Inadequate ACCT training and knowledge gaps
Practice Plus Group received 2 coroners' reports about this hazard between 4 Dec 2024 and 4 Jan 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
Original on judiciary.uk ↗ Practice Plus Group responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions.”
“We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison.”
- 1 year 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“- the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
Original on judiciary.uk ↗ Repeated from the earlier report:ACCTreviews
Practice Plus Group responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Practice Plus Group
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2024 → 2026Rickie Poon1 year 1 month after Kayleigh Melhuish · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify shortcomings in ACCT-related training and knowledge among prison staff. The earlier report cites a lack of understanding of ACCT review requirements, while the later report notes expired ACCT training and over-reliance on a single presentation.
Kayleigh Melhuish · 4 Dec 2024
“there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
Original on judiciary.uk ↗ Rickie Poon · 4 Jan 2026
“- the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions.”
Stated action
“We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions.”
Stated action
“We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Practice Plus Group at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2024 → 2026 | 0.69 | 0.10 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.