Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete or meaningless ACCT observations in prison
The earlier warning
Daniel Akam · 10 Dec 2019 · Georgina Gibbs, South Yorkshire (East)
“(1) CCTV evidence in the inquest established that 18 observations on Mr [name redacted] were not carried out.”
What was promised
No published response from His Majesty's Prison and Probation Service was found for the earlier reports.
What recurred
- 7 Aug 2024 · Kevin McDonnell · Laurinda Bower · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Daniel Akam · 10 Dec 2019
“(1) CCTV evidence in the inquest established that 18 observations on Mr [name redacted] were not carried out.”
Later · Kevin McDonnell · 7 Aug 2024
“Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose.”
What happened next
No web check of the stated actions has been published for this chain.