Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of relevant information sharing during ACCT reviews
The earlier warning
Geraldine Kilborn · 10 Dec 2014 · Andrew Tweddle, County Durham & Darlington
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews.”
What was promised
Stated action 1 · response to Geraldine Kilborn (10 Dec 2014) · stated timescale: none stated
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
Stated action 2 · response to Geraldine Kilborn (10 Dec 2014) · stated timescale: April 2015
“From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model .The National Health Service Commissioning Board has procured seven services - GP Services including Pharmacy, Dental, Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services.”
What recurred
- 18 Dec 2017 · Mark Doyle · Heather Williams · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Geraldine Kilborn · 10 Dec 2014
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews.”
Later · Mark Doyle · 18 Dec 2017
“Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner's ACCT in relation to matters that could bear on risk, 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 and the infrequent occasions that Care UK staff made entries on Mr [name redacted] ACCT daily record.”
What happened next
No evidence found either way · a stated action in a response
“When a loved one is sent to prison, it's natural to feel concerned about their well-being, especially in the unfamiliar environment of a custodial setting. One of the key priorities of the prison service is **safer custody**, which refers to the systems and procedures in place to protect individuals from harm, ensure their physical and mental well-being, and prevent self-harm or incidents of violence”
Prisoner Wellbeing (Safer Custody) - POPS · partnersofprisoners.co.uk/…/prisoner-wellbeing-safer-custody
No evidence found does not mean the action did not happen.