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recurance

Inaccurate ACCT documentation affecting prisoner safety

Closely relatedConfidence 0.80 · moderate2 reports · 2019–2026No published response to an earlier report One-page brief (print or PDF)

HM Inspectorate of Prisons received 2 coroners' reports about this hazard between 10 Dec 2019 and 13 May 2026.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

No published response from HM Inspectorate of Prisons was found for the earlier reports.

2
reports
2
different coroners
2019–2026
years
0.80
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Daniel Akam↗

    10 Dec 2019 · Georgina Gibbs · South Yorkshire (East)

    “Failure to carry out ACCT observations recorded in the ACCT log”
    Original on judiciary.uk ↗

    No published response from HM Inspectorate of Prisons was found for this report.

  2. 6 years 5 months later

    Raised again · 1st time

    Roy Sinclair↗

    13 May 2026 · Sean Cummings · Milton Keynes

    Closely relatedConfidence 0.80 · moderatea different coroner
    “serious difficulty in the recording, communication, and use of ACCT documentation”
    Original on judiciary.uk ↗

    HM Inspectorate of Prisons responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗

  3. All reports to HM Inspectorate of Prisons

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error