Dean Saunders

“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with | the result that mandatory provisions in the ACCT process were not being adhered to.”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”

“The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction”

“In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure.”

“The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody.”

“Despite not being informed by the BCPFT liaison and diversion nurse that Mr [name redacted] was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018.”

“The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner's family.”

“There was no involvement of the family and so a source of important information was missed.”

“FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody.”

“The L&D police custody suite model has not commissioned psychiatrists.”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”

“The training of agency staff in the ACCT process and recognising the appropriate threshold to open an ACCT. The training of agency staff in ACCT does not appear to be part of the commissioning process by NHS England”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet”

“3. Training of staff in the ACCT process. 4. Prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”

“I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison.”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training”

“The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POELT training and the other 1 month experience.”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”

“Officers involved in Mr [name redacted] ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork.”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff”

“(3) When Prison Officers and/or Healthcare staff are given ACCT induction training at HMP Wandsworth, there is no training in the principles of risk formulation”