PFD report

Mark Daniel VAGNONI · Prevention of Future Deaths report

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Issued 11 Oct 2017•Bedfordshire and Luton

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
8

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 raised3

  1. Inability to carry out risk assessments with mental health input during patrol state
    Part of recurring concern: Inadequate mental health risk assessmentPart of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
  2. Lack of Wing Transfer documentation conveying past ACCTs and risk factors
    Part of recurring concern: Failure to ensure safe prisoner transfers
  3. NOMIS failing to alert staff to past ACCTs from the initial screen
    Part of recurring concern: Unreliable NOMIS safety-critical information access and visibility
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.1

  1. Action

    Issue Bedford guidance requiring staff to share prisoner risk information during location changes verbally, on NOMIS and in wing observation books, with monthly recording checks.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    NOMIS provides current alerts and accessible historical ACCT information, with staff training on locating prisoner information.

    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

Inability to carry out risk assessments with mental health input during patrol state

Wider context from the report

“1. The ACCT was opened during patrol state. The first review was planned the following morning. Apart from 30 minute observations and the information on NOMIS (which was scant) there was no ability to carry out a risk assessment with mental health input. It seems to me that prisoners are especially vulnerable during this patrol state period and greater observations and/or other strategies should be undertaken until the first review can take place. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; 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

Lack of Wing Transfer documentation conveying past ACCTs and risk factors

Wider context from the report

“3. The jury were also concerned that there appears to be no Wing Transfer documentation, which could have included information about past ACCTs and indeed past risk factors. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe prisoner transfers.

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

NOMIS failing to alert staff to past ACCTs from the initial screen

Wider context from the report

“2. The jury expressed concerns that the NOMIS layout were not helpful to staff in that the staff needed to drill down beyond the initial screen to be alerted to past ACCTs ”

Is this part of a recurring concern?

Yes — Unreliable NOMIS safety-critical information access and visibility.

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 Bedford guidance requiring staff to share prisoner risk information during location changes verbally, on NOMIS and in wing observation books, with monthly recording checks.

Verbatim wording from the response

“In October 2017 all staff at HMP Bedford were reminded through a Notice to Staff of the importance of ensuring that all available information, including any identified risk factors, must be considered prior to changing a prisoner’s location, and shared with staff responsible for their care at the receiving location. Information must be shared both verbally and on NOMIS, with entries also made in the wing observation book. Residential managers are required to undertake monthly checks on wing observation books and NOMIS to ensure that information is being recorded accurately and comprehensively.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 3 · response
Published 27 November 2017

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

NOMIS provides current alerts and accessible historical ACCT information, with staff training on locating prisoner information.

Verbatim wording from the response

“The current layout of NOMIS contains alerts on the home screen which allow staff to see important, current information on a prisoner, including whether they are on an open ACCT. Past information is easily accessible through the prisoner’s history section, and all prison staff who need to access NOMIS are trained in its use before being given access to the system. The course is designed to make staff aware of where and how the information about a prisoner is recorded.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 27 November 2017

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

Existing policy requires recording and sharing prisoner risks and needs before location changes through wing books, NOMIS and verbal communication.

Verbatim wording from the response

“As you may be aware, PS1 75/2011 Residential Services requires that any information regarding the needs, risks or behaviours of prisoners who are showing signs of distress or self-harm must be properly recorded in the wing occurrence book or equivalent, and shared appropriately with other teams.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 3 · response
Published 27 November 2017

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

Risk-based ACCT observation levels already account for increased night-state risk when full review and mental-health input are unavailable.

Verbatim wording from the response

“Prison Service Instruction 64/2011 Safer Custody states that the level of ACCT observations needs to be set on the basis of a consideration of the level of risk, and with particular regard to any factors which may increase risk, and this would include an inability to undertake a full ACCT case review with mental health input during the night state. National policy also states that observation levels must be clearly documented on the front cover of the ACCT document, with observations made at unpredictable times.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 27 November 2017

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.7

  1. 1

    Redesign and roll out a revised ACCT document containing a summary sheet for observations and conversations to improve information sharing.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
  2. 2

    Issue Bedford staff guidance reinforcing ACCT risk assessment, observation levels, timely case reviews and escalation when risk changes.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
  3. 3

    Issue a national learning bulletin reminding prison staff to set appropriate ACCT observation levels.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
  4. 4

    Publish Bedford guidance reminding staff to refresh NOMIS knowledge, complete e-learning, record ACCT information clearly and address learning needs through staff reviews.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
  5. 5

    Train relevant Bedford staff to set appropriate ACCT observation levels for prisoners at risk.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
  6. 6

    Develop and implement a standardised NOMIS induction programme for new staff using the system, effective by December 2017.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
  7. 7

    Introduce improved ACCT documentation assurance checks, with senior managers conducting weekly reviews and providing feedback to staff.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.

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

Redesign and roll out a revised ACCT document containing a summary sheet for observations and conversations to improve information sharing.

Verbatim wording from the response

“You may find it helpful to know that the ACCT is currently being redesigned and there are plans to roll out a revised version of the document. As part of this redesign, a summary sheet of ACCT observations and conversations will be included to improve information sharing.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 27 November 2017

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 Bedford staff guidance reinforcing ACCT risk assessment, observation levels, timely case reviews and escalation when risk changes.

Verbatim wording from the response

“In July 2017 HMPPS issued a learning bulletin entitled ‘ACCT - Conversations and Observations’ to all prisons, reminding staff of the importance of setting appropriate observation levels for prisoners supported by the ACCT process. HMP Bedford additionally issued a staff notice in October 2017 to remind all ACCT case managers about assessing risk and setting appropriate observation levels, and the importance of undertaking a full ACCT case review within 24 hours of an ACCT being opened. It also reminded staff that if a prisoner’s level of risk changes, especially during the night state, they must immediately inform the night orderly officer who will ensure the ACCT is reviewed and observation levels increased if necessary. Additional support, including consideration of use of Samaritans phones or access to Listeners, may also be given depending on the needs of the prisoner.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 27 November 2017

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 a national learning bulletin reminding prison staff to set appropriate ACCT observation levels.

Verbatim wording from the response

“In July 2017 HMPPS issued a learning bulletin entitled ‘ACCT - Conversations and Observations’ to all prisons, reminding staff of the importance of setting appropriate observation levels for prisoners supported by the ACCT process. HMP Bedford additionally issued a staff notice in October 2017 to remind all ACCT case managers about assessing risk and setting appropriate observation levels, and the importance of undertaking a full ACCT case review within 24 hours of an ACCT being opened. It also reminded staff that if a prisoner’s level of risk changes, especially during the night state, they must immediately inform the night orderly officer who will ensure the ACCT is reviewed and observation levels increased if necessary. Additional support, including consideration of use of Samaritans phones or access to Listeners, may also be given depending on the needs of the prisoner.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 27 November 2017

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

Publish Bedford guidance reminding staff to refresh NOMIS knowledge, complete e-learning, record ACCT information clearly and address learning needs through staff reviews.

Verbatim wording from the response

“The investigations into the death of Mr Vagnoni brought to the attention of the Governor the fact that some staff at Bedford were not fully familiar with the use of NOMIS. In light of this, a Notice to Staff was published in October 2017 reminding them of the importance of refreshing their knowledge by completing the e-learning course. Any staff identified as needing additional support in the use of NOMIS will have this included in their staff learning and performance review. The Notice to Staff set out where important information regarding a prisoner’s ACCT history is located, and the importance of clearly recording information on NOMIS. HMP Bedford is currently developing a standardised induction programme for all new staff who will be using NOMIS to ensure that they have the knowledge required to use the system effectively.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 3 · response
Published 27 November 2017

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 relevant Bedford staff to set appropriate ACCT observation levels for prisoners at risk.

Verbatim wording from the response

“All relevant staff at HMP Bedford have received training in setting the appropriate level of ACCT observations for a prisoner at risk. An improved assurance check on completed ACCT documentation was introduced at the establishment in October 2017. Senior managers now complete weekly checks on documentation, as well as providing feedback and guidance to ACCT case managers and staff.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 27 November 2017

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 and implement a standardised NOMIS induction programme for new staff using the system, effective by December 2017.

Verbatim wording from the response

“The investigations into the death of Mr Vagnoni brought to the attention of the Governor the fact that some staff at Bedford were not fully familiar with the use of NOMIS. In light of this, a Notice to Staff was published in October 2017 reminding them of the importance of refreshing their knowledge by completing the e-learning course. Any staff identified as needing additional support in the use of NOMIS will have this included in their staff learning and performance review. The Notice to Staff set out where important information regarding a prisoner’s ACCT history is located, and the importance of clearly recording information on NOMIS. HMP Bedford is currently developing a standardised induction programme for all new staff who will be using NOMIS to ensure that they have the knowledge required to use the system effectively.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 3 · response
Published 27 November 2017

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 improved ACCT documentation assurance checks, with senior managers conducting weekly reviews and providing feedback to staff.

Verbatim wording from the response

“All relevant staff at HMP Bedford have received training in setting the appropriate level of ACCT observations for a prisoner at risk. An improved assurance check on completed ACCT documentation was introduced at the establishment in October 2017. Senior managers now complete weekly checks on documentation, as well as providing feedback and guidance to ACCT case managers and staff.”

Source location

2017-0286-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 27 November 2017

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