Source · Prevention of Future Deaths

Roy Hