PFD report

Kevin Scarlett · Prevention of Future Deaths report

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Issued 15 Apr 2014•Milton Keynes

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 assess the risk of suicide
    Part of recurring concern: Unreliable assessment of suicide and self-harm risk
  2. Unavailability of a suicide risk assessment tool or protocol
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.2

  1. Action

    Revise the local ACCT case-review process, including enhanced reviews for prisoners with complex needs.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 April 2014.
  2. Action

    Issue staff guidance and notices covering revised ACCT reviews, suicide and self-harm triggers, and learning from recent custody deaths.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 April 2014.

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

  1. Position

    Existing processes are considered comprehensive and effective for identifying and assessing prisoners at risk of suicide or self-harm.

    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 assess the risk of suicide

Wider context from the report

“I felt that the prison service and healthcare did not assess the risk of Mr. Scarlett taking his own life, and I was informed that the staff did not have access to a risk assessment tool or protocol for assessing such risks. ”

Is this part of a recurring concern?

Yes — Unreliable assessment of suicide and self-harm risk.

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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

Unavailability of a suicide risk assessment tool or protocol

Wider context from the report

“I felt that the prison service and healthcare did not assess the risk of Mr. Scarlett taking his own life, and I was informed that the staff did not have access to a risk assessment tool or protocol for assessing such risks. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 the local ACCT case-review process, including enhanced reviews for prisoners with complex needs.

Verbatim wording from the response

“Turning to the circumstances leading up to Mr Scarlett’s death, NOMS accepts the findings of the PPO report and the inquest that, whilst there was an assessment of the risk of suicide or self-harm, this should have been conducted in a more rigorous manner. You may be aware that in response to the PPO’s recommendations in this case, HMP Woodhill reviewed the local ACCT process in December 2013. The case review process was revised, and guidance on this, including the use of enhanced case reviews for prisoners with complex needs, was issued to all staff (see attached staff information notice 027/14, issued in January 2014). Notices have also been issued to remind staff of known triggers and risk factors, and more recently to highlight key learning from recent deaths in custody across the prison estate (see attached staff information notice 073/14, issued in March 2014).”

Source location

2014-0174-Response-by-NOMS
Page 2 · response
Published 15 April 2014

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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

Issue staff guidance and notices covering revised ACCT reviews, suicide and self-harm triggers, and learning from recent custody deaths.

Verbatim wording from the response

“Turning to the circumstances leading up to Mr Scarlett’s death, NOMS accepts the findings of the PPO report and the inquest that, whilst there was an assessment of the risk of suicide or self-harm, this should have been conducted in a more rigorous manner. You may be aware that in response to the PPO’s recommendations in this case, HMP Woodhill reviewed the local ACCT process in December 2013. The case review process was revised, and guidance on this, including the use of enhanced case reviews for prisoners with complex needs, was issued to all staff (see attached staff information notice 027/14, issued in January 2014). Notices have also been issued to remind staff of known triggers and risk factors, and more recently to highlight key learning from recent deaths in custody across the prison estate (see attached staff information notice 073/14, issued in March 2014).”

Source location

2014-0174-Response-by-NOMS
Page 2 · response
Published 15 April 2014

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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

Existing processes are considered comprehensive and effective for identifying and assessing prisoners at risk of suicide or self-harm.

Verbatim wording from the response

“I hope this provides assurance that there is a comprehensive and effective set of systems for identifying that a prisoner is at risk, and that where this occurs a further detailed assessment is undertaken to ensure that all relevant factors are considered and risks identified. Some specific tools, such as the reception healthcare screen, are used, but of necessity they form only a small part of this very broad set of processes.”

Source location

2014-0174-Response-by-NOMS
Page 2 · response
Published 15 April 2014

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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.1

  1. 1

    Appoint a named governor to manage each complex-needs prisoner’s ACCT case and chair reviews.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 April 2014.

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

Appoint a named governor to manage each complex-needs prisoner’s ACCT case and chair reviews.

Verbatim wording from the response

“Under the new arrangements consistency of decision making is achieved through the appointment of a named governor grade to manage the case of each prisoner subject to the ACCT process who is assessed as having complex needs. The case manager chairs each review and ensures that there is joined up management of the case in accordance with the risk management plan, devised in conjunction with the mental health team. Particular attention is given to ensuring that the prisoner is located appropriately (in a safer cell where necessary) and that items retained in possession are consistent with the level of assessed risk and the plan to reduce it.”

Source location

2014-0174-Response-by-NOMS
Page 2 · response
Published 15 April 2014

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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