PFD report

Kelvin Sean Speakman · Prevention of Future Deaths report

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Issued 27 Feb 2019•Worcestershire

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
5

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
13

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 raised5

  1. Failure to operate the ACCT process in accordance with national and local policies
    Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
  2. Inadequate ACCT documentation
    Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
  3. Inconsistent or undocumented communication between staff involved in ACCT decisions
    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.11

  1. Action

    Operate a senior leadership quality-assurance process with daily review of ACCT documents and associated healthcare attendance and action completion.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  2. Action

    Make the updated ACCT guidance available to all prison staff through the intranet.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
  3. Action

    Develop clearer national ACCT guidance covering decision recording and healthcare attendance at case reviews.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

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 operate the ACCT process in accordance with national and local policies

Wider context from the report

“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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

Inadequate ACCT documentation

Wider context from the report

“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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

Inconsistent or undocumented communication between staff involved in ACCT decisions

Wider context from the report

“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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 rectify recurring ACCT process failings

Wider context from the report

“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”

Is this part of a recurring concern?

Yes — Ineffective prison suicide and self-harm prevention systems; Unreliable ACCT suicide and self-harm prevention processes.

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

Absence or unclear identification of health care department input to ACCT reviews

Wider context from the report

“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”

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

Operate a senior leadership quality-assurance process with daily review of ACCT documents and associated healthcare attendance and action completion.

Verbatim wording from the response

“Since January 2019, HMP Hewell has been operating a new quality assurance process. A member of the senior leadership team now carries out a daily review of all ACCT documents, making sure that they have been completed in accordance with instructions. They also check that healthcare staff attended first case reviews and that all necessary actions have been taken.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Make the updated ACCT guidance available to all prison staff through the intranet.

Verbatim wording from the response

“On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Develop clearer national ACCT guidance covering decision recording and healthcare attendance at case reviews.

Verbatim wording from the response

“On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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 a case-review document recording contributors, key conversations, and relevant events.

Verbatim wording from the response

“On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Work with prison senior managers to improve adherence to the ACCT process.

Verbatim wording from the response

“In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 1 · response
Published 9 June 2019

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

Deliver ACCT coaching sessions for case managers, focusing on information sharing and accurate, comprehensive recording.

Verbatim wording from the response

“In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 1 · response
Published 9 June 2019

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

Roll out a quality-assurance tool alongside the updated ACCT document to assess compliance with the process.

Verbatim wording from the response

“A new quality assurance tool is also being rolled out alongside the updated ACCT document, which assesses whether the process is being followed correctly.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Issue written reminders requiring healthcare staff to attend, document, and record relevant risk information for ACCT case reviews.

Verbatim wording from the response

“In terms of healthcare attendance at all first case reviews, in March 2019 all members of healthcare staff at the prison were reminded by way of a written staff briefing that they must attend all first ACCT case reviews, as well as any subsequent reviews when necessary, and must record their attendance clearly in the ACCT document and on their IT system. They must also record any information relevant to risk. In the event that healthcare staff are exceptionally unable to attend the first review, an ad hoc review will be held as soon as possible after the initial review in order that healthcare views can inform the management of the case. Staff have also been reminded about the HMPPS Learning Bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations), which was issued to all prisons in July 2018.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Roll out the final revised ACCT case-management system nationally after evaluation.

Verbatim wording from the response

“On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Pilot and evaluate an updated ACCT case-management system.

Verbatim wording from the response

“On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Carry out bi-monthly assurance checks of ACCT documentation.

Verbatim wording from the response

“In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 1 · response
Published 9 June 2019

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

    Share learning from Kelvin Speakman’s death with colleagues 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 9 June 2019.
  2. 2

    Discuss learning from coaching and assurance checks with the Governor and relevant prison safety meetings.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.

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 Kelvin Speakman’s death with colleagues across the prison estate.

Verbatim wording from the response

“Thank you again for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of Kelvin’s tragic death will be shared more widely with colleagues across the prison estate.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 2 · response
Published 9 June 2019

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

Discuss learning from coaching and assurance checks with the Governor and relevant prison safety meetings.

Verbatim wording from the response

“In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison.”

Source location

2019-0074-Response-by-HM-Prison-and-Probation-Services
Page 1 · response
Published 9 June 2019

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