Stuart Robinson
16 May 2023 · Coroner Kate Ainge · Liverpool and Wirral
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. prisoners with mental health issues entering prison
“significant numbers of prisoners who enter the prison system with known or undiagnosed mental health issues”
2. absence of mental health expert at ACCT reviews
“need for specific attendance of an RMN or other mental health expert at any review”
3. policy ensuring mental health attendance at ACCT reviews
“question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending.”
4. issues not identified by other professionals
“identify issues which may not be picked up by other professionals involved, to enable support to be put in place by way of separate care plans”
5. impact on SASH (self‑harm) in prison
“notable impact upon SASH in the prison”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
This report
“question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending.”
Responses
2023-0161-Response-from-HM-Prison-Probation-Service.pdf ↗· Ministry of Justice
Stated action
“The policy requires that healthcare staff are always invited to attend, or otherwise contribute, to the first case review, allowing the case review team to consider the need for any additional mental health support for the individual, including referral to the mental health team, and their attendance at subsequent case reviews.”