HM Prison and Probation Service
Central Government
Action Taken
HMPPS has revised training for ACCT case managers, emphasising consistency, Caremap completion, and information sharing, with guidance sent to existing case managers at Long Lartin and training for all Band 4 and 5 staff by June 2020. They have also reviewed the ACCT process and devised a new version of the form and associated guidance, piloted in ten establishments in 2019. (AI summary)
View full response
Dear Mr Reid
Thank you for your Regulation 28 report of 30 October 2019 addressed to the Governor of HMP Long Lartin, following the inquest into the death of David John Kirsch at the prison on 19 March 2018. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS), and will describe the work that and his team are taking forward locally as well as some developments at national level that are relevant to the concerns that you have raised.
I know that you will share a copy of this response with Mr Kirsch’s family, and I would like first to express my condolences for their loss. The safety of those in our care is my absolute priority, and every death in custody is a tragedy.
You have identified five matters of concern and I will respond to each in turn.
(1) No Case Manager had been allocated to oversee Mr Kirsch’s ACCT document. This lack of oversight resulted in a number of deficiencies in the ACCT process.
Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.
(2) The person whose name had been entered as Case Manager on the ACCT document confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it. More worryingly, another unknown person appears to have signed off the first page of the Caremap using initials.
A full investigation has been commissioned into the apparent appending of
details on an ACCT document without his knowledge. This is scheduled for completion by the end of January 2020.
An online log of all open ACCT documents, complete with details of the assigned case manager, is now accessible to all staff at the prison. This forms part of the daily briefing document shared with all staff. This prompts case managers to take ownership of their cases, as well as avoiding any confusion about who has been assigned each case.
(3) Despite the ACCT document being open for more than 6 weeks it was not escalated to a more senior member of staff, as per prison policy.
At Long Lartin, a weekly multi-disciplinary safety intervention meeting is convened where cases that are complex and/or require a higher level of input are now discussed. This provides an opportunity to discuss cases approaching the six-week point in order to identify a more senior member of staff to take over as case manager and/or to devise an enhanced care plan as appropriate.
(4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document being opened, and of the issues set out therein which needed to be monitored.
Introduction to Suicide and Self Harm Prevention (SASH) training is being delivered to all HMPPS staff with prisoner contact, and is also offered to staff of partners and contractors. The course is made up of six modules, including ‘Recognising Risks and Triggers’, ‘Opening ACCT Documents’, and ‘An Introduction to Mental Health Awareness’.
At Long Lartin, a comprehensive training plan has been put in place that will see regular full-day training courses being delivered to groups of staff. All operational staff will be trained by August 2020, and all non-operational staff and staff from partner agencies by November 2020. To facilitate this, several members of staff from the prison are being trained as SASH trainers in January 2020.
(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that last review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self- harm. When asked how he had proposed to assess Mr. Kirsch’s level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation.
As explained at (1) above, all existing case managers at Long Lartin have been provided with additional guidance, and all staff taking on this role will be attending initial or refresher training by June 2020. This training is clear that judgements about risk must be made on the basis of a range of information and thorough engagement with the individual, as well as their presentation at the review meeting.
A number of the matters that you have raised are related to deficiencies in the implementation of the ACCT process that are not confined to this case or to Long Lartin. We are working hard to address these through the training described in the responses to the specific points. More generally, we have reviewed the ACCT process and devised a new version of the form and associated guidance. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was
piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal evaluation report and expect to make some further changes before rolling out the new version of ACCT across the prison estate later in 2020. I am confident that this will bring further improvements to the work that staff do to keep prisoners safe.
Thank you again for bringing these concerns to my attention. I hope this response has provided assurance that they are being addressed.
Thank you for your Regulation 28 report of 30 October 2019 addressed to the Governor of HMP Long Lartin, following the inquest into the death of David John Kirsch at the prison on 19 March 2018. I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS), and will describe the work that and his team are taking forward locally as well as some developments at national level that are relevant to the concerns that you have raised.
I know that you will share a copy of this response with Mr Kirsch’s family, and I would like first to express my condolences for their loss. The safety of those in our care is my absolute priority, and every death in custody is a tragedy.
You have identified five matters of concern and I will respond to each in turn.
(1) No Case Manager had been allocated to oversee Mr Kirsch’s ACCT document. This lack of oversight resulted in a number of deficiencies in the ACCT process.
Consistency of case management, effective completion of Caremaps and the importance of information sharing are all covered in the revised training for ACCT case managers that has been introduced nationally. Guidance on these points has been sent to all existing case managers at Long Lartin and, between November 2019 and June 2020, all Band 4 and Band 5 operational staff will attend initial or refresher training in ACCT case management.
(2) The person whose name had been entered as Case Manager on the ACCT document confirmed in evidence that he was not aware of this, and had never had any involvement with this ACCT document because he had not been told about it. More worryingly, another unknown person appears to have signed off the first page of the Caremap using initials.
A full investigation has been commissioned into the apparent appending of
details on an ACCT document without his knowledge. This is scheduled for completion by the end of January 2020.
An online log of all open ACCT documents, complete with details of the assigned case manager, is now accessible to all staff at the prison. This forms part of the daily briefing document shared with all staff. This prompts case managers to take ownership of their cases, as well as avoiding any confusion about who has been assigned each case.
(3) Despite the ACCT document being open for more than 6 weeks it was not escalated to a more senior member of staff, as per prison policy.
At Long Lartin, a weekly multi-disciplinary safety intervention meeting is convened where cases that are complex and/or require a higher level of input are now discussed. This provides an opportunity to discuss cases approaching the six-week point in order to identify a more senior member of staff to take over as case manager and/or to devise an enhanced care plan as appropriate.
(4) Some prison officers appeared to have had a worrying lack of knowledge of the reasons for the ACCT document being opened, and of the issues set out therein which needed to be monitored.
Introduction to Suicide and Self Harm Prevention (SASH) training is being delivered to all HMPPS staff with prisoner contact, and is also offered to staff of partners and contractors. The course is made up of six modules, including ‘Recognising Risks and Triggers’, ‘Opening ACCT Documents’, and ‘An Introduction to Mental Health Awareness’.
At Long Lartin, a comprehensive training plan has been put in place that will see regular full-day training courses being delivered to groups of staff. All operational staff will be trained by August 2020, and all non-operational staff and staff from partner agencies by November 2020. To facilitate this, several members of staff from the prison are being trained as SASH trainers in January 2020.
(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that last review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self- harm. When asked how he had proposed to assess Mr. Kirsch’s level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation.
As explained at (1) above, all existing case managers at Long Lartin have been provided with additional guidance, and all staff taking on this role will be attending initial or refresher training by June 2020. This training is clear that judgements about risk must be made on the basis of a range of information and thorough engagement with the individual, as well as their presentation at the review meeting.
A number of the matters that you have raised are related to deficiencies in the implementation of the ACCT process that are not confined to this case or to Long Lartin. We are working hard to address these through the training described in the responses to the specific points. More generally, we have reviewed the ACCT process and devised a new version of the form and associated guidance. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was
piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal evaluation report and expect to make some further changes before rolling out the new version of ACCT across the prison estate later in 2020. I am confident that this will bring further improvements to the work that staff do to keep prisoners safe.
Thank you again for bringing these concerns to my attention. I hope this response has provided assurance that they are being addressed.