Thomas Huntley
14 May 2023 · Coroner Robert Simpson · Hampshire, Portsmouth and Southampton
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. inadequate ACCT training and refresher training
“In evidence at the inquest ACCT assessors and case managers accepted that they had not complied with various mandatory actions required under PSI 64/2011: Managing Prisoner Safety in Custody”
2. incomplete information sharing between healthcare and prison staff
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff”
3. ligature points in cells for at-risk prisoners
“telephone points which provide a ligature point may remain within cells which prison and health care staff consider to be suitable for use by those at risk of self harm”
4. absence of certified safer cells
“lack of certified Safer Cells at HMP Winchester”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
This report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff”
Closely relatedConfidence 0.85 · high
This report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff.”
Later report
“(b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff;”
Closely relatedConfidence 0.90 · high
This report
“The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years.”
Later report
“I am concerned that as long as”
Closely relatedConfidence 0.92 · high
This report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff.”
Later report
“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Responses
2023-0461-Response-from-HM-Prison-and-Probation-Service-.pdf ↗· His Majesty's Prison and Probation Service
Stated action · end of 2023
“HMP Winchester is currently delivering monthly training and awareness sessions for all staff which incorporates both ACCT v6 and SASH training.”
Stated action
“The Safety Intervention Meeting (SIM) is a multi-disciplinary safety risk management meeting, chaired by the Senior Management Team (SMT), providing support and multi-disciplinary guidance to Case Coordinators and case review teams.”
Stated action
“All establishments are required to have an ACCT quality assurance process in place that ensures that quality assurance is carried out at a level and frequency that enables meaningful insight into how effectively support through ACCT is being implemented.”
Stated action
“Following Mr [name redacted] death, HMP Winchester undertook a review of the quality assurance checks in place to ensure these are being completed appropriately, and which resulted in the implementation of a system for accountability which has robust procedures to follow up any identified concerns and promote effective practice throughout the staff group.”
Stated action · too early to say
“The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible.”