Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Matthew Purser · 30 May 2014 · Philip Rogers, Swansea & Neath Port Talbot
“The Doctor who saw Mr. [name redacted] for the second health screen on the day after admission had not received ACCT training as required by PS1 64/2011 and HMP Swansea Suicide Prevention Policy 2010 and was not aware of the requirement for him to be trained in the procedures although he was aware of the procedures.”
judiciary.uk/prevention-of-future-death-reports/matthew-purser
What was promised
Stated action 1 · response to Liam Lambert (20 Sept 2016) · stated timescale: none stated
“Consideration should be given to formally confirming that all necessary documentation has been considered prior fo the ACCT review, and fo ensure the officers and Healthcare staff are aware of their responsibilities.”
Stated action 2 · response to Liam Lambert (20 Sept 2016) · stated timescale: October 2016
“Anew scheduling system was also introduced in October 2016, and this will ensure that sufficien# time is allocated to all future case review meetings.”
Stated action 3 · response to Liam Lambert (20 Sept 2016) · stated timescale: August 2016
“The Safer Custody toolkit that was introduced in August 2016 provides clear instructions to staff regarding ACCT procedures, including the importance of ensuring that ail relevant risks and triggers are considered before the ACCT document is closed.”
18 further stated actions are listed on the full chain page.
What recurred
- 10 Dec 2014 · Geraldine Kilborn · Andrew Tweddle
- 30 Jun 2016 · John Betteridge · Andrew Tweddle · Identical hazard · confidence 0.90 (high)
- 20 Sept 2016 · Liam Lambert · Lydia Brown · Identical hazard · confidence 0.90 (high)
- 17 Feb 2017 · Dean Saunders · Caroline Beasley-Murray · Identical hazard · confidence 0.92 (high)
- 28 Jul 2017 · Sarah Reed · Sir Peter Thornton QC · Closely related · confidence 0.80 (moderate)
- 18 Dec 2017 · Mark Doyle · Heather Williams
- 21 Jun 2019 · Ryan Trimmer · James Healy-Pratt · Closely related · confidence 0.80 (moderate)
- 14 May 2023 · Thomas Huntley · Robert Simpson · Closely related · confidence 0.90 (high)
- 31 May 2024 · Frazer Williams · Rachael Griffin · Closely related · confidence 0.85 (high)
- 1 Aug 2024 · Matthew Braben · Anton van Dellen · Identical hazard · confidence 0.90 (high)
- 2 May 2025 · Sarah Boyle · Victoria Davies · Closely related · confidence 0.90 (high)
- 18 Jul 2025 · Patryk Gladysz · Priya Malhotra · Closely related · confidence 0.85 (high)
- 25 Jul 2025 · Michael Pugh · Patricia Harding · Identical hazard · confidence 0.90 (high)
- 29 Jul 2025 · Azroy Dawes-Clarke (3) · Ian Brownhill · Identical hazard · confidence 0.94 (high)
- 13 May 2026 · Roy Sinclair · Sean Cummings · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Dean Saunders · 17 Feb 2017
“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”
Later · Azroy Dawes-Clarke (3) · 29 Jul 2025
“Officers involved in Mr [name redacted] ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork.”
What happened next
No evidence found either way · stated action 1
“Employee documentation covers various types of records and is essential for maintaining a transparent and compliant workplace. This includes first-day paperwork to the day that they leave.”
What You Need To Know about Employee Documentation | LegalNature · legalnature.com/…/what-you-need-to-know-about-employee-document…
“Maintaining correct documentation not only ensures regulatory compliance but also enhances resident safety.”
Best Practices for Staff Documentation in Assisted Living Communities | Gallagher · ajg.com/…/best-practices-for-staff-documentation-in-assisted-li…
No evidence found does not mean the action did not happen.
Evidence found · stated action 2
“Building A Better Case Review Together 1 Building A Better Case Review Together Re-evaluate, re-invigorate, re-energize Why Should I Attend Case Review - Why case review is important - Creating/Evaluating Case Review Protocol - Ground Rules/Guiding Principles - Draft Protocol - Sample Case Review Agendas - Role of the Facilitator - Case Flow Charts - Resources The intent of this template is to help”
Building A Better Case Review Together · mrcac.org/…/Case-Review-Guidelines-final.pdf
“Case review should present opportunities to: - Evaluate the child's interview - Discuss, plan, and monitor the progress of the investigation, including what has been done and what still needs to be done on the case - Review findings from the medical examination, if any and/or discuss any future medical needs - Discuss child protection issues and safety concerns, if any - Discuss resources for the”
Building a Better Case Review Together · regionalcacs.org/…/Building-A-Better-Case-Review-Together-Oct20…
“1 Case Review Requirements and Checklist Staff should share the Team links AND call-in information with families and all other parties prior to the meeting, unless deemed inappropriate by the Worker and Supervisor. This is for staffings and Semi-Annual Reviews (SAR). ALL Case Review (CR) meetings are LIVE meetings and any outcome is possible. Therefore, all parties (including parents, relative”
Case Review Requirements and Checklist · cuyahogacms.blob.core.windows.net/…/case-review-requirement-and…
No evidence found either way · stated action 3
“Pact has developed systems and resources to improve communication between prisons and prisoners' family members where there are concerns about a prisoner's welfare. The project, which has benefitted from HMPPS Innovation Grant funding and has been co-delivered with HMPPS and prisoners' families, aims to improve the wellbeing and safety of prisoners across England and Wales.”
Safer Custody · prisonadvice.org.uk/get-help/safer-custody
“Assessment, Care in Custody and Teamwork - or ACCT - is how we plan support for someone in prison who is at risk of self-harm or suicide.”
Assessment, Care in Custody and Teamwork (ACCT) · prisonersfamilies.org/…/assessment-care-in-custody-and-teamwork…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “In September 2016 ACCT case managers were reminded of the importance of a multi- discipiinary approach to ACCT reviews, particularly when making decisions to close the document”
The sources discuss multidisciplinary team practices and case management approaches but do not mention any action by ACCT or its case managers in September 2016.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “A notice has been issued to remind staff of their responsibilities when attending ACCT case reviews, and a local template for reviews was introduced In October 2016.”
“Board papers Board Papers | Page 2 Good board papers ensure your key decision makers have well-written, relevant, and accurate information to support their decision-making.”
Board papers guidance · governanceinstitute.com.au/…/govinst_guidance-board_papers_2021…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Staffing levels in public sector prisons have been set through a benchmarking process, designed to provide sufficient staff for the prison to operate safely, decently and securely. .The Governor has raised concerns about the staffing level at [name redacted], and recently submitted a business case to increase by 12 prison officers the benchmark operating level set for the prison”
The promised staffing increase for Glen Parva prison was referenced in a submitted business case but no specific implementation timeline was provided.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times. Two on-site first aid trainers will be delivering first aid training to staff as part of the prison's monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior”
“Mental Health First Aid (MHFA) for Corrections Professionals equips staff with the knowledge and skills to identify, understand and respond to mental health and substance use challenges in their peers”
Mental Health First Aid for Corrections Professionals 2026-09-30 · nicic.gov/…/mental-health-first-aid-corrections-professionals-3
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “HMP Winchester is currently delivering monthly training and awareness sessions for all staff which incorporates both ACCT v6 and SASH training.”
“Action required by: HMPPS HQ X Governors X Public Sector Prisons X Heads of Group X Contracted Prisons The Probation Service X Under 18 Young Offender Institutions (ACCT policy only)”
Prison Safety Policy Framework · assets.publishing.service.gov.uk/…/prison-safety-policy-framewo…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Safety Intervention Meeting (SIM) is a multi-disciplinary safety risk management meeting, chaired by the Senior Management Team (SMT), providing support and multi-disciplinary guidance to Case Coordinators and case review teams.”
“This glossary provides an alphabetical guide to some of the terminology in our reports. We review this glossary regularly, but please let us know if you find any entries that need updating. Email us at [HMIPrisons.Enquiries@hmiprisons.gov.uk](mailto:HMIPrisons.Enquiries@hmiprisons.gov.uk)”
Glossary of terms – HM Inspectorate of Prisons · hmiprisons.justiceinspectorates.gov.uk/glossary-of-terms
“Prison Safety Policy Framework Re-issue Date: 14 January 2026 Implementation Date: 01 January 2025 Replaces the following documents (e.g. PSIs, PSOs, Custodial Service Specs) which are hereby cancelled: PSI 64/2011 Management of prisoners at risk of harm to self, to others and from others (Safer Custody) - chapters 1-11 and 14 and Annex to PSI 64/2011 (ACCT version 6). Introduces amendments to the”
Prison Safety Policy Framework · assets.publishing.service.gov.uk/…/prison-safety-policy-framewo…
“His Majesty's Prison and Probation Service | Headquarters at [102 Petty France](https://en.wikipedia.org/wiki/102_Petty_France "102 Petty France"), London | | [Executive Agency](https://en.wikipedia.org/wiki/Executive_Agency "Executive Agency") overview | | Formed | 2004 (2004) (as NOMS) | | Jurisdiction | England and Wales, [United Kingdom](https://en.wikipedia.org/wiki/United_Kingdom "United Kingdom”
HM Prison and Probation Service - Wikipedia · en.wikipedia.org/wiki/HM_Prison_and_Probation_Service
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “All establishments are required to have an ACCT quality assurance process in place that ensures that quality assurance is carried out at a level and frequency that enables meaningful insight into how effectively support through ACCT is being implemented.”
The Prison Safety Policy Framework requires all establishments to implement an ACCT quality assurance process, but it does not specify a timeframe for implementation.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Following Mr [name redacted] death, HMP Winchester undertook a review of the quality assurance checks in place to ensure these are being completed appropriately, and which resulted in the implementation of a system for accountability which has robust procedures to follow up any identified concerns and promote effective practice throughout the staff group.”
“This document was developed as part of a multiyear cooperative agreement between the National Institute of Corrections (NIC) and the Crime and Justice Institute (CJI) for an initiative entitled Implementing Effective Correctional Management in the Community.”
Implementing Evidence-Based Practice in Community ... · pa.gov/…/EBP1.pdf
“Accountability and Models for Accountability Association for the Prevention of Torture and the Office for Democratic Institutions and Human Rights, Monitoring Places for Detention: A Practical Guide for NGOs [non-governmental organizations], December 2002, https://tortureprevention.ch/content/files_res/monitoring-guide-for-ngos-en.pdf accessed 6/19/2020”
IMPROVING ACCOUNTABILITY AND TRANSPARENCY IN ... · cipp.org/uploads/3/7/5/7/37578255/2_25_2021.pdf
“Prisons- Transparency and Accountability Policy Overview As jails and prisons are inherently closed institutions, persons detained in them are particularly susceptible to abuse and human rights violations, violence, overcrowding, sexual assault, and poor living and working conditions.”
Prisons— Transparency and Accountability · opengovpartnership.org/…/Open-Justice_Justice-II_Prisons_Dec202…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible.”
The promised review of ligature-resistant cells is described as ongoing without a specific completion date.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The reforms proposed in the Bill will speed up access to specialist inpatient care and treatment by introducing a new statutory time limit of 28 days for the transfer of patients from prison and other places of detention to hospital.”
“The Mental Health Act 2025, which introduces a statutory 28-day deadline for transfers to take place, is due to be implemented by the end of”
#newsround: Mental Health Act 'may fail to get prisoners ... · facebook.com/…/1393676439456365
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at”
“The ambition of the 18 month 'Cell Furniture' project was to engage with HMPPS staff and prisoners via co-creation processes to improve safety, functionality, robustness and sustainability of prison furniture that was often destroyed - what prisoners term "flat packed"1”
Made in Prison – Understanding knowledge exchange, co ... · ualresearchonline.arts.ac.uk/…/2021_Gamman%20and%20Caulfield_Ma…
“His Majesty's Prison and Probation Service | Headquarters at [102 Petty France](https://en.wikipedia.org/wiki/102_Petty_France "102 Petty France"), London | | [Executive Agency”
HM Prison and Probation Service - Wikipedia · en.wikipedia.org/wiki/HM_Prison_and_Probation_Service
No evidence found does not mean the action did not happen.