Inadequate ACCT review for high-risk prisoners
Ministry of Justice received 5 coroners' reports about this hazard between 9 Mar 2015 and 4 Dec 2024.
They came from 5 different coroners in 5 coroner areas. A similar concern was raised again 4 times after the first warning.
A published response was found for 3 of the 4 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures )”
Original on judiciary.uk ↗ No published response from Ministry of Justice was found for this report.
- 10 months later
“When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others.”
Original on judiciary.uk ↗ Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“providing clear information for staff and prisoners about the ACCT process and their role in it”
Web search (Tavily): No evidence found either way
A short guide to the Ministry of Justice ↗ - 5 years 8 months laterClosely relatedConfidence 0.85 · higha different coroner
“I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.”
Original on judiciary.uk ↗ Repeated from the earlier report:ACCTcareinmate
Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“implemented across the prison estate in July 2021”
Stated timescale: July 2021
- 2 years 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“'Normal' or 'standard' cells may not be best for cellular confinement, particularly for a prisoner placed on an ACCT”
Original on judiciary.uk ↗ Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“In April 2021, as part of a wider organisational change, HMP Foston Hall implemented ACCT version 6. The new version of the ACCT document was developed following a review of the previous version, and is designed to encourage a person-centred and multidisciplinary case management approach. In addition to the introduction of the new document, guidance documents that focus on various aspects including the ongoing record were produced to assist staff in conducting their duties. The ongoing record”
Stated timescale: April 2021
- 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
Original on judiciary.uk ↗ Repeated from the earlier report:ACCTcare
Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison.”
- All reports to Ministry of Justice
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.
2016 → 2021Stephen Cope5 years 8 months after Lee Rushton · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight concerns that the ACCT review process may be insufficient when circumstances change, such as a CSRA indicating solitary confinement or a prisoner transfer. They differ in focusing on policy reminders/training versus procedural safeguards for transfers.
Lee Rushton · 19 Jan 2016
“When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others.”
Original on judiciary.uk ↗ Stephen Cope · 30 Sept 2021
“I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“providing clear information for staff and prisoners about the ACCT process and their role in it”
2015 → 2024Yasmin Adams9 years 3 months after Craig Bell · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that the prison estate lacks sufficient cells designed to safely hold prisoners under ACCT or similar risk management. The earlier report focuses on the shortage of safer cells across wings, while the later report questions whether standard cells are appropriate for cellular confinement of ACCT prisoners.
Craig Bell · 9 Mar 2015
“there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures )”
Original on judiciary.uk ↗ Yasmin Adams · 20 Jun 2024
“'Normal' or 'standard' cells may not be best for cellular confinement, particularly for a prisoner placed on an ACCT”
Original on judiciary.uk ↗ 2016 → 2024Yasmin Adams8 years 5 months after Lee Rushton · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight concerns about placing prisoners under ACCT in standard prison cells that may be unsafe due to ligature points and limited observation.
Lee Rushton · 19 Jan 2016
“When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others.”
Original on judiciary.uk ↗ Yasmin Adams · 20 Jun 2024
“[the deceased] was subject to cellular confinement on a residential prison wing. 'Normal' or 'standard' cells may not be best for cellular confinement, particularly for a prisoner placed on an ACCT and therefore deemed at risk and vulnerable, due to cell environment and ligature points and less ability to check and observe by prison staff.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“providing clear information for staff and prisoners about the ACCT process and their role in it”
2016 → 2024Kayleigh Melhuish8 years 11 months after Lee Rushton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight shortcomings in staff understanding and application of the ACCT review process, particularly regarding care plan completion and updates.
Lee Rushton · 19 Jan 2016
“When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others.”
Original on judiciary.uk ↗ Kayleigh Melhuish · 4 Dec 2024
“ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“providing clear information for staff and prisoners about the ACCT process and their role in it”
No published response from Ministry of Justice was found for this report.
Stated action
“providing clear information for staff and prisoners about the ACCT process and their role in it”
What happened next: No evidence found either way
The Ministry of Justice has not published a specific guide detailing staff and prisoner information about the ACCT process.
“A Short Guide to the Ministry of Justice Legal aid HM Courts & Tribunals Service Prison Service Probation Service Appendices Overview”
“The MoJ is a large Department, controlled from a small central core. In order to carry out its responsibilities it devolves the delivery of many of its functions to Arm's Length Bodies (ALBs).”
No evidence found does not mean the action did not happen.
Stated action · timescale: July 2021
“implemented across the prison estate in July 2021”
Stated action · timescale: April 2021
“In April 2021, as part of a wider organisational change, HMP Foston Hall implemented ACCT version 6. The new version of the ACCT document was developed following a review of the previous version, and is designed to encourage a person-centred and multidisciplinary case management approach. In addition to the introduction of the new document, guidance documents that focus on various aspects including the ongoing record were produced to assist staff in conducting their duties. The ongoing record”
Stated action
“We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison.”
- 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 Ministry of Justice 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 |
|---|---|---|---|---|
| 2016 → 2021 | 0.76 | 0.11 | Closely related · 0.85 | different |
| 2015 → 2024 | 0.82 | 0.21 | Closely related · 0.80 | different |
| 2016 → 2024 | 0.77 | 0.10 | Closely related · 0.80 | different |
| 2016 → 2024 | 0.73 | 0.18 | Closely related · 0.90 | 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.