Matthew Braben
1 Aug 2024 · Coroner Anton van Dellen · West London
This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. under-estimation of child's birth significance on mental health
“The birth of a child is not recognised as a specific risk factor in PSI 64/2011 which means that staff may under-estimate its significance on mental health.”
2. inadequate ACCT post-closure process after relocation
“The robustness of the process for ensuring that the ACCT post-closure process is followed, particularly following a move to another location.”
3. insufficient staff training in ACCT process
“Training of staff in the ACCT process.”
4. prisoners confined up to 23 hours daily harming mental health
“Prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.”
5. shortage of gym instructors causing prolonged cell confinement harming mental health
“The manner of training of gym instructors which entails potential trainees having to attend training at a distant location for significant period of times rather than locally as well as the length of the course, both of which serve as significant disincentives for staff to be trained as gym instructors. The shortage of gym instructors leads directly to more prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“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”
This report
“During the inquest, the evidence revealed matters giving rise to concern. - 1.”
Identical hazardConfidence 0.90 · high
Earlier report
“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”
This report
“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.”
Closely relatedConfidence 0.90 · high
This report
“The robustness of the process for ensuring that the ACCT post-closure process is followed, particularly following a move to another location. 3. Training of staff in the ACCT process.”
Later report
“observations were explained but I didn't have a fair idea what to do or how to undergo the process”
Identical hazardConfidence 0.90 · high
This report
“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.”
Later report
“(2) 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. Capacity to provide training to frontline officers and other civilian staff within the prison appeared to be limited.”
Responses
No published response was found on judiciary.uk.