PFD report

Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report

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Issued 27 Oct 2014•Surrey

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
4

Named on the report

Responses found
1

Of 4 recipients

Stated actions
7

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 to retain complete primary source data within the Phoenix Programme
    Part of recurring concern: Failure to retain safety-critical source records and evidencePart of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Open and accessible ligature points within prisoner cells
    Part of recurring concern: Failure to control ligature risks in inpatient and custodial environments
  3. Failure to ensure multidisciplinary attendance or input at ACCT reviews
    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.4

  1. Action

    Issue staff guidance on the importance, timing and procedures for multidisciplinary ACCT case reviews.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 October 2014.
  2. Action

    Remind all staff to record significant self-harm and suicide-risk information on Cnomis as well as SystmOne.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 October 2014.
  3. Action

    Record significant personnel involved in a prisoner’s care in ACCT documents and request their input before reviews.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 October 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 Ministry of Justice Estate Directorate is responsible for delivering prison construction and refurbishment projects addressing accessible ligature points.

    Stated by HM Prison and Probation ServiceRedirects 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

Failure to retain complete primary source data within the Phoenix Programme

Wider context from the report

“3. Retention of Primary Source Data within the Phoenix Programme Consideration should be given to ensuring that all primary source data (ie data provided by the prisoner to the therapist), should be kept either in hard copy format or by way of faithfully recoding all the detail contained therein on the prisoner’s System One record. ”

Is this part of a recurring concern?

Yes — Failure to retain safety-critical source records and evidence; Incomplete, inaccurate or unavailable clinical and care records.

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

Open and accessible ligature points within prisoner cells

Wider context from the report

“1. Open pipe work within the cell Whilst it may not be possible to remove all potential ligature points within a cell, removal of easily accessible and obvious ligature points may serve to reduce the risk of self harm and suicide to vulnerable prisoners. ”

Is this part of a recurring concern?

Yes — Failure to control ligature risks in inpatient and custodial environments.

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 multidisciplinary attendance or input at ACCT reviews

Wider context from the report

“2. Multi-Disciplinary Attendance / Input at ACCT Reviews Consideration should be given to ensuring that all staff, including prison staff, healthcare staff and In Reach staff understand the importance of requiring and providing multi-disciplinary attendance, or alternatively, multi-disciplinary input at all ACCT reviews. ”

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 record significant medical events in prisoner non-medical records accessible to discipline staff

Wider context from the report

“4. Recording Significant Medical Events on a prisoner’s Non-medical Records Consideration should be given to ensuring that all members of healthcare and In Reach staff working within a prison environment record all significant medical events that may impact upon a prisoner’s risk assessment for self-harm or suicide in a place or manner that is readily accessible to the discipline staff at the prison, in addition to any entry made in respect thereof in the System One record. ”

Is this part of a recurring concern?

Yes — Failure to make significant medical events accessible to relevant non-clinical staff.

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

Issue staff guidance on the importance, timing and procedures for multidisciplinary ACCT case reviews.

Verbatim wording from the response

“PSI 64/2011 on Safer Custody aims to support effective multi-disciplinary case management and sharing of information to reduce incidents of harm. In line with PSI 64/2011 Safer Custody, HMP Downview when it re-opens in 2015, will issue a notice to staff explaining the importance of and procedures for conducting multi-disciplinary ACCT case reviews. Particular emphasis will be given to the fact that multi-disciplinary case reviews are to be held at the appropriate times, and where possible, a consistent case manager and”

Source location

2014-0470-Response-by-NOMS
Page 1 · response
Published 27 October 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

Remind all staff to record significant self-harm and suicide-risk information on Cnomis as well as SystmOne.

Verbatim wording from the response

“All staff, including health care staff, will be reminded of the ACCT procedures and the requirement to record significant information about an individual’s self-harm or suicide risks, on Cnomis (Custodial National Offender Management Information System) in addition to recording the information on SystmOne- (the electronic medical records system). The induction pack available for health care staff has also been updated to include governance information about ACCT procedures and what information can be shared with non healthcare professionals.”

Source location

2014-0470-Response-by-NOMS
Page 2 · response
Published 27 October 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

Record significant personnel involved in a prisoner’s care in ACCT documents and request their input before reviews.

