Source · Prevention of Future Deaths

Kevin McDonnell

Ref: 2024-0433 Date: 7 Aug 2024 Coroner: Laurinda Bower Area: Nottingham City and Nottinghamshire Responses identified: 1 / 1 View PDF

Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.

Date 7 Aug 2024

56-day deadline 2 Oct 2024 est.

Responses identified 1 of 1

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

1. Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose. Witnesses repeatedly described these checks as simply “proof of life” checks. One witness gave the example of an ACCT observation being completed simply by hearing a noise from within the cell or observing the prisoner collecting his lunch from two landings above. Such cursory observations of prisoners at risk of suicide and self-harm is inconsistent with the aims and objectives of the ACCT PSI (64/22011).

2. Prison staff have not read and understood the July 2021 annex to PSI 64/2011. There was a failure to share risk pertinent information about Kevin to all staff caring for him that day.

3. Failure to secure and retain documentary evidence following a death in custody. If post-death investigations are misled by inaccurate documentation that has been amended post-death, then the ability to learn from deaths in custody will be hampered. The preservation of accurate documentary evidence must be of paramount concern when a person dies in custody.

Responses

1 respondent

HM Prison and Probation Service Central Government

18 Oct 2024 PDF

Action Taken

HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality checks to ensure contemporaneous entries. (AI summary)

View full response

Dear Ms Bower,

Thank you for your Regulation 28 report of 7 August 2024, addressed to the Governor of HMP Nottingham. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr McDonnell’s’ family, and I would first 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 raised concerns relating to the need for ACCT observations and conversations to be meaningful and have purpose, the sharing of pertinent risk information, and the securing of documentary evidence following a death, I will be responding to these issues below.

HMPPS is committed to ensuring that all staff are equipped with the necessary skills and knowledge to perform their role effectively and safely. I have been informed by the Governor of HMP Nottingham that the prison have increased their delivery of SASH/ACCT awareness and upskilling via training days and one-to-one refresher sessions, resulting in a greater number of staff being trained in these areas. The prison will continue to offer ACCT training and upskilling sessions to all staff to increase these numbers further.

In respect of information sharing, the Governor informs me that HMP Nottingham have introduced a ‘trigger’ database which contains any important/pertinent information that may impact on an individual’s risk. This database is accessible to all staff and enables the sharing of information specific to those in crisis ensuring they are supported during this time.

The matter of accurate documentary evidence being secured following a death in custody is something that I take extremely seriously. I am satisfied that the actions taken by staff in this instance were not malicious or done with the intention of misleading any investigation or enquiry. Nevertheless, this was not best practice and I understand that ACCT books are no longer taken

off the wing while undergoing quality assurance checks so that staff are able to make contemporaneous entries, to ensure this does not happen again.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.

Report sections

Investigation and inquest

On 30 September 2022, I opened an investigation touching the death of Kevin John McDonnell, aged 47 years. The inquest into his death concluded before a Jury on 22 July 2024. The conclusion of the inquest was that Kevin had died by suicide. The Jury further recorded a narrative conclusion capturing a series of failings in his prison and health care, which probably more than minimally contributed to his death from suicide.

Circumstances of the death

On 29 September 2022, Kevin was discovered deceased in his cell, having died as a result of ligature asphyxiation. He had a long history of mental ill health, paranoia and self-harm behaviours. He was placed on an ACCT plan and had identified 29 September 2022 as a trigger date when he might be more susceptible to self-harm and suicide on account of this being the anniversary of a relative’s death. There was a failure by prison staff to perform a planned ACCT review on 28 September 2022 and on 29 September 2022. Staff on the wing were unaware of the trigger date identified in the ACCT because this risk pertinent information was not passed on in handover and the ACCT booklet had been taken off of the wing for quality assurance (so was not accessible to staff). Landing staff were unaware that Kevin was on an ACCT so did not perform any ACCT checks on the morning of his death. Kevin had appeared agitated overnight and had not slept at all. This information was not shared with day staff. There was a failure to provide Kevin with the necessary support for his mental health in terms of therapy, medication review and psychiatric assessment. Following the death, the ACCT observation and conversation history sheet for 29 September 2022 (which had been blank from the day shift at the time of death) was amended by staff, under the supervision of a senior officer, to record all interactions with Kevin that morning, even though none of those interactions were in fact ACCT checks. This tampering with evidence misled the Prison and Probation Ombudsman’s investigation, and only fully came to light during the inquest.

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Billy Wright Inquiry HMP Maghaberry lessons learned

Report details

Reference: 2024-0433
Date of report: 7 August 2024
Coroner: Laurinda Bower
Coroner area: Nottingham City and Nottinghamshire

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: 2 Oct 2024 (estimated).

Sent to

HM Prison and Probation Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.