PFD report

Corin Bonaparte · Prevention of Future Deaths report

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Issued 7 May 2021•Exeter and Greater Devon

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
18

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

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Concerns raised3

  1. Inadequate arrangements for the swift departure of ambulances from the prison in blue-light emergencies
    Part of recurring concern: Failure to provide timely emergency hospital conveyance
  2. Failure to open an ACCT following disclosure of recent deliberate self-harm
    Part of recurring concern: Ineffective prison suicide and self-harm prevention systemsPart of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
  3. Lack of adequate training for mental health workers responding to deliberate self-harm
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.14

  1. Action

    Implement the approved revised healthcare ACCT operating procedure requiring documentation of reported or observed self-harm and opening an ACCT where required.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
  2. Action

    Hold weekly collaborative healthcare meetings to discuss ACCT practice, record keeping, transfers, discharge, mental-health awareness and shared learning.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  3. Action

    Include healthcare staff in multidisciplinary ACCT V6 training at HMP Dartmoor to refresh responsibilities, vulnerability awareness and ACCT-opening criteria.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.

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

  1. Position

    The prison’s existing Local Security Strategy provides for ambulance dispatch before risk assessment when necessary in a blue-light emergency.

    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

Inadequate arrangements for the swift departure of ambulances from the prison in blue-light emergencies

Wider context from the report

“(2) Addressed to the Governor, HMP Dartmoor A witness gave convincing evidence to the effect that the ambulance with Corin Bonaparte on board was kept waiting 8 minutes at the main gate while a prisoner escort was found. Although there was no evidence to suggest that this delay in transporting the deceased to hospital contributed to Corin Bonaparte’s death, the fact of such a delay was disturbing and suggested that there were inadequate arrangements in place to ensure the swift departure of an ambulance from the prison in a blue light emergency. ”

Is this part of a recurring concern?

Yes — Failure to provide timely emergency hospital conveyance.

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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 open an ACCT following disclosure of recent deliberate self-harm

Wider context from the report

“(1) Addressed to the Head of Healthcare and the Governor, HMP Dartmoor Corin sought help from the mental health department at HMP Dartmoor. He revealed to a nurse in the mental health department the fact that he had recently deliberately harmed himself and made this fact known to other mental health workers. An ACCT was not opened despite the provisions in Chapter 2 of PSI 64 / 2011 which made the opening of an ACCT in these circumstances mandatory. In the light of the evidence from relevant witnesses at the inquest hearing it could not be confidently assumed that their actions would be any different if similar circumstances were to arise in the future. This suggested a lack of adequate training. ”

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

Lack of adequate training for mental health workers responding to deliberate self-harm

Wider context from the report

“(1) Addressed to the Head of Healthcare and the Governor, HMP Dartmoor Corin sought help from the mental health department at HMP Dartmoor. He revealed to a nurse in the mental health department the fact that he had recently deliberately harmed himself and made this fact known to other mental health workers. An ACCT was not opened despite the provisions in Chapter 2 of PSI 64 / 2011 which made the opening of an ACCT in these circumstances mandatory. In the light of the evidence from relevant witnesses at the inquest hearing it could not be confidently assumed that their actions would be any different if similar circumstances were to arise in the future. This suggested a lack of adequate training. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Implement the approved revised healthcare ACCT operating procedure requiring documentation of reported or observed self-harm and opening an ACCT where required.

Verbatim wording from the response

“The Head of Healthcare and clinical team at HMP Dartmoor have reviewed and made additions to the Local Operating Procedure (LOP) for healthcare involvement in the ACCT (Assessment, Care, Custody & Teamwork) process. The additions that have been made specify that recently reported or observed self-harm must be documented and that, in accordance with the requirements of PSI 64/2011, an ACCT must be opened. The revised LOP was submitted to the Local Quality Assurance Meeting and approved on 22nd June 2021. A staff signatory sheet will be signed by all staff acknowledging they have read and understood this guidance by 12th July 2021.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 2 · response
Published 7 May 2021

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

Hold weekly collaborative healthcare meetings to discuss ACCT practice, record keeping, transfers, discharge, mental-health awareness and shared learning.

