Michael Pugh
25 Jul 2025 · Coroner Patricia Harding · Kent and Medway
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. incomplete understanding of ACCT process
“observations were explained but I didn't have a fair idea what to do or how to undergo the process”
Linked reports
Closely relatedConfidence 0.80 · moderate
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
“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
Earlier report
“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier 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.”
This report
“observations were explained but I didn't have a fair idea what to do or how to undergo the process”