Delayed ACCT case review and documentation failure
HMP Hewell received 2 coroners' reports about this hazard between 16 Sept 2013 and 17 Sept 2021.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view.”
Original on judiciary.uk ↗ HMP Hewell responded, stating 1 specific action.Response (PDF) ↗
“Since Mr [name redacted]' death, HMP Bristol has introduced a system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm. In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments. These conversations are recorded on Prison-NOMIS”
- 8 years laterClosely relatedConfidence 0.80 · moderatea different coroner
“that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
Original on judiciary.uk ↗ Repeated from the earlier report:ACCTwithin
HMP Hewell responded.Response (PDF) ↗
- All reports to HMP Hewell
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.
2013 → 2021Colin Blackburn8 years after Reggie Johns · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in the proper use and documentation of the ACCT (Assessment, Care in Custody and Teamwork) process concerning prisoner safety.
Reggie Johns · 16 Sept 2013
“(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view.”
Original on judiciary.uk ↗ Colin Blackburn · 17 Sept 2021
“that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Since Mr [name redacted]' death, HMP Bristol has introduced a system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm. In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments. These conversations are recorded on Prison-NOMIS”
Stated action
“Since Mr [name redacted]' death, HMP Bristol has introduced a system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm. In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments. These conversations are recorded on Prison-NOMIS”
No specific action could be extracted with a verified quote.
- 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 HMP Hewell 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 |
|---|---|---|---|---|
| 2013 → 2021 | 0.66 | 0.05 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.