Samuel Gale
23 Oct 2015 · Coroner John Sleightholme · South Yorkshire (East)
The coroner's concerns
1. closure of ACCT by unauthorized staff
“The ACCT was closed by a person who had previous dealings with [the deceased] without reference to healthcare, the chaplaincy or a unit manager or any officer who had carried out an ACCT review.”
2. potential misuse of authority to close ACCT
“Deputy Director was asked to consider whether only the person who is primarily responsible for a prisoner's ACCT should be the one to close it”