Inadequate ACCT training leading to incomplete documentation

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. ?Every quote shown was checked by code to appear word for word in the original report.

• 2014 → 2016John Betteridge2 years 1 month after Matthew Purser · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that staff were performing duties without having received required ACCT training, leading to failures in following the ACCT process.

  Matthew Purser · 30 May 2014

  “The Doctor who saw Mr. [name redacted] for the second health screen on the day after admission had not received ACCT training as required by PS1 64/2011 and HMP Swansea Suicide Prevention Policy 2010 and was not aware of the requirement for him to be trained in the procedures although he was aware of the procedures.”

  Check it in the source

  John Betteridge · 30 Jun 2016

  “A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2014 → 2016Liam Lambert1 year 9 months after Geraldine Kilborn · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that the Assessment, Care in Custody and Teamwork (ACCT) document was not properly read or used during reviews, leading to reliance on incomplete information.

  Geraldine Kilborn · 10 Dec 2014

  “Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”

  Check it in the source

  Liam Lambert · 20 Sept 2016

  “Available documentary information was not read or used, and pressures of time were cited to explain these failings.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2017Dean Saunders8 months after John Betteridge · different coronerIdentical hazardConfidence 0.92 · high

  Identical hazardConfidence 0.92 · high

  Both reports highlight insufficient training of staff on the ACCT process as a safety concern. They describe the same hazard—lack of proper ACCT training leading to non‑adherence with mandatory procedures.

  John Betteridge · 30 Jun 2016

  “some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with | the result that mandatory provisions in the ACCT process were not being adhered to.”

  Check it in the source

  Dean Saunders · 17 Feb 2017

  “Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2017Sarah Reed10 months after Liam Lambert · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures in the proper completion and review of the ACCT document concerning prisoner safety. The earlier report cites incomplete documentation and lack of accompaniment, while the later report notes that team members did not fully review the ACCT document before decisions.

  Liam Lambert · 20 Sept 2016

  “The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have and not all appropriate individuals were invited to the reviews.”

  Check it in the source

  Sarah Reed · 28 Jul 2017

  “(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2019Ryan Trimmer3 years after John Betteridge · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight problems with the ACCT process stemming from insufficient staff training and inadequate application of its requirements.

  John Betteridge · 30 Jun 2016

  “some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”

  Check it in the source

  Ryan Trimmer · 21 Jun 2019

  “The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2017 → 2023Thomas Huntley5 years 5 months after Mark Doyle · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight that information vital for ACCT assessments is not shared because healthcare and prison staff use separate systems (SystemOne vs NOMIS) and rely solely on the ACCT document. The later report stresses the same lack of cross‑system review, while the earlier one adds concerns about trigger factors and staff familiarity.

  Mark Doyle · 18 Dec 2017

  “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”

  Check it in the source

  Thomas Huntley · 14 May 2023

  “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”

  Check it in the source

  Stated action in the response to the earlier report

  “Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”

  Earlier report in the app · Later report in the app

• 2019 → 2024Frazer Williams4 years 11 months after Ryan Trimmer · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports identify problems with the Assessment, Care in Custody and Teamwork (ACCT) process concerning its effectiveness and record‑keeping. The earlier report cites an ineffective ACCT process and inadequate reviews, while the later report highlights incomplete and inadequate ACCT records and missed case reviews.

  Ryan Trimmer · 21 Jun 2019

  “The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”

  Check it in the source

  Frazer Williams · 31 May 2024

  “An ACCT was opened in relation to [the deceased] on the 15th January 2022 and remained open until his death. Between 15th January and 7th March 2022 there were 11 case reviews.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2024Frazer Williams7 years 8 months after Liam Lambert · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight problems with the Assessment, Care in Custody and Teamwork (ACCT) documentation process, specifically incomplete or inadequate records. They differ in the particular aspects emphasized: the earlier report focuses on missing documentation and lack of accompaniment, while the later report stresses missed case reviews and gaps in quality assurance.

  Liam Lambert · 20 Sept 2016

  “The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have and not all appropriate individuals were invited to the reviews.”

  Check it in the source

  Frazer Williams · 31 May 2024

  “The ACCT records were incomplete and inadequate. The last case review took place on 1st March 2022. The next case review was scheduled for 3rd March 2022, however this did not take place and there was no further case review prior to [the deceased]'s death.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2017 → 2024Matthew Braben7 years 5 months after Dean Saunders · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight deficiencies in staff training concerning the ACCT process.

  Dean Saunders · 17 Feb 2017

  “Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet”

  Check it in the source

  Matthew Braben · 1 Aug 2024

  “3. Training of staff in the ACCT process. 4. Prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2024Matthew Braben8 years 1 month after John Betteridge · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight insufficient training of staff in the ACCT process as a safety concern. The earlier report describes specific gaps in training leading to non‑adherence, while the later report lists training of staff in the ACCT process as a distinct area needing improvement.

  John Betteridge · 30 Jun 2016

  “some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”

  Check it in the source

  Matthew Braben · 1 Aug 2024

  “During the inquest, the evidence revealed matters giving rise to concern. - 1.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2019 → 2025Sarah Boyle5 years 10 months after Ryan Trimmer · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify the ACCT process/system as ineffective in preventing self‑harm or suicide. The earlier report concerns HMP Lewes while the later report concerns HMP Styal, differing in setting.

