PFD report

Carl John Newman · Prevention of Future Deaths report

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Issued 6 Mar 2020•Liverpool and the Wirral

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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. Lack of ready access to prison staff training records
    Part of recurring concern: Failure to maintain training records that verify staff competencePart of recurring concern: Ineffective prison suicide and self-harm prevention systems
  2. Failure to ensure current ACCT and safer custody process training for prison staff
    Part of recurring concern: Ineffective prison suicide and self-harm prevention systems
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

    Update ACCT-related training packages and refresh the broader safety-training approach to reduce duplication and align content.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 March 2020.
  2. Action

    Issue a staff information notice promoting myLearning access and reminding staff about refresher-training requirements.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
  3. Action

    Provide local training coordination to assist staff and ensure attendance at required refresher training.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.

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

  1. Position

    The myLearning database provides outcomes equivalent to certificates with expiry dates for recording and monitoring staff training.

    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

Lack of ready access to prison staff training records

Wider context from the report

“During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training. As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience. What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes? ”

Is this part of a recurring concern?

Yes — Failure to maintain training records that verify staff competence; Ineffective prison suicide and self-harm prevention systems.

Open source report

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 ensure current ACCT and safer custody process training for prison staff

Wider context from the report

“During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training. As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience. What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes? ”

Is this part of a recurring concern?

Yes — Ineffective prison suicide and self-harm prevention systems.

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

Update ACCT-related training packages and refresh the broader safety-training approach to reduce duplication and align content.

Verbatim wording from the response

“As you know, we intend to roll out a new version of the ACCT case management system soon, and we will be taking this opportunity to update the related training packages, and to refresh our approach to safety training more broadly. This will allow us to reduce duplication between courses whilst ensuring that the content is consistent and makes appropriate links between related issues. As we develop this new set of training materials we will ensure that expectations as to which staff should attend which courses, and the frequency of refresher training, are clear.”

Source location

2020-0056-Response-from-Director-General-of-Prisons
Page 2 · response
Published 18 March 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

Issue a staff information notice promoting myLearning access and reminding staff about refresher-training requirements.

Verbatim wording from the response

“As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.”

Source location

2020-0056-Response-from-Director-General-of-Prisons
Page 2 · response
Published 18 March 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

Provide local training coordination to assist staff and ensure attendance at required refresher training.

Verbatim wording from the response

“As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.”

Source location

2020-0056-Response-from-Director-General-of-Prisons
Page 2 · response
Published 18 March 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

Provide a comprehensive guide explaining how staff can use myLearning to access personal training records.

Verbatim wording from the response

“As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.”

Source location

2020-0056-Response-from-Director-General-of-Prisons
Page 2 · response
Published 18 March 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 myLearning database provides outcomes equivalent to certificates with expiry dates for recording and monitoring staff training.

Verbatim wording from the response

“on successful completion of the training, their record is updated to reflect their attendance (and pass/fail outcome for some courses). Both the learner themselves and the local training department have access to this record. Training departments are also able to run a report to see who has attended and/or passed a particular course, and when. We consider that this electronic system achieves the same outcomes as the system of certificates with expiry dates that you mention in your letter.”

Source location

2020-0056-Response-from-Director-General-of-Prisons
Page 2 · response
Published 18 March 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

    Roll out a new version of the ACCT case management system.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 March 2020.
  2. 2

    Share learning from the incident widely across the prison estate.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 18 March 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

Roll out a new version of the ACCT case management system.

Verbatim wording from the response

“As you know, we intend to roll out a new version of the ACCT case management system soon, and we will be taking this opportunity to update the related training packages, and to refresh our approach to safety training more broadly. This will allow us to reduce duplication between courses whilst ensuring that the content is consistent and makes appropriate links between related issues. As we develop this new set of training materials we will ensure that expectations as to which staff should attend which courses, and the frequency of refresher training, are clear.”

Source location

2020-0056-Response-from-Director-General-of-Prisons
Page 2 · response
Published 18 March 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

Share learning from the incident widely across the prison estate.

Verbatim wording from the response

“Thank you again for bringing these matters of concern to my attention. We will ensure that learning from this tragic incident is shared widely across the prison estate.”

Source location

2020-0056-Response-from-Director-General-of-Prisons
Page 2 · response
Published 18 March 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