Frazer Williams
31 May 2024 · Coroner Rachael Griffin · Dorset
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of national directory for prison healthcare facilities
“no national directory that explains what healthcare facilities are available at each prison and PPG have created one internally for the prisons they provide healthcare at”
2. absence of guidance for managing self neglect in prison
“no national guidance on how to manage self neglect in prison”
3. lack of national specification for healthcare units
“no national specification in relation to healthcare units”
4. inadequate ACCT documentation
“ACCT records were incomplete and inadequate”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have and not all appropriate individuals were invited to the reviews.”
This report
“The ACCT records were incomplete and inadequate. The last case review took place on 1st March 2022. The next case review was scheduled for 3rd March 2022, however this did not take place and there was no further case review prior to [the deceased]'s death.”
Closely relatedConfidence 0.85 · high
Earlier report
“The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”
This report
“An ACCT was opened in relation to [the deceased] on the 15th January 2022 and remained open until his death. Between 15th January and 7th March 2022 there were 11 case reviews.”
Closely relatedConfidence 0.86 · high
This report
“The ACCT records were incomplete and inadequate. The last case review took place on 1st March 2022. The next case review was scheduled for 3rd March 2022, however this did not take place and there was no further case review prior to [the deceased]'s death.”
Later report
“The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation. After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Responses
2024-0294-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action
“The reforms proposed in the Bill will speed up access to specialist inpatient care and treatment by introducing a new statutory time limit of 28 days for the transfer of patients from prison and other places of detention to hospital.”
2024-0294-Response-from-HMPPS-HMP-Guys-Marsh.pdf ↗· HMP Guys Marsh
2024-0294-Response-from-NHS-England.pdf ↗· NHS England
2024-0294-Response-from-Unilink.pdf ↗· Unilink Software Ltd