Roy Hoey
13 Oct 2016 · Coroner Andre Rebello · Liverpool and Wirral
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. confusion over safer custody guidance
“During the course of this investigation inquest a considerable amount of time was taken up with the detailed questioning of witnesses around the meaning of local and national safer custody guidance”
2. misinterpretation of guidance
“The court ruled that this general catch-all chapter covers everything covered by the policy, self-harm, violence and bullying of others and protection from others”
3. mandatory ACCT opening without assessment
“Any member of staff who receives information, including that from family members or external agencies, or observes behaviour which may indicate a risk of suicide/self-harm must open an ACCT by completing the Concern and Keep Safe form”
4. mandatory ACCT opening without assessment
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.”
This report
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
Closely relatedConfidence 0.90 · high
This report
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
Later report
“He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death.”
Responses
2016-0360-Response-by-NOMS.pdf ↗· His Majesty's Prison and Probation Service
Stated action · endjof April 2017
“NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the endjof April 2017.”