John Betteridge

“The Doctor who saw Mr. [name redacted] for the second health screen on the day after admission had not received ACCT training as required by PS1 64/2011 and HMP Swansea Suicide Prevention Policy 2010 and was not aware of the requirement for him to be trained in the procedures although he was aware of the procedures.”

“A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training.”

“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with | the result that mandatory provisions in the ACCT process were not being adhered to.”

“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 yet the same mistakes are being repeated.”

“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”

“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”

“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”

“The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”

“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”

“During the inquest, the evidence revealed matters giving rise to concern. - 1.”

“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”

“observations were explained but I didn't have a fair idea what to do or how to undergo the process”