PFD report

Marlon Roy WATSON · Prevention of Future Deaths report

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Issued 14 Jan 2020•Staffordshire South

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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. Lack of full and proper understanding of the ACCT process among healthcare staff
    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.2

  1. Action

    Request the prison to provide additional ACCT and refresher training for the GP and all healthcare staff within 12 weeks.

    Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
  2. Action

    Arrange additional ACCT and suicide and self-harm awareness refresher training for the GP and all staff.

    Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.

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

  1. Position

    The prison is responsible for providing ACCT training because ACCT is a prison process.

    Stated by Care UKRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 full and proper understanding of the ACCT process among healthcare staff

Wider context from the report

“1. At the inquest there was a concern that members of healthcare staff at HMP Dovegate do not have a full and proper understanding of the ACCT process. I would appreciate reassurance that appropriate initial training and refresher training takes place and that (if possible) this is audited. ”

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

Request the prison to provide additional ACCT and refresher training for the GP and all healthcare staff within 12 weeks.

Verbatim wording from the response

“Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites.”

Source location

Response from Care UK
Page 2 · response
Published 8 February 2020

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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

Arrange additional ACCT and suicide and self-harm awareness refresher training for the GP and all staff.

Verbatim wording from the response

“Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites.”

Source location

2020-0010-Response-from-HMP-Dovegate-Redacted
Page 2 · response
Published 8 February 2020

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

The prison is responsible for providing ACCT training because ACCT is a prison process.

Verbatim wording from the response

“Assessment, Care in Custody and Teamwork (ACCT) is the care planning process for prisoners identified as being at risk of suicide or self-harm. The ACCT process requires that certain actions are taken to ensure that the risk of suicide and self-harm is reduced. This is a prison process and training is provided by the prison as part of a professional’s induction before they work within the prison. The GP received that training on 25th July, 2018 as part of his induction.”

Source location

Response from Care UK
Page 2 · response
Published 8 February 2020

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 training is a prison process, with delivery assigned to HMP Dovegate rather than Care UK.

Verbatim wording from the response

“Assessment, Care in Custody and Teamwork (ACCT) is the care planning process for prisoners identified as being at risk of suicide or self-harm. The ACCT process requires that certain actions are taken to ensure that the risk of suicide and self-harm is reduced. This is a prison process and training is provided by the prison as part of a professional’s induction before they work within the prison. The GP received that training on 25th July, 2018 as part of his induction.”

Source location

2020-0010-Response-from-HMP-Dovegate-Redacted
Page 2 · response
Published 8 February 2020

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.2

  1. 1

    Implement senior oversight of ACCT and SASH training uptake across all Care UK prison healthcare sites.

    Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.
  2. 2

    Implement senior oversight of ACCT and suicide and self-harm awareness training uptake across Care UK prison healthcare sites.

    Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.

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

Implement senior oversight of ACCT and SASH training uptake across all Care UK prison healthcare sites.

Verbatim wording from the response

“Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites.”

Source location

Response from Care UK
Page 2 · response
Published 8 February 2020

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

Implement senior oversight of ACCT and suicide and self-harm awareness training uptake across Care UK prison healthcare sites.

Verbatim wording from the response

“Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites.”

Source location

2020-0010-Response-from-HMP-Dovegate-Redacted
Page 2 · response
Published 8 February 2020

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