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recurance

Inadequate ACCT training and supervision leading to observation failures

Closely relatedConfidence 0.90 · high2 reports · 2019–2023No published response to an earlier report One-page brief (print or PDF)

His Majesty's Prison and Probation Service received 2 coroners' reports about this hazard between 10 Dec 2019 and 19 Dec 2023.

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.

2
reports
2
different coroners
2019–2023
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Daniel Akam↗

    10 Dec 2019 · Georgina Gibbs · South Yorkshire (East)

    “Unless adequate and repeated ACCT training is provided for all officers, particularly for those junior and more inexperienced officers”
    Original on judiciary.uk ↗

    No published response from His Majesty's Prison and Probation Service was found for this report.

  2. 4 years later

    Raised again · 1st time

    Martin Willis↗

    19 Dec 2023 · John Ellery · Shropshire, Telford and Wrekin

    Closely relatedConfidence 0.90 · higha different coroner
    “The ACCT procedure was not properly implemented, complied with or supervised.”
    Original on judiciary.uk ↗

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “I will be presenting an Operational Briefing on 21st December to all staff, taking into consideration the Governors Order GO 01/2023 which reads as follows: The purpose of this Governors Orders is to make you aware that it is the responsibility of the Cleaning Officer to ensure that ACCT observations and conversations are conducted and recorded in the ACCT document between the hours of 0745 - 1715. Between the hours of 1745 - 1915 an Officer will be detailed on the Night Orderly Officers detail”

    Stated timescale: 21st December

  3. All reports to His Majesty's Prison and Probation Service

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error