Incomplete or meaningless ACCT observations in prison
His Majesty's Prison and Probation Service received 2 coroners' reports about this hazard between 10 Dec 2019 and 7 Aug 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from His Majesty's Prison and Probation Service was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“(1) CCTV evidence in the inquest established that 18 observations on Mr [name redacted] were not carried out.”
Original on judiciary.uk ↗ No published response from His Majesty's Prison and Probation Service was found for this report.
- 4 years 8 months later
Raised again · 1st time
Kevin McDonnell↗
7 Aug 2024 · Laurinda Bower · Nottingham City and Nottinghamshire
Closely relatedConfidence 0.90 · higha different coroner“Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose.”
Original on judiciary.uk ↗ His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗
“HMPPS is committed to ensuring that all staff are equipped with the necessary skills and knowledge to perform their role effectively and safely. I have been informed by the Governor of HMP Nottingham that the prison have increased their delivery of SASH/ACCT awareness and upskilling via training days and one-to-one refresher sessions, resulting in a greater number of staff being trained in these areas. The prison will continue to offer ACCT training and upskilling sessions to all staff to increase”
- All reports to His Majesty's Prison and Probation Service
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2024Kevin McDonnell4 years 8 months after Daniel Akam · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that prison staff are not properly conducting ACCT observations, either by failing to perform them or by treating them as meaningless checks.
Daniel Akam · 10 Dec 2019
“(1) CCTV evidence in the inquest established that 18 observations on Mr [name redacted] were not carried out.”
Original on judiciary.uk ↗ Kevin McDonnell · 7 Aug 2024
“Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose.”
Original on judiciary.uk ↗
No published response from His Majesty's Prison and Probation Service was found for this report.
Stated action
“HMPPS is committed to ensuring that all staff are equipped with the necessary skills and knowledge to perform their role effectively and safely. I have been informed by the Governor of HMP Nottingham that the prison have increased their delivery of SASH/ACCT awareness and upskilling via training days and one-to-one refresher sessions, resulting in a greater number of staff being trained in these areas. The prison will continue to offer ACCT training and upskilling sessions to all staff to increase”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to His Majesty's Prison and Probation Service at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2024 | 0.85 | 0.40 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for His Majesty's Prison and Probation Service
- Obscured observation panels hinder monitoring3 reports · 2024–2026
- Lack of basic first aid training and CPR among prison officers12 reports · 2015–2026
- Inadequate ACCT training leading to incomplete documentation16 reports · 2014–2026
- Lack of certified safer cells outside segregation unit4 reports · 2023–2025
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.