Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate ACCT document review and agency input documentation
The earlier warning
Geraldine Kilborn · 10 Dec 2014 · Andrew Tweddle, County Durham & Darlington
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
What was promised
Stated action 1 · response to Geraldine Kilborn (10 Dec 2014) · stated timescale: none stated
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
Stated action 2 · response to Geraldine Kilborn (10 Dec 2014) · stated timescale: April 2015
“From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model .The National Health Service Commissioning Board has procured seven services - GP Services including Pharmacy, Dental, Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services.”
Stated action 3 · response to Warren Sampson (6 Sept 2016) · stated timescale: within 72 hours
“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House.”
What recurred
- 6 Sept 2016 · Warren Sampson · Caroline Beasley-Murray · Closely related · confidence 0.70 (moderate)
- 28 Mar 2017 · John Williams · ME Hassell · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Geraldine Kilborn · 10 Dec 2014
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
Later · John Williams · 28 Mar 2017
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
What happened next
No web check of the stated actions has been published for this chain.