Source · Prevention of Future Deaths

Callum Smith

Ref: 2017-0185 Date: 7 Jun 2017 Coroner: Maria Voisin Area: Avon Responses identified: 1 / 3 View PDF

There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.

Date 7 Jun 2017

56-day deadline 2 Aug 2017

Responses identified 1 of 3

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

At the conclusion of the inquest expressed my concern in relation to assessing risk of suicide and self-harm how from the evidence heard it appeared that there was a possible conflict between how healthcarelmental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011. There was evidence that healthcarelmental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment andlor risk assessment of a patients risk of suicide or self harm for medicallmental health care and treatment as per PSI 64/2011_ was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore would ask that this is reviewed to ensure that healthcarelmental healthcare staff receive detailed training on the ACCT process as it is clearly an important and recognized policy in preventing a risk of self-harm or suicide. indicated that | would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcarelmental healthcare staff:

Responses

1 respondent

Prison Health Services

PDF

Action Planned

Following the inquest, all healthcare staff will revisit the Prison Service Instruction (PSI) through Suicide and Self Harm (SASH) training and local training/meetings to ensure staff are fully aware of their obligations when adhering to PSI 64/2011. (AI summary)

View full response

Inspire Better Health Prevention of Future Deaths Following the above inquest; the Coroner expressed concerns about the way Bristol Community Health manage risk of self harm and suicide and has made recommendations in regard to the prevention of future deaths. These concerns have highlighted learning for Bristol Community Health and the action plan has been completed to address this learning: The inquest demonstrated that healthcare understanding of the Prison Service Instruction (PSI) 64/2011 did not fully meet the requirements of this policy. In particular this related to the low threshold in place for opening an ACCT document; Healthcare were considered to be possibly applying clinical judgement in response to a prisoners declaration of self harm/suicide and this does not reconcile with the required actions within the PSI All healthcare staff will therefore revisit the PSI through Suicide and Self Harm (SASH) training and local training/meetings. This training will ensure that staff are fully aware of their obligations when adhering to PSI 64/2011 2 Staff who gave witness statements within the inquest did not appear to recall their ACCT training or provide assurance they had completed this_ A number of activities will be completed to reinforce the meaning and purpose of the PSI to support this recollection. This will also include the process of how and when to open an ACCT and healthcare responsibilities in regard to attending First Case Reviews_ Evidence of training and local learning will made available for review to the Coroner: Head of Prison Health Services 13/07/2017 Agenda Page 1 of 1 has

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Report sections

Circumstances of the death

Callum was in the care of HMP Bristol at the time of his death. He was found hanging in his cell by a prison officer

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0185
Date of report: 7 June 2017
Coroner: Maria Voisin
Coroner area: Avon

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Aug 2017.

Sent to

Avon and Wiltshire Mental Health NHS Trust

Bristol Community Health

HMP Bristol

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.