Thomas Huntley

ACCT documents In evidence at the inquest ACCT assessors and case managers accepted that they had not complied with various mandatory actions required under PSI 64/2011: Managing Prisoner Safety in Custody. They were not able to identify in evidence the risk factors it was mandatory to consider for persons at risk of suicide or self-harm. They had not recorded triggers in the relevant section of the ACCT nor recorded all risk factors in the Caremap section. One ACCT case manager stated that they did not know whether it was necessary to record a trigger if action had been taken to mitigate it. They also stated they categorised risk based on ‘remaining’ risk after action had been taken despite having not recorded the trigger. This leads me to have 2 concerns: The first regards the provision and quality of ACCT training and refresher training given this evidence was given some 2 years after the death of Mr Huntley and well after the disruptions brought about by the Covid-19 pandemic. I also heard evidence that despite an ACCT being a ‘whole prison’ document (which can and should be opened by any member of staff) training was not mandatory for non-security staff. In 2019 there was no joint training for prison and heathcare staff on the use of ACCT documents. I am informed by CNWL that under ACCT v6 (which has been in force since July 2021) joint training is provided for and this is reassuring. However I understand that the frequency of this training is determined in relation to operational capacity at individual establishment level. This is of concern given the evidence from witnesses at this inquest some 20 months after this version came into force. The second relates to the quality and effectiveness of ACCT audits. We heard evidence that ACCT documents are reviewed annually. The case manager mentioned above advised that he had not received any adverse feedback about the quality of his ACCT documents and no issues with them had been identified. Given the inadequate nature of the ACCT document opened on Mr Huntley and apparent lack of understanding about completing the documents the quality of the audits is brought into question. Information sharing. In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff. Healthcare staff record and share their information within SystemOne which the prison security staff do not have access to. Prison security staff record information within NOMIS which healthcare staff do not have access to. Evidence from witnesses revealed that these information systems are not necessarily fully reviewed for relevant information prior to attending ACCT meetings. In addition a decision relating to Mr Huntley’s care (i.e. the move to a different cell) was taken by healthcare staff at their own meeting when they did not have the benefit of information available to prison staff. of HMP Winchester informed me that a Safety Intervention Meeting was now carried out weekly, chaired by a Senior Governor and attended by representatives of the prison, physical and mental health care providers and the probation service. This meeting covers each person subject to an ACCT and any relevant information is share via the ACCT case manager, NOMIS and the multi disciplinary team. could not assist me with whether this was a HMP Winchester initiative or had a wide application across the prison estate. My concern is therefore that the current procedures and policies for sharing information are incomplete or not fully complied with. This renders the information on which separate teams make decisions about a prisoner incomplete and increases the risk that important factors are not considered. Cells At HMP Winchester within the area, considered and referred to by most healthcare and prison staff, as the ‘mental health’ cells there are 2 cells which are not equipped in a way to reduce the amount of available ligature points. It was clear from the evidence of the healthcare staff at the MDT meeting on the 28/05/2020 that they did not consider the contents of the cell when deciding to move Mr Huntley to the ‘mental health cells’ simply due to the fact he was on an ACCT. I heard evidence that the policy of CNWL has now changed and that a cell move risk assessment must now be carried out and that there is now a revised ligature audit process. HMP Winchester informed me that there is now an annual ligature audit carried out in conjunction with the new healthcare provider at that establishment. In addition I was informed that all telephone points in the ‘mental health cells’ at HMP Winchester have now been removed and placed outside the cells. These are welcome developments. However at inquest those representing the HMPPS could not inform me whether all telephone points within cells designed for use by those at risk of self harm across the prison estate had been removed. Nor was any evidence available as to what consideration had been given to reducing the risk of the telephone points by design of the points themselves or the manner of their installation. Those representing were invited to provide this information after the hearing but have not done so. I am concerned that telephone points which provide a ligature point may remain within cells which prison and health care staff consider to be suitable for use by those at risk of self harm. The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years. The evidence from prison governors was that, generally speaking within the prison estate, they were not used or proved too hard to maintain to the certified standard. However certified Safer Cells are still referred to in PSI 64/2011 as a means of managing risk from ligatures. It was heard in evidence that HMP Winchester experience high levels of self-harm and suicide and yet it did not appear that consideration had been given recently to introducing these. Those representing the HMPSS at the were invited to provide information about the status and use of safer certified cells across the prison estate. No such information has been forthcoming. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.