Inadequate ACCT documentation and communication

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. ?Every quote shown was checked by code to appear word for word in the original report.

• 2016 → 2017Sarah Reed8 months after Matthew Russell · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight shortcomings in the conduct of ACCT Case Reviews, specifically regarding staff awareness and engagement with the review process.

  Matthew Russell · 27 Nov 2016

  “Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their care.”

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  Sarah Reed · 28 Jul 2017

  “The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2026Ronald Meikle9 years 4 months after Matthew Russell · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports concern the ACCT (Assessment, Care in Custody and Teamwork) procedure used for prisoners at risk. The earlier report focuses on ensuring staff receive adequate training in ACCT, while the later report highlights failures to initiate ACCT despite clear vulnerability indicators.

  Matthew Russell · 27 Nov 2016

  “Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”

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  Ronald Meikle · 24 Mar 2026

  “The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr [name redacted] was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement.”

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  Earlier report in the app · Later report in the app

• 2016 → 2026Roy Sinclair9 years 5 months after Matthew Russell · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports concern failures in the ACCT process affecting prisoner safety. The earlier report focuses on insufficient staff training, while the later report highlights problems with recording, communication, and use of ACCT documentation.

  Matthew Russell · 27 Nov 2016

  “Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”

  Check it in the source

  Roy Sinclair · 13 May 2026

  “After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”

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  Earlier report in the app · Later report in the app

• 2017 → 2026Roy Sinclair8 years 9 months after Sarah Reed · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight problems with how ACCT documentation is handled, specifically gaps in reviewing, recording, and communicating the information.

  Sarah Reed · 28 Jul 2017

  “(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”

  Check it in the source

  Roy Sinclair · 13 May 2026

  “1.ACCT documentation and operation. The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation.”

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  Stated action in the response to the earlier report

  “CNWL Offender Care has developed its own bespoke training for the management of harm and suicide in prison environments. This training forms part of our mandatory training list and is retaken annually by all staff. Across Offender Care, we are currently 94% compliant with this requirement.”

  Earlier report in the app · Later report in the app