Kayleigh Melhuish
4 Dec 2024 · Coroner M.E. Voisin · Avon
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of mandatory neurodiversity and ACCT training leading to insufficient supervision and care plan compliance
“training issues in relation to the following areas for new and existing staff: Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory; 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; Little or no understanding of when constant supervision can be used and how is it used; Healthcare (AWP and PPG): training issues arose”
2. ligature point creating suicide risk
“the ligature point in Residential Unit 3 where the privacy screen meets the wall”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“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;”
Closely relatedConfidence 0.90 · high
This report
“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;”
Later report
“- the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
Responses
2024-0672-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-Trust.pdf ↗· Avon and Wiltshire Mental Health Partnership NHS Trust
2024-0672-Response-from-HMPPS.pdf ↗· Avon and Wiltshire Mental Health Partnership NHS Trust
Stated action
“We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison.”
2024-0672-Response-from-Practice-Plus-Group.pdf ↗· Practice Plus Group
Stated action
“We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions.”