Liam Lambert
20 Sept 2016 · Coroner Lydia Brown · Leicester City and Leicestershire South
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. incomplete ACCT documentation
“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. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.”
2. premature closure of ACCT
“This ACCT was only open for a short period. It did not serve [the deceased]'s needs properly and was closed before any review system picked up the inadequacies.”
3. insufficient resources for officer safety
“The Governor provided evidence that resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self harm. In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
This report
“Available documentary information was not read or used, and pressures of time were cited to explain these failings.”
Closely relatedConfidence 0.80 · moderate
This 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.”
Later report
“(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
Closely relatedConfidence 0.85 · high
This 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.”
Later 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.”
Identical hazardConfidence 0.90 · high
This 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.”
Later report
“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Responses
2016-0335-Response-by-NOMS.pdf ↗· His Majesty's Prison and Probation Service
Stated action
“Consideration should be given to formally confirming that all necessary documentation has been considered prior fo the ACCT review, and fo ensure the officers and Healthcare staff are aware of their responsibilities.”
Stated action · October 2016
“Anew scheduling system was also introduced in October 2016, and this will ensure that sufficien# time is allocated to all future case review meetings.”
Stated action · August 2016
“The Safer Custody toolkit that was introduced in August 2016 provides clear instructions to staff regarding ACCT procedures, including the importance of ensuring that ail relevant risks and triggers are considered before the ACCT document is closed.”
Stated action · September 2016
“In September 2016 ACCT case managers were reminded of the importance of a multi- discipiinary approach to ACCT reviews, particularly when making decisions to close the document”
Stated action · October 2016
“A notice has been issued to remind staff of their responsibilities when attending ACCT case reviews, and a local template for reviews was introduced In October 2016.”
Stated action
“Staffing levels in public sector prisons have been set through a benchmarking process, designed to provide sufficient staff for the prison to operate safely, decently and securely. .The Governor has raised concerns about the staffing level at [name redacted], and recently submitted a business case to increase by 12 prison officers the benchmark operating level set for the prison”