Saul Thomas
21 Dec 2021 · Coroner David Reid · Worcestershire
The coroner's concerns
1. lack of ACCT training among staff
“an ACCT document should have been opened for Mr [name redacted] at HMP Birmingham at some point after 11.5.19, and that a failure so to do probably caused or contributed to his death”
2. inadequate handover of mental health information
“the unsatisfactory handover about Mr [name redacted] provided by HMP Birmingham to HMP Hewell possibly caused or contributed to his death”