Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Craig Bell · 9 Mar 2015 · Nigel Meadows, Manchester City
“there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures )”
What was promised
Stated action 1 · response to Lee Rushton (19 Jan 2016) · stated timescale: none stated
“providing clear information for staff and prisoners about the ACCT process and their role in it”
judiciary.uk/…/Lee-Rushton-Liverpool-Regulation-28-response.pdf
Stated action 2 · response to Stephen Cope (30 Sept 2021) · stated timescale: July 2021
“implemented across the prison estate in July 2021”
Stated action 3 · response to Yasmin Adams (20 Jun 2024) · stated timescale: April 2021
“In April 2021, as part of a wider organisational change, HMP Foston Hall implemented ACCT version 6. The new version of the ACCT document was developed following a review of the previous version, and is designed to encourage a person-centred and multidisciplinary case management approach. In addition to the introduction of the new document, guidance documents that focus on various aspects including the ongoing record were produced to assist staff in conducting their duties. The ongoing record”
What recurred
- 19 Jan 2016 · Lee Rushton · Andre Rebello
- 30 Sept 2021 · Stephen Cope · Dr Julian Morris · Closely related · confidence 0.85 (high)
- 20 Jun 2024 · Yasmin Adams · Peter Nieto · Closely related · confidence 0.80 (moderate)
- 4 Dec 2024 · Kayleigh Melhuish · M.E. Voisin · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Lee Rushton · 19 Jan 2016
“When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others.”
Later · Kayleigh Melhuish · 4 Dec 2024
“ACCT, 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;”
What happened next
No evidence found either way · stated action 1
“A Short Guide to the Ministry of Justice Legal aid HM Courts & Tribunals Service Prison Service Probation Service Appendices Overview”
A short guide to the Ministry of Justice · nao.org.uk/…/A-Short-Guide-to-the-Ministry-of-Justice.pdf
“The MoJ is a large Department, controlled from a small central core. In order to carry out its responsibilities it devolves the delivery of many of its functions to Arm's Length Bodies (ALBs).”
House of Commons - The budget and structure of the Ministry of Justice - Justice Committee · publications.parliament.uk/…/9705.htm
No evidence found does not mean the action did not happen.