Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate ACCT documentation and healthcare absence during reviews
The earlier warning
Ian Brown · 26 May 2016 · Thomas Osborne, Milton Keynes
“(1)During the course of the evidence | was referred to the most recent report from the HM Inspector of Prisons that highlighted”
What was promised
Stated action 1 · response to Ian Brown (26 May 2016) · stated timescale: none stated
“The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open.”
What recurred
- 6 Nov 2019 · Darren Williams · Tom Osborne · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Ian Brown · 26 May 2016
“(1)During the course of the evidence | was referred to the most recent report from the HM Inspector of Prisons that highlighted”
Later · Darren Williams · 6 Nov 2019
“it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance.”
What happened next
No web check of the stated actions has been published for this chain.