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recurance

Martin Willis

19 Dec 2023 · Coroner John Ellery · Shropshire, Telford and Wrekin

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

No concerns could be extracted with a verified quote. Read the original report.

Linked reports

Repeats an earlier warningDaniel Akam10 Dec 2019 · 4 years earlier
Closely relatedConfidence 0.90 · high

Earlier report

“Unless adequate and repeated ACCT training is provided for all officers, particularly for those junior and more inexperienced officers”
Original on judiciary.uk ↗

This report

“The ACCT procedure was not properly implemented, complied with or supervised.”
Full chain: Inadequate ACCT training and supervision leading to observation failures

Responses

2024-0171-Response-from-HMPPS.pdf ↗· His Majesty's Prison and Probation Service

Stated action · 21st December

“I will be presenting an Operational Briefing on 21st December to all staff, taking into consideration the Governors Order GO 01/2023 which reads as follows: The purpose of this Governors Orders is to make you aware that it is the responsibility of the Cleaning Officer to ensure that ACCT observations and conversations are conducted and recorded in the ACCT document between the hours of 0745 - 1715. Between the hours of 1745 - 1915 an Officer will be detailed on the Night Orderly Officers detail”

2024-0171-Response-from-Midlands-Partnership-University.pdf ↗· Midlands Partnership NHS Foundation Trust

Stated action · July 2024

“The ACCT procedure was not properly implemented, complied with or supervised. A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.”

Stated action · July 2024

“All Midlands Partnership University NHS Foundation Trust staff working in HMP YOI Stoke Heath are required to complete suicide prevention training and also the ACCT training provided by HMP YOI Stoke Heath. Completion timescale July 2024.”

Stated action · September 2024

“In addition to the above actions the Midlands Partnership University NHS Foundation Trust have commenced discussions with NHS England regarding a review of their Standard Operating Procedure concerning the referral of and transfer of prisoners to prison establishments with a hospital wing which was an agreed outcome of the inter-agency review. Completion timescale September 2024.”

Stated action

“The interagency review was conducted on 29th January 2024, as part of our on-going service delivery commitments we will conduct on-going meetings with the Shropshire Community Health NHS Trust and HMP YOI Stoke Heath.”

2024-0171-Response-from-North-Staffordshire-Combined-Healthcare.pdf ↗· North Staffordshire Combined Healthcare NHS trust

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error