Recurance · prevention of future deaths reports
Pre-inquest brief
Risk of suicide and self-harm in newly arrived prisoners
The earlier warning
Daniel Byrne · 14 Dec 2015 · Thomas Osborne, Milton Keynes
“staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.”
judiciary.uk/prevention-of-future-death-reports/daniel-byrne-2
What was promised
Stated action 1 · response to Daniel Byrne (14 Dec 2015) · stated timescale: January 2016
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre.”
Stated action 2 · response to Daniel Byrne (14 Dec 2015) · stated timescale: January 2016
“The reviews will evaluate existing procedures which relate to all aspects of safer custody including suicide prevention and self-harm management and violence reduction. The reviews will look to explore the following issues; = Early days in custody - Transfer from court/ reception timings, reception interview and assessment, first night interview and induction package, healthcare screening and mental health referrals; = Assessment, Care in Custody and Teamwork - compliance and delivery, quality”
Stated action 3 · response to Roy Hoey (13 Oct 2016) · stated timescale: endjof April 2017
“NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the endjof April 2017.”
What recurred
- 13 Oct 2016 · Roy Hoey · Andre Rebello · Closely related · confidence 0.90 (high)
- 13 Sept 2017 · Sam Molyneux · Andre Rebello · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Daniel Byrne · 14 Dec 2015
“staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.”
Later · Roy Hoey · 13 Oct 2016
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
What happened next
No web check of the stated actions has been published for this chain.