Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate ACCT documentation and communication
The earlier warning
Matthew Russell · 27 Nov 2016 · Richard Travers, Surrey
“Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”
judiciary.uk/prevention-of-future-death-reports/matthew-russell
What was promised
Stated action 1 · response to Matthew Russell (27 Nov 2016) · stated timescale: none stated
“prescriber is responsible for ensuring the ongoing monitorin effectiveness of medication, including side effects (GPs and CNWL Psychiatrists/ NMP). This is supported through: e In-line with community equivalence the GP would continue with repeat prescribing but would ensure the treatment plan assures them that the patient is in receipt of the appropriate level of supervision via primary care services. However, should the GP have any concerns around ongoing monitoring or psychological”
judiciary.uk/…/2016-0430-Response-by-Central-and-North-West-Lon…
Stated action 2 · response to Sarah Reed (28 Jul 2017) · stated timescale: July 2017
“psychiatric reports. Work to review the procedures for obtaining and providing psychiatric reports is already underway, recognising the particular gap in relation to provision of reports for the purposes of fitness to plead. Following your letter to , Chief Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re- issued existing guidance from 2010 on this process, with the caveat that it is recognised that some information may be out of date. The Senior Presiding Judge has”
Stated action 3 · response to Sarah Reed (28 Jul 2017) · stated timescale: none stated
“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.”
8 further stated actions are listed on the full chain page.
What recurred
- 28 Jul 2017 · Sarah Reed · Sir Peter Thornton QC · Closely related · confidence 0.85 (high)
- 24 Mar 2026 · Ronald Meikle · Sean Cummings · Closely related · confidence 0.80 (moderate)
- 13 May 2026 · Roy Sinclair · Sean Cummings · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.