  Ryan Trimmer · 21 Jun 2019

  “The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”

  Check it in the source

  Sarah Boyle · 2 May 2025

  “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2017 → 2025Sarah Boyle8 years 2 months after Dean Saunders · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports focus on the ACCT process used to manage prisoners at risk of self‑harm. The earlier report highlights inadequate training, while the later report notes the process itself is not working effectively.

  Dean Saunders · 17 Feb 2017

  “Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”

  Check it in the source

  Sarah Boyle · 2 May 2025

  “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2025Patryk Gladysz2 years 2 months after Thomas Huntley · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight problems with communication and information sharing between prison and healthcare staff concerning access to the NOMIS system.

  Thomas Huntley · 14 May 2023

  “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.”

  Check it in the source

  Patryk Gladysz · 18 Jul 2025

  “(b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff;”

  Check it in the source

  Stated action in the response to the earlier report

  “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.”

  Earlier report in the app · Later report in the app

• 2017 → 2025Michael Pugh8 years 5 months after Dean Saunders · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight inadequate training or understanding of the ACCT process among prison staff. They describe a gap between training provided and actual competence in applying the process.

  Dean Saunders · 17 Feb 2017

  “Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training”

  Check it in the source

  Michael Pugh · 25 Jul 2025

  “The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POELT training and the other 1 month experience.”

  Check it in the source

  Stated action in the response to the earlier report

  “The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Michael Pugh1 year after Matthew Braben · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight inadequate training of prison staff in the ACCT process, leading to misunderstandings about how to conduct observations. The earlier report notes a general lack of training, while the later report gives a concrete example of new officers being unsure what to do.

  Matthew Braben · 1 Aug 2024

  “The robustness of the process for ensuring that the ACCT post-closure process is followed, particularly following a move to another location. 3. Training of staff in the ACCT process.”

  Check it in the source

  Michael Pugh · 25 Jul 2025

  “observations were explained but I didn't have a fair idea what to do or how to undergo the process”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2025Michael Pugh9 years 1 month after John Betteridge · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight that prison staff lacked adequate training or understanding of the ACCT process, leading to failures in following required procedures. The earlier report notes untrained staff overall, while the later report describes new recruits with incomplete knowledge of observation specifics.

  John Betteridge · 30 Jun 2016

  “some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”

  Check it in the source

  Michael Pugh · 25 Jul 2025

  “observations were explained but I didn't have a fair idea what to do or how to undergo the process”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2017 → 2025Azroy Dawes-Clarke (3)8 years 5 months after Dean Saunders · different coronerIdentical hazardConfidence 0.94 · high

  Identical hazardConfidence 0.94 · high

  Both reports highlight deficiencies in staff training concerning the Assessment, Care in Custody and Teamwork (ACCT) process. They note inconsistent familiarity, difficulty with paperwork, and limited capacity to deliver training.

  Dean Saunders · 17 Feb 2017

  “Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”

  Check it in the source

  Azroy Dawes-Clarke (3) · 29 Jul 2025

  “Officers involved in Mr [name redacted] ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2025Azroy Dawes-Clarke (3)1 year after Matthew Braben · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight insufficient or inconsistent training of staff in the ACCT process, leading to concerns about proper implementation and record‑keeping.

  Matthew Braben · 1 Aug 2024

  “3. Training of staff in the ACCT process. 4. Prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.”

  Check it in the source

  Azroy Dawes-Clarke (3) · 29 Jul 2025

  “(2) Officers involved in Mr [name redacted] ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork. Capacity to provide training to frontline officers and other civilian staff within the prison appeared to be limited.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2026Roy Sinclair3 years after Thomas Huntley · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight problems with the ACCT document as the primary means of sharing information between healthcare and prison staff, noting gaps in recording and communication.

  Thomas Huntley · 14 May 2023

  “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.”

  Check it in the source

  Roy Sinclair · 13 May 2026

  “After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”

  Check it in the source

  Stated action in the response to the earlier report

  “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.”

  Earlier report in the app · Later report in the app

• 2016 → 2026Roy Sinclair9 years 8 months after Liam Lambert · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight problems with the completion, communication, and use of ACCT documentation in prisons.

  Liam Lambert · 20 Sept 2016

  “The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have and not all appropriate individuals were invited to the reviews.”

  Check it in the source

  Roy Sinclair · 13 May 2026

  “After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2026Roy Sinclair1 year 11 months after Frazer Williams · different coronerClosely relatedConfidence 0.86 · high

  Closely relatedConfidence 0.86 · high

  Both reports highlight problems with the Assessment, Care in Custody and Teamwork (ACCT) documentation system, specifically its incomplete or inadequate recording and use.

  Frazer Williams · 31 May 2024

  “The ACCT records were incomplete and inadequate. The last case review took place on 1st March 2022. The next case review was scheduled for 3rd March 2022, however this did not take place and there was no further case review prior to [the deceased]'s death.”

  Check it in the source

  Roy Sinclair · 13 May 2026

  “The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation. After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”

  Check it in the source

  Earlier report in the app · Later report in the app