Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate ACCT training and knowledge gaps
The earlier warning
Kayleigh Melhuish · 4 Dec 2024 · M.E. Voisin, Avon
“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;”
judiciary.uk/…/kayleigh-melhuish-prevention-of-future-deaths-re…
What was promised
Stated action 1 · response to Kayleigh Melhuish (4 Dec 2024) · stated timescale: none stated
“We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions.”
judiciary.uk/…/2024-0672-Response-from-Practice-Plus-Group.pdf
Stated action 2 · response to Kayleigh Melhuish (4 Dec 2024) · stated timescale: none stated
“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.”
What recurred
- 4 Jan 2026 · Rickie Poon · Mary Hassell · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Kayleigh Melhuish · 4 Dec 2024
“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;”
Later · Rickie Poon · 4 Jan 2026
“- the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
What happened next
No web check of the stated actions has been published for this chain.