Verbatim wording from the response

“relevant personnel must attend the reviews. Where a relevant member of staff cannot attend an ACCT review, then in exceptional circumstances, and per the instructions of PSI64/2011, a written report will be submitted. When HMP Downview was a female prison, a system was in place to ensure that all staff who arrived for duty were provided with a list of prisoners subject to an ACCT and the date of the next ACCT case review in order that they could arrange to attend the review if they were involved in that prisoner’s care. This system will be reintroduced in Spring 2015. In addition, case managers will record in the ACCT document any significant personnel who are involved with the offender, including, health care, offender management and interventions or learning and development.”

Source location

2014-0470-Response-by-NOMS
Page 2 · response
Published 27 October 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

Reintroduce the system notifying on-duty staff about prisoners subject to ACCT and upcoming case reviews.

Verbatim wording from the response

“relevant personnel must attend the reviews. Where a relevant member of staff cannot attend an ACCT review, then in exceptional circumstances, and per the instructions of PSI64/2011, a written report will be submitted. When HMP Downview was a female prison, a system was in place to ensure that all staff who arrived for duty were provided with a list of prisoners subject to an ACCT and the date of the next ACCT case review in order that they could arrange to attend the review if they were involved in that prisoner’s care. This system will be reintroduced in Spring 2015. In addition, case managers will record in the ACCT document any significant personnel who are involved with the offender, including, health care, offender management and interventions or learning and development.”

Source location

2014-0470-Response-by-NOMS
Page 2 · response
Published 27 October 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 Ministry of Justice Estate Directorate is responsible for delivering prison construction and refurbishment projects addressing accessible ligature points.

Verbatim wording from the response

“The Ministry of Justice Estate Directorate (MoJ ED) are responsible for the delivery of prison and construction projects. MoJ ED now routinely provide ‘safer cells’ in all new prison construction projects. “Safer cells” are specifically designed to remove known ligature points thereby reducing the opportunities for a prisoner to self-harm by means of ligature. MoJ ED also routinely provide “safer cells” when refurbishing existing accommodation wherever it is physically possible to do so. The programme of new construction and planned refurbishments means that the numbers of safer cells are increasing across the prison estate.”

Source location

2014-0470-Response-by-NOMS
Page 1 · response
Published 27 October 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

    Review and strengthen local policies and procedures for managing relevant data-sharing practices.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 October 2014.
  2. 2

    Update the healthcare staff induction pack with ACCT governance and information-sharing guidance.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 October 2014.
  3. 3

    Provide initial or refresher ACCT training to prison and partnership-agency staff, repeat it biennially, and monitor delivery.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 October 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    NHS England is responsible for auditing and reporting access to clinical records and the appropriate use of patient information.

    Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Review and strengthen local policies and procedures for managing relevant data-sharing practices.

Verbatim wording from the response

“The local policies and procedures at HMP Downview have been reviewed and strengthened where necessary. The NHS England Area Team has produced data sharing Agreements which set out the required standard for sharing data between clinicians and also for a non-clinical (secondary) purpose.”

Source location

2014-0470-Response-by-NOMS
Page 2 · response
Published 27 October 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

Update the healthcare staff induction pack with ACCT governance and information-sharing guidance.

Verbatim wording from the response

“All staff, including health care staff, will be reminded of the ACCT procedures and the requirement to record significant information about an individual’s self-harm or suicide risks, on Cnomis (Custodial National Offender Management Information System) in addition to recording the information on SystmOne- (the electronic medical records system). The induction pack available for health care staff has also been updated to include governance information about ACCT procedures and what information can be shared with non healthcare professionals.”

Source location

2014-0470-Response-by-NOMS
Page 2 · response
Published 27 October 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 initial or refresher ACCT training to prison and partnership-agency staff, repeat it biennially, and monitor delivery.

Verbatim wording from the response

“Prior to the re-opening of HMP, Downview, all prison staff, including personnel employed by partnership agencies within the prison will receive initial training or refresher training in the application of the ACCT procedures as part of their induction programme. The 2.5 hour training package will then be delivered by trained facilitators to each member of staff every 2 years, and the programme of training will be monitored by the HR hub at the prison.”

Source location

2014-0470-Response-by-NOMS
Page 2 · response
Published 27 October 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

NHS England is responsible for auditing and reporting access to clinical records and the appropriate use of patient information.

Verbatim wording from the response

“NHS England is responsible for managing the audit and reporting for access to records in the clinical system (TPP SystmOne and its successor) and for the appropriate use of patient information.”

Source location

2014-0470-Response-by-NOMS
Page 2 · response
Published 27 October 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