy Director was asked to consider whether only the person who is primarily responsible for a prisoner’s ACCT should be the one to close it. ”

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

Move to a nominated-case-manager model to improve continuity and enable more frequent reviews by the same manager.

Verbatim wording from the response

“Staff sickness, annual leave and lost days also render this impractical. Notwithstanding this, HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved resulting in case reviews being completed by the same manager on a more frequent basis. The timing for completion of this objective is by June 2016.”

Source location

2015-0454-Response-by-Serco
Page 2 · response
Published 23 October 2015

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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

Restrict ACCT closure authority to manager-grade staff.

Verbatim wording from the response

“a) Policy changes have been made since this incident so that only a manager grade can close an ACCT.”

Source location

2015-0454-Response-by-Serco
Page 1 · response
Published 23 October 2015

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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

Limit Case Manager roles to manager-grade staff.

Verbatim wording from the response

“b) Case Managers will comprise of manager grades only.”

Source location

2015-0454-Response-by-Serco
Page 1 · response
Published 23 October 2015

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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

Require ACCT closure reviews to involve at least two people and completion of all CAREMAP actions.

Verbatim wording from the response

“c) ACCT cannot be closed unless the case review comprises of at least two people and all the actions on the CAREMAP have been completed.”

Source location

2015-0454-Response-by-Serco
Page 1 · response
Published 23 October 2015

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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

Review national templates, including first-night screening and risk assessment, with the relevant information and clinical reference organisations.

Verbatim wording from the response

“The new Health & Justice Information System will be a national system for the residential estate and as part of the deployment we are working with the Health and Social Care Information Centre and NHS England Clinical Reference Group to review a number of templates and first night screening and risk assessment is one of these templates.”

Source location

2015-0454-Response-by-NHS-England
Page 1 · response
Published 23 October 2015

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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

Deploy and roll out the new Health & Justice Information System to all sites, including any new national templates, with full functionality planned by July 2017.

Verbatim wording from the response

“The timeline for the work is that from July 2016 NHS England will be undertaking the deployment and roll out to all sites of the new system, with an expectation that the full functionality will be in place by July 2017. This will include the roll out of any new national templates.”

Source location

2015-0454-Response-by-NHS-England
Page 1 · response
Published 23 October 2015

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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

Staff sickness, annual leave and lost days make limiting ACCT closure to the primarily responsible person impractical.

Verbatim wording from the response

“Staff sickness, annual leave and lost days also render this impractical. Notwithstanding this, HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved resulting in case reviews being completed by the same manager on a more frequent basis. The timing for completion of this objective is by June 2016.”

Source location

2015-0454-Response-by-Serco
Page 2 · response
Published 23 October 2015

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

Limiting ACCT closure to the primarily responsible person may reduce scrutiny and support in ways detrimental to prisoner wellbeing.

Verbatim wording from the response

“d) It would be impractical to implement a process whereby only the person who is primarily responsible for a prisoner’s ACCT should be the one to close it. Such action may leave a prisoner under a level of scrutiny and support that is not conducive to a prisoner’s ongoing wellbeing.”

Source location

2015-0454-Response-by-Serco
Page 1 · response
Published 23 October 2015

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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