Source · Prevention of Future Deaths

Michael Pugh

Ref: 2025-0378 Date: 25 Jul 2025 Coroner: Patricia Harding Area: Kent and Medway 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryNewly recruited prison officers had an incomplete understanding of the ACCT process and observation requirements, specifically regarding unpredictable timing and staggering observations, following their training.

Date 25 Jul 2025
56-day deadline 19 Sep 2025 stated in the report
Responses identified 1 of 1
State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary
Newly recruited prison officers had an incomplete understanding of the ACCT process and observation requirements, specifically regarding unpredictable timing and staggering observations, following their training.
View full coroner's concerns
(1) The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POELT training and the other 1 month experience. Both officers gave evidence that following their POELT training their understanding of the ACCT process was incomplete; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00.

Responses

1 respondent

HM Prison Probation Service

Central Government
Letter dated 12 Sep 2025 PDF
AI-classified response stance Action Taken
AI-generated response summary

• New prison officers receive a full day of training on suicide and self-harm prevention, including ACCT process and observation requirements, during initial training. • Local induction at HMP Swaleside includes ACCT upskilling and sessions on completing and recording observations. • HMP Swaleside will promote the Safety Learning Reference Library, which contains ACCT guidance and observation best practice, to new staff during induction and to all staff during the annual national safety focus initiative.

View full response
Dear Ms Harding,

Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death of Michael Pugh at HMP Swaleside on 29 June 2024. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the interim Director General of Operations.

I know that you will share a copy of this response with Mr Pugh’s family, and I would firstly like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

You have expressed concern regarding the Assessment, Care in Custody and Teamwork (ACCT) training provided to new prison officers during their initial Prison Officer Entry Level Training (POELT).

I would like to assure you that HMPPS are committed to providing prison officers with the right support, training and tools to empower them to do their jobs.

All new members of staff receive a full day of training on suicide and self-harm prevention during their POELT training. This includes training on the ACCT process and the appropriate timings and intervals of when ACCT observations need to be carried out and recorded. Following completion of POELT training, new entry officers have a two week local induction before ‘going live’ and becoming fully operational. Part of this local induction programme at Swaleside includes ACCT upskilling and a session based on completion of ACCT documents and recording of ACCT observations. The local training team keep a record of these sessions. Any further training needs for staff would be identified and delivered locally.

Additionally, any member of staff who undertakes a key role relating to ACCT case management, for example ACCT assessors or case co-ordinators, receives training specific to these roles.

In addition to the training HMPPS has an online Safety Learning Reference Library which holds various guidance, templates and training material, all of which are accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT where staff can access a ‘Recording Observations’ video guide as well as a written guide, both of which

include examples of best practice for carrying out ACCT observations. Going forward HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during their induction and, furthermore, will signpost the Safety Learning Reference Library to all staff during the HMPPS annual national safety focus initiative being held next month.

I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken following Mr Pugh’s death.

Report sections

Investigation and inquest
On 3rd July 2024 I commenced an investigation into the death of Michael Pugh, 29 years. The investigation concluded at the end of the inquest on 21st July2025. The conclusion of the inquest was suicide; Mr. Pugh having suspended himself in his cell at HMP Swaleside .
Circumstances of the death
Michael Pugh was found in his cell on 29th June 2024 having died. He was subject of an ACCT at the time of his death. It was determined at the last ACCT review before his death that he should be subject to hourly observations. Observations were carried out on the afternoon of 28th June 2024 but recorded incorrectly. No observations were carried out on 29th June 2024 between 07.22 and 09.57 when Mr. Pugh was discovered having died, but the ongoing record was completed retrospectively to show that they had been carried out

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Shared signals

Report details

Reference
2025-0378
Date of report
25 July 2025
Coroner
Patricia Harding
Coroner area
Kent and Medway

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Sep 2025 (stated in the report).

Sent to

His Majesty’s Prison and Probation Service

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