PFD report

Ryan Patrick John Clark · Prevention of Future Deaths report

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Issued 3 Feb 2014•West Yorkshire (East)

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
11

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 raised4

  1. Failure of the Personal Officer Scheme to operate effectively for trainees
  2. Failure to conduct ACCT checks at the times prescribed by the trainee's ACCT document
  3. Failure of Prison Officers to follow the correct procedure for roll counts of trainees
    Part of recurring concern: Unreliable prison roll-check procedures
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.8

  1. Action

    Brief all staff on the importance of conducting roll checks.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 February 2014.
  2. Action

    Introduce an additional management-check layer for all ACCT documents.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 February 2014.
  3. Action

    Reissue full ACCT guidance to staff.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 February 2014.

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

  1. Position

    The isolated ACCT check failure is not representative of practice at HMP and YOI Wetherby.

    Stated by HM Prison and Probation ServiceDisputes 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

Failure of the Personal Officer Scheme to operate effectively for trainees

Wider context from the report

“At HMYOI Wetherby (1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees; (2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document; (3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers; (4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 conduct ACCT checks at the times prescribed by the trainee's ACCT document

Wider context from the report

“At HMYOI Wetherby (1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees; (2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document; (3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers; (4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 of Prison Officers to follow the correct procedure for roll counts of trainees

Wider context from the report

“At HMYOI Wetherby (1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees; (2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document; (3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers; (4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto. ”

Is this part of a recurring concern?

Yes — Unreliable prison roll-check procedures.

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

Insufficient Prison Officer competence and refresher training in first aid and CPR

Wider context from the report

“At HMYOI Wetherby (1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees; (2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document; (3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers; (4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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

Brief all staff on the importance of conducting roll checks.

Verbatim wording from the response

“Roll Checks The two failures to follow the procedure for roll checks identified in this case have been the subject of investigations, and disciplinary action has been taken against the staff involved. All staff have been briefed on the importance of roll checks, and these are now subject to covert checks by managers. If, following a cover check, there is any doubt as to whether or not a proper roll check was carried out, CCTV evidence is examined, and a disciplinary investigation is instigated where necessary.”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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

Introduce an additional management-check layer for all ACCT documents.

Verbatim wording from the response

“ACCT Checks The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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

Reissue full ACCT guidance to staff.

Verbatim wording from the response

“ACCT Checks The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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

Brief staff on ACCT check timings, quality interactions and observations at the start of each shift.

Verbatim wording from the response

“ACCT Checks The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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

Conduct covert managerial checks of roll checks.

Verbatim wording from the response

“Roll Checks The two failures to follow the procedure for roll checks identified in this case have been the subject of investigations, and disciplinary action has been taken against the staff involved. All staff have been briefed on the importance of roll checks, and these are now subject to covert checks by managers. If, following a cover check, there is any doubt as to whether or not a proper roll check was carried out, CCTV evidence is examined, and a disciplinary investigation is instigated where necessary.”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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

Train all custodial managers in First Aid at Work and operational support night-patrol staff in Emergency First Aid at Work.

Verbatim wording from the response

“First Aid and CPR PSI 01/2014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its duty of care to its employees, to prisoners and to visitors to our premises. Governors are required to ensure that at all times such numbers of suitably trained first aiders as is sufficient and appropriate for the circumstances are available. A First Aid risk/needs assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW).”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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 a revised personal officer scheme with staff continuity, relief cover and supportive-role briefing.

Verbatim wording from the response

“In October 2013 HMP and YOI Wetherby implemented a revised personal officer scheme that aims to ensure greater continuity in the allocation of staff to young people and includes a ‘relief’ arrangement whereby a paired officer is available to cover during the periods of absence that are inevitable with staff working shifts. The new scheme emphasises the”

Source location

2014-0057-Response-by-NOMS
Page 1 · response
Published 3 February 2014

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 ACCT refresher training for all staff.

Verbatim wording from the response

“ACCT Checks The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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 isolated ACCT check failure is not representative of practice at HMP and YOI Wetherby.

Verbatim wording from the response

“ACCT Checks The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.”

Source location

2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014

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.3

  1. 1

    Provide the receiving institution with a joint or individual report and any additional relevant information within 24 hours of custody arrival.

    Stated by Leeds City CouncilStated plannedThe respondent said that this action was planned when they made their response on 3 February 2014.
  2. 2

    Request relevant information from the social worker, escalating unavailable responses through the appropriate management chain.

    Stated by Leeds City CouncilStated plannedThe respondent said that this action was planned when they made their response on 3 February 2014.
  3. 3

    Collate relevant information, concerns, vulnerabilities and issues, and check whether the child has a social worker before custody.

    Stated by Leeds City CouncilStated plannedThe respondent said that this action was planned when they made their response on 3 February 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

Provide the receiving institution with a joint or individual report and any additional relevant information within 24 hours of custody arrival.

Verbatim wording from the response

“This information will form part of a joint report to be delivered to the relevant institution within 24 hours of the young person arriving in custody. Where there is no allocated social worker, the YOS Court Officer will provide an individual report within 24 hours of the young person arriving in custody.”

Source location

2014-0057-Response-by-Leeds-City-Council
Page 2 · response
Published 3 February 2014

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

Request relevant information from the social worker, escalating unavailable responses through the appropriate management chain.

Verbatim wording from the response

“If the child does have a social worker the YOS Officer will contact the social worker to request all relevant information, concerns, vulnerabilities and issues about the young”

Source location

2014-0057-Response-by-Leeds-City-Council
Page 1 · response
Published 3 February 2014

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

Collate relevant information, concerns, vulnerabilities and issues, and check whether the child has a social worker before custody.

Verbatim wording from the response

“The following procedure has been agreed between Leeds Children’s Social Work Service (“CSWS”) and Leeds Youth Offending Service (“YOS”) in response to the above concerns set out by Miss Melanie J Williamson, Assistant Coroner, in her regulation 28 report, dated 3 February 2014:”

Source location

2014-0057-Response-by-Leeds-City-Council
Page 1 · response
Published 3 February 2014

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