Roy Sinclair
13 May 2026 · Coroner Sean Cummings · Milton Keynes
This report repeats 6 earlier warnings. See the linked reports.
The coroner's concerns
1. inaccurate ACCT documentation
“serious difficulty in the recording, communication, and use of ACCT documentation”
2. unclear overdose management framework
“no formal policy then in place governing paracetamol overdose”
3. uninvestigated source of paracetamol
“No prison intelligence report was raised after the first reported overdose”
4. unmanaged prisoner debt
“debt to other prisoners connected with vapes”
5. operational pressures compromising safeguarding
“serious staffing shortages, recruitment and retention difficulties”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have and not all appropriate individuals were invited to the reviews.”
This report
“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Closely relatedConfidence 0.90 · high
Earlier report
“Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”
This report
“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Closely relatedConfidence 0.90 · high
Earlier report
“(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
This report
“1.ACCT documentation and operation. The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“Failure to carry out ACCT observations recorded in the ACCT log”
This report
“serious difficulty in the recording, communication, and use of ACCT documentation”
Closely relatedConfidence 0.92 · high
Earlier report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff.”
This report
“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Closely relatedConfidence 0.86 · high
Earlier report
“The ACCT records were incomplete and inadequate. The last case review took place on 1st March 2022. The next case review was scheduled for 3rd March 2022, however this did not take place and there was no further case review prior to [the deceased]'s death.”
This report
“The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation. After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”