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Adam Clark: Prevention of future deaths report (1)

27 Jul 2026 · Coroner David Reid · Worcestershire
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The coroner's concerns

  1. 1. lack of suicide and self-harm risk training for prison staff

    “a maths tutor at HMP Hewell, who had noted significant concerns about the deceased's mental health at the end of November 2024 ( only a week before he died ), had not received any training about (a) the risk of suicide and/or self-harm in prisoners, or (b) the Assessment, Care in Custody and Teamwork ( ACCT ) process which is designed to protect those prisoners at increased risk of self-harm, since she had started working at the prison in June 2024”

  2. 2. ongoing training deficit among prison staff

    “there were still staff working at the prison who had not received this training”

  3. 3. delayed implementation of training measures

    “measures had been put in place to address this "training deficit" within the next 4 weeks ( i.e. by 19.8.26 )”

Responses

2026-0379-Response-from-HM-Prison-Probation-Service.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Adam Clark: Prevention of future deaths report (1) · Recurance