Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed ACCT case review and inadequate process management
The earlier warning
Colin Blackburn · 17 Sept 2021 · David Reid, Worcestershire
“(a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
judiciary.uk/…/colin-blackburn-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to Colin Blackburn (17 Sept 2021) · stated timescale: 31st October 2021
“The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)1 will cease to be an option for referrals to the mental health team.”
judiciary.uk/…/2021-0311-Response-from-Practice-Plus-Group.pdf
What recurred
- 4 Jan 2026 · Rickie Poon · Mary Hassell · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Colin Blackburn · 17 Sept 2021
“(a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
Later · 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;”
What happened next
No web check of the stated actions has been published for this chain.