Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate staff training and understanding of ACCT protocol
The earlier warning
Satheeskumar Mahatheaven · 19 Sept 2014 · ME Hassell, London Inner (North)
“inadequate training for staff at the prison services have contributed to this accident.”
What was promised
Stated action 1 · response to Satheeskumar Mahatheaven (19 Sept 2014) · stated timescale: 28 November 2014
“Action should therefore be taken to prevent future deaths and I believe that you have the power to take such action.”
Stated action 2 · response to Satheeskumar Mahatheaven (19 Sept 2014) · stated timescale: none stated
“Local policies are now in place at HMP Pentonville and HMP Thameside to ensure that information is shared appropriately and that there is effective communication between prison staff and the healthcare provider.”
What recurred
- 28 Mar 2017 · John Williams · ME Hassell · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Satheeskumar Mahatheaven · 19 Sept 2014
“inadequate training for staff at the prison services have contributed to this accident.”
Later · John Williams · 28 Mar 2017
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
What happened next
No web check of the stated actions has been published for this chain.