Verbatim wording from the response

“In a further collaborative learning initiative, Practice Plus Group and Devon Partnership Trust have arranged to hold weekly meetings for all healthcare staff to discuss ‘hot topics’ (for example ACCT reviews, clinical record keeping, transfer and discharge processes, mental health awareness sessions and other clinical bitesize sharing best practice sessions). This will further support embedding of lessons learned in to daily practice.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 3 · response
Published 7 May 2021

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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

Include healthcare staff in multidisciplinary ACCT V6 training at HMP Dartmoor to refresh responsibilities, vulnerability awareness and ACCT-opening criteria.

Verbatim wording from the response

“In addition to the above, from July 2021, nationally updated ACCT guidance (V6) is being rolled out across all prisons in England & Wales by Her Majesty’s Prison and Probation Service. This training provides further clarity on the roles and responsibilities of healthcare staff within the ACCT process. The training is multi-disciplinary and will be open to all colleagues (including healthcare). The ACCT V6 training will commence at HMP Dartmoor on 5th July 2021 and the Head of Healthcare has received assurance that healthcare staff will be included in the updated training programme. This will provide the opportunity for joint training sessions in which all healthcare staff and discipline colleagues will review and refresh their knowledge of the ACCT process, increase their awareness of vulnerability and risk factors, and enhance their understanding of when an ACCT should be opened.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 3 · response
Published 7 May 2021

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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

Add Head of Healthcare sign-off to confirm completion of new-staff induction covering the ACCT process.

Verbatim wording from the response

“In addition to the above, the Practice Plus Group General Induction Booklet contains a section on the ACCT process and as part of our induction process for new staff, ACCT is discussed within the twelve week induction period. A confirmatory signature is required from the inducting supervisor to evidence completion. To ensure a robust and quality induction experience, additional sign off will now be undertaken by the Head of Healthcare on completion of the induction period. Devon Partnership Trust have a similar process in place for the mental healthcare team, with an induction booklet signed by both the individual staff member and the Mental Health Team Manager. We will monitor this and obtain further assurance that all new starters in the mental health team have sufficient knowledge of how and when to open an ACCT through our quarterly sub-contractor review meetings with DPT.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 3 · response
Published 7 May 2021

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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

Obtain staff acknowledgements confirming that all healthcare staff have read and understood the revised ACCT guidance.

Verbatim wording from the response

“The Head of Healthcare and clinical team at HMP Dartmoor have reviewed and made additions to the Local Operating Procedure (LOP) for healthcare involvement in the ACCT (Assessment, Care, Custody & Teamwork) process. The additions that have been made specify that recently reported or observed self-harm must be documented and that, in accordance with the requirements of PSI 64/2011, an ACCT must be opened. The revised LOP was submitted to the Local Quality Assurance Meeting and approved on 22nd June 2021. A staff signatory sheet will be signed by all staff acknowledging they have read and understood this guidance by 12th July 2021.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 2 · response
Published 7 May 2021

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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

Deliver ACCT/SASH training to healthcare staff who require it, with sessions booked and attendance recorded and monitored.

Verbatim wording from the response

“With regard to promoting staff training and awareness, the prison last held ACCT / Suicide and Self-Harm (SASH) training on 8th December 2020 and this was attended by twelve health staff. Following this all healthcare staff in post had completed prison ACCT training. Training was then placed on hold due to the Covid-19 outbreak, as a result of which, at the time of the inquest, we had four new members of staff requiring training. However, for two of these members of staff this would have constituted refresher training as they had transferred from other prison establishments and had received ACCT training before.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 2 · response
Published 7 May 2021

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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

Audit healthcare involvement in the ACCT process through the P.R.O.T.E.C.T. patient-safety audit and escalate findings through quality-assurance governance where required.

Verbatim wording from the response

“Managing healthcare involvement within the ACCT process is also audited through our Practice Plus Group bespoke prisons patient safety audit, which is called ‘P.R.O.T.E.C.T’. This audit tool was developed from an evidence base of key themes from lessons learnt through deaths in custody, and is undertaken throughout the year on an annual audit schedule. The audit standards assess compliance in mental health referrals, timeliness of assessment, and of mental health team involvement in the ACCT process. Results of the audits are reviewed and discussed through Local Quality Assurance meetings within HMP Dartmoor. Where required themes are escalated to Regional Quality Assurance meetings and to quarterly National Quality Assurance meetings to evaluate the effectiveness of action planning and implementation within the audit cycle.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 4 · response
Published 7 May 2021

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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

Work with the ambulance service on an emergency contingency-plan exercise and use its learning to strengthen the contingency plan.

Verbatim wording from the response

“When COVID-19 restrictions have been relaxed sufficiently, the prison will be working with the ambulance service on a contingency plan development exercise. This will involve a run through of an emergency situation to check how quickly an ambulance can get through the prison gates and how long it should take for a quick departure without delay. This will also provide an opportunity for both organisations to set out their expectations, and the learning will be used to strengthen the contingency plan for emergency situations. Improved monitoring will be introduced to identify any delays in ambulances departing the prison in future so that swift action can be taken to improve.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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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

Deliver SASH training to healthcare staff and prioritise attendance at monthly sessions.

Verbatim wording from the response

“understanding self-harm, the ACCT v6 process and supporting individuals who self-harm. Training is currently being delivered at HMP Dartmoor and is available to all staff, including healthcare colleagues. Introduction to Suicide and Self-Harm Prevention (SASH) training is being delivered to healthcare attendance at the monthly sessions has been prioritised in order to support the up-skilling of staff in recognising risks and triggers for self-harm, as well as to build confidence in decision making around the opening of ACCT documents.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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

Identify at least two officers at the start of each shift to support emergency escort duties.

Verbatim wording from the response

“In order to ensure that all staff are aware of the requirements in the LSS, and are confident in their decision making in emergency situations, briefing sessions have been delivered and staff have been required to provide written confirmation that they understand the instructions. Duty managers have also been instructed to ensure that at least two officers are identified at the beginning of each shift to assist with escorting duties in the event of an emergency. A Governor’s order has been published to reinforce the expectations of staff responding to emergency situations.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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 revised ACCT v6 process across the prison estate.

Verbatim wording from the response

“ACCT is a prison service document that assists staff in providing multi-disciplinary care and support to individuals at risk of harm to themselves, in order to minimise that risk. It is to be utilised by all members of staff working within prisons, including healthcare colleagues, and it is important staff feel confident in recognising risk and making the decision to open an ACCT in order to support prisoners through their period of crisis.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 1 · response
Published 7 May 2021

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 v6 training to prison staff, including healthcare colleagues, at HMP Dartmoor.

Verbatim wording from the response

“In July 2021, a new version of ACCT (Version 6, known as “ACCT v6”) was rolled out across the prison estate. The changes made to ACCT are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person centred approach which meets the needs of each individual in order to minimise their risk of harm to self. Training packages have been developed to assist in the understanding and delivery of the new ACCT process and include sessions on”

Source location

2021-0143-Response-from-HMPPS_Published
Page 1 · response
Published 7 May 2021

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 monitoring to identify delays in ambulance departures and support corrective action.

Verbatim wording from the response

“When COVID-19 restrictions have been relaxed sufficiently, the prison will be working with the ambulance service on a contingency plan development exercise. This will involve a run through of an emergency situation to check how quickly an ambulance can get through the prison gates and how long it should take for a quick departure without delay. This will also provide an opportunity for both organisations to set out their expectations, and the learning will be used to strengthen the contingency plan for emergency situations. Improved monitoring will be introduced to identify any delays in ambulances departing the prison in future so that swift action can be taken to improve.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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

Review the prison’s Local Security Strategy and confirm emergency ambulance departure requirements.

Verbatim wording from the response

“Your second concern is that there were inadequate arrangements in place to ensure the swift departure of an ambulance from the prison in a blue light emergency. Following the inquest, the Governor ordered a review of the prison’s Local Security Strategy (LSS) and has confirmed that it sets out the action that must be taken in the event of a medical emergency, which include making escort staff available once a medical emergency code has been called and, where necessary in a blue light emergency, dispatching an ambulance before a risk assessment of the prisoner has been completed.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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 prison’s existing Local Security Strategy provides for ambulance dispatch before risk assessment when necessary in a blue-light emergency.

Verbatim wording from the response

“Your second concern is that there were inadequate arrangements in place to ensure the swift departure of an ambulance from the prison in a blue light emergency. Following the inquest, the Governor ordered a review of the prison’s Local Security Strategy (LSS) and has confirmed that it sets out the action that must be taken in the event of a medical emergency, which include making escort staff available once a medical emergency code has been called and, where necessary in a blue light emergency, dispatching an ambulance before a risk assessment of the prisoner has been completed.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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.4

  1. 1

    Implement lessons learned at HMP Dartmoor and share them across the provider’s prison healthcare services in England.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  2. 2

    Review progress against the response actions through the Local Quality and Delivery Board’s safe-care governance arrangements.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
  3. 3

    Brief staff on emergency requirements and obtain written confirmation that they understand the instructions.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
  4. 4

    Publish a Governor’s order reinforcing staff expectations during emergency situations.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.

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 lessons learned at HMP Dartmoor and share them across the provider’s prison healthcare services in England.

Verbatim wording from the response

“We hope that the above response provides assurance that Practice Plus Group are committed to providing a high quality healthcare service at HMP Dartmoor. In response to the specific concerns raised in relation to the death of Mr Bonaparte, we will ensure that the lessons learnt are implemented at HMP Dartmoor and are shared across all of our healthcare services in prisons throughout England.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 5 · response
Published 7 May 2021

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

Review progress against the response actions through the Local Quality and Delivery Board’s safe-care governance arrangements.

Verbatim wording from the response

“Finally, the Head of Healthcare at HMP Dartmoor also attends the Local Quality and Delivery Board (LQDB) with the Governor of the prison to discuss healthcare performance and operational issues requiring a partnership approach. Within the standing agenda items for LQDB there is a section for ‘Safe Care and Treatment’, where learning from incidents and learning generated as a result of the introduction of new policies is discussed. Our progress against actions identified in this PFD response will be reviewed within LQDB.”

Source location

2021-0143-Practice-Plus-Group_Published
Page 5 · response
Published 7 May 2021

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 emergency requirements and obtain written confirmation that they understand the instructions.

Verbatim wording from the response

“In order to ensure that all staff are aware of the requirements in the LSS, and are confident in their decision making in emergency situations, briefing sessions have been delivered and staff have been required to provide written confirmation that they understand the instructions. Duty managers have also been instructed to ensure that at least two officers are identified at the beginning of each shift to assist with escorting duties in the event of an emergency. A Governor’s order has been published to reinforce the expectations of staff responding to emergency situations.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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 a Governor’s order reinforcing staff expectations during emergency situations.

Verbatim wording from the response

“In order to ensure that all staff are aware of the requirements in the LSS, and are confident in their decision making in emergency situations, briefing sessions have been delivered and staff have been required to provide written confirmation that they understand the instructions. Duty managers have also been instructed to ensure that at least two officers are identified at the beginning of each shift to assist with escorting duties in the event of an emergency. A Governor’s order has been published to reinforce the expectations of staff responding to emergency situations.”

Source location

2021-0143-Response-from-HMPPS_Published
Page 2 · response
Published 7 May 2021

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