Yasmin Adams

1. 1. gap in ACCT observations

   “Immediately prior to [the deceased]'s death there had been a gap of twenty-nine minutes in her ACCT observations and at the time she was subject to four checks per hour. The relevant guidance for ACCT observation checks understandably states that the checks should not take place at set time to lessen the chances of a prisoner being able to predict when observations will occur, but the guidance does not advise avoiding overly long gaps between observation (e.g. twenty-nine minutes as in [the deceased]'s case).”

2. 2. fixed shower rails as ligature points

   “HMP Foston Hall no longer has fixed shower rails in prisoner's cell bathroom areas. It could not be confirmed to the court that other prisons across the prion estate do not have fixed shower rails in prisoner's cell bathroom areas, or other shower areas where prisoners may be out of view of staff. Although potential ligature points are multiple within prisons, and cannot totally be eliminated, fixed shower rails present particular and clear risk of use as ligature points.”

3. 3. lack of training on personality disorder and learning disability

   “There was lack of clarity concerning what training and awareness prison staff receive on personality disorder. [the deceased] was diagnosed with emotionally unstable personality disorder which could make her behaviour impulsive, and unpredictable. She had also been diagnosed with learning disability in the community which was relevant to her understanding and communication with her. I have been provided with the training course slides for Introduction to Mental Health Awareness, produced by HMPPS Learning”

4. 4. inappropriate cellular confinement for ACCT prisoners

   “[the deceased] was subject to cellular confinement on a residential prison wing. 'Normal' or 'standard' cells may not be best for cellular confinement, particularly for a prisoner placed on an ACCT and therefore deemed at risk and vulnerable, due to cell environment and ligature points and less ability to check and observe by prison staff. It is unclear whether appropriate cells are now used for placement of prisoners subject to ACCTS who are also subject to cellular confinement, across the prison”

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