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recurance

Yohannes Kidane

3 Sept 2014 · Coroner Louise Hunt · Birmingham & Solihull

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. insufficient nighttime staffing in healthcare wards

    “The healthcare department has 2 wards with 15 patients on each ward. The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards. Evidence confirmed there were a number of prisoners on ward 2 who required ACCT observation plus other prisoners requiring attention. At the time only 1 nurse was present as the Prison officer was on the other ward.”
  2. 2. inadequate staffing affecting ACCT observations

    “am concerned that the ability to undertake effective ACCT observations is compromised by the lack of sufficient staff.”
  3. 3. lack of staff breaks affecting care and staff wellbeing

    “When | asked how staff took breaks at night | was told staff did not take breaks during the night. | am concerned about the impact this would have on the care and wellbeing of prisoners and on the staff. Staff must need to take comfort breaks throughout the night which would add an additional burden on the already stretched staffing levels.”

Linked reports

Raised again laterJohn Delahaye18 Dec 2018 · 4 years 3 months later
Closely relatedConfidence 0.80 · moderate

This report

“The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards.”

Later report

“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Original on judiciary.uk ↗
Full chain: Insufficient nighttime staffing leading to missed healthcare involvement in ACCT

Responses

2014-0392-Response-by-Birmingham-Solihull-NHS.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust

2014-0392-Response-by-NOMS.pdf ↗· Birmingham Prison

Stated action

“The night staffing level for HMP. Birmingham was reviewed. when responsibility for its Operation was transferred to G4S, and NOMS is ste that it is acceptable. G4S has chosen to deploy a Prison Custody Officer (PCO) to patro] the healthcare centre at night, and this is beyond the public sector benchmark which would require the use. an Operational Support Grade (OSG) for this purpose. This allows extr: flexibility, as a PCO is trained and authorised to perform additional dutles, such-as to unoch”
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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