Corin Bonaparte
7 May 2021 · Coroner Nicholas Rheinberg · Exeter and Greater Devon
The coroner's concerns
1. lack of adequate training
“[the deceased] sought help from the mental health department at HMP Dartmoor. He revealed to a nurse in the mental health department the fact that he had recently deliberately harmed himself and made this fact known to other mental health workers. An ACCT was not opened despite the provisions in Chapter 2 of PSI 64 / 2011 which made the opening of an ACCT in these circumstances mandatory. In the light of the evidence from relevant witnesses at the inquest hearing it could not be confidently assumed that”