Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Dean Saunders · 17 Feb 2017 · Caroline Beasley-Murray, Essex
“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”
judiciary.uk/prevention-of-future-death-reports/dean-saunders
What was promised
Stated action 1 · response to Dean Saunders (17 Feb 2017) · stated timescale: none stated
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Stated action 2 · response to Jack Zarrop (2 Oct 2023) · stated timescale: none stated
“NHS England is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners (RCGP) and has been adopted by the National Prison Partnership Board1. The definition broadly states the aim is to ensure people detained in prisons in England, are offered provision of and access to appropriate services and”
What recurred
- 28 Mar 2017 · John Williams · ME Hassell
- 2 Oct 2023 · Jack Zarrop · Anton van Dellen · Closely related · confidence 0.85 (high)
- 19 Feb 2026 · Rajwinder Singh · Bernard Richmond · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Jack Zarrop · 2 Oct 2023
“The training of agency staff in ACCT does not appear to be part of the commissioning process by NHS England and individual providers do not appear to provide training to agency staff in the ACCT process.”
Later · Rajwinder Singh · 19 Feb 2026
“(2) There are no mandatory procedures to ensure that, before they are deployed in the prison setting, Oxleas agency staff have the same mandatory ACCT training as that provided to permanent healthcare staff.”
What happened next
Evidence found · stated action 1
“The commissioning of Healthcare for Police Custody Suites is to transfer to NHS England by 2016. This work will continue to be developed and”
Health and Justice Commissioning Intentions 2015/16 · england.nhs.uk/…/hj-comms-ints-refresh.pdf
No evidence found either way · stated action 2
The provided sources discuss the principle of equivalence of care for prisoners and its implementation challenges, but none confirm that NHS England has completed or published the promised regular data reporting on healthcare access and outcomes across prisons.
No evidence found does not mean the action did not happen.