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Sean Higgins

11 Mar 2025 · Coroner Patricia Harding · Mid Kent and Medway
Check this reportOriginal

The coroner's concerns

  1. 1. incomplete risk assessment

    “evidence was given at the inquest that some officers chairing reviews did not read relevant documentation beyond the last ACCT review prior to the review taking place”

  2. 2. premature closure of ACCT

    “Some of the officers chairing reviews did not understand how to complete the support plan paperwork such that the ACCT was closed when some of the support plans had not started or had not been completed”

Responses

2025-0133-Response-from-HMPPS.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error