Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed ACCT case review and documentation failure
The earlier warning
Reggie Johns · 16 Sept 2013 · G U Williams, Worcestershire
“(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view.”
judiciary.uk/prevention-of-future-death-reports/reggie-johns
What was promised
Stated action 1 · response to Reggie Johns (16 Sept 2013) · stated timescale: none stated
“Since Mr [name redacted]' death, HMP Bristol has introduced a system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm. In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments. These conversations are recorded on Prison-NOMIS”
What recurred
- 17 Sept 2021 · Colin Blackburn · David Reid · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Reggie Johns · 16 Sept 2013
“(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view.”
Later · Colin Blackburn · 17 Sept 2021
“that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
What happened next
No web check of the stated actions has been published for this chain.