Kevin McDonnell
7 Aug 2024 · Coroner Laurinda Bower · Nottingham City and Nottinghamshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. meaningless ACCT observations
“Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose. Witnesses repeatedly described these checks as simply”
2. failure to share risk pertinent information
“Prison staff have not read and understood the July 2021 annex to PSI 64/2011. There was a failure to share risk pertinent information about [the deceased] to all staff caring for him that day.”
3. failure to secure and retain documentary evidence
“Failure to secure and retain documentary evidence following a death in custody. If post-death investigations are misled by inaccurate documentation that has been amended post-death, then the ability to learn from deaths in custody will be hampered.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“(1) CCTV evidence in the inquest established that 18 observations on Mr [name redacted] were not carried out.”
This report
“Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose.”
Responses
2024-0433-Response-from-HM-Prison-and-Probation-Service.pdf ↗· His Majesty's Prison and Probation Service
Stated action
“HMPPS is committed to ensuring that all staff are equipped with the necessary skills and knowledge to perform their role effectively and safely. I have been informed by the Governor of HMP Nottingham that the prison have increased their delivery of SASH/ACCT awareness and upskilling via training days and one-to-one refresher sessions, resulting in a greater number of staff being trained in these areas. The prison will continue to offer ACCT training and upskilling sessions to all staff to increase”