HM Prison and Probation Service
Central Government
Action Taken
HMPPS has briefed staff and issued a Governor's order reinforcing the Local Security Strategy requirements for ambulance escorts. They also plan to work with the ambulance service on a contingency plan exercise and improve monitoring of ambulance departure times. (AI summary)
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Dear Mr Rheinberg, Thank you for your Regulation 28 report of 7 May 2021 following the inquest into the death of Corin Bonaparte at HMP Dartmoor on 28 February 2017. I am grateful to you for granting an extension to the statutory deadline for my response. I know that you will share a copy of this response with the family of Mr Bonaparte and I would 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 expressed concern following evidence heard at the inquest that healthcare staff did not open an Assessment Care in Custody and Teamwork (ACCT) and suggested that this may be the result of a lack of training. You also raised a concern that there were inadequate arrangements in place to ensure that ambulances could leave the establishment without delay in a blue light emergency. I am grateful to you for bringing your concerns to my attention and will respond to them in the order in which you have raised them. I understand that a response is also being provided by Practice Plus Group (PPG), the healthcare provider at HMP Dartmoor, so in relation to your first concern I will limit my comments to explaining the recent changes to the ACCT system and the training that HMPPS makes available to healthcare staff. ACCT is a prison service document that assists staff in providing multi-disciplinary care and support to individuals at risk of harm to themselves, in order to minimise that risk. It is to be utilised by all members of staff working within prisons, including healthcare colleagues, and it is important staff feel confident in recognising risk and making the decision to open an ACCT in order to support prisoners through their period of crisis. In July 2021, a new version of ACCT (Version 6, known as “ACCT v6”) was rolled out across the prison estate. The changes made to ACCT are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person centred approach which meets the needs of each individual in order to minimise their risk of harm to self. Training packages have been developed to assist in the understanding and delivery of the new ACCT process and include sessions on
understanding self-harm, the ACCT v6 process and supporting individuals who self-harm. Training is currently being delivered at HMP Dartmoor and is available to all staff, including healthcare colleagues. Introduction to Suicide and Self-Harm Prevention (SASH) training is being delivered and healthcare attendance at the monthly sessions has been prioritised in order to support the up-skilling of staff in recognising risks and triggers for self-harm, as well as to build confidence in decision making around the opening of ACCT documents. Your second concern is that there were inadequate arrangements in place to ensure the swift departure of an ambulance from the prison in a blue light emergency. Following the inquest, the Governor ordered a review of the prison’s Local Security Strategy (LSS) and has confirmed that it sets out the action that must be taken in the event of a medical emergency, which include making escort staff available once a medical emergency code has been called and, where necessary in a blue light emergency, dispatching an ambulance before a risk assessment of the prisoner has been completed. In order to ensure that all staff are aware of the requirements in the LSS, and are confident in their decision making in emergency situations, briefing sessions have been delivered and staff have been required to provide written confirmation that they understand the instructions. Duty managers have also been instructed to ensure that at least two officers are identified at the beginning of each shift to assist with escorting duties in the event of an emergency. A Governor’s order has been published to reinforce the expectations of staff responding to emergency situations. When COVID-19 restrictions have been relaxed sufficiently, the prison will be working with the ambulance service on a contingency plan development exercise. This will involve a run through of an emergency situation to check how quickly an ambulance can get through the prison gates and how long it should take for a quick departure without delay. This will also provide an opportunity for both organisations to set out their expectations, and the learning will be used to strengthen the contingency plan for emergency situations. Improved monitoring will be introduced to identify any delays in ambulances departing the prison in future so that swift action can be taken to improve. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.
understanding self-harm, the ACCT v6 process and supporting individuals who self-harm. Training is currently being delivered at HMP Dartmoor and is available to all staff, including healthcare colleagues. Introduction to Suicide and Self-Harm Prevention (SASH) training is being delivered and healthcare attendance at the monthly sessions has been prioritised in order to support the up-skilling of staff in recognising risks and triggers for self-harm, as well as to build confidence in decision making around the opening of ACCT documents. Your second concern is that there were inadequate arrangements in place to ensure the swift departure of an ambulance from the prison in a blue light emergency. Following the inquest, the Governor ordered a review of the prison’s Local Security Strategy (LSS) and has confirmed that it sets out the action that must be taken in the event of a medical emergency, which include making escort staff available once a medical emergency code has been called and, where necessary in a blue light emergency, dispatching an ambulance before a risk assessment of the prisoner has been completed. In order to ensure that all staff are aware of the requirements in the LSS, and are confident in their decision making in emergency situations, briefing sessions have been delivered and staff have been required to provide written confirmation that they understand the instructions. Duty managers have also been instructed to ensure that at least two officers are identified at the beginning of each shift to assist with escorting duties in the event of an emergency. A Governor’s order has been published to reinforce the expectations of staff responding to emergency situations. When COVID-19 restrictions have been relaxed sufficiently, the prison will be working with the ambulance service on a contingency plan development exercise. This will involve a run through of an emergency situation to check how quickly an ambulance can get through the prison gates and how long it should take for a quick departure without delay. This will also provide an opportunity for both organisations to set out their expectations, and the learning will be used to strengthen the contingency plan for emergency situations. Improved monitoring will be introduced to identify any delays in ambulances departing the prison in future so that swift action can be taken to improve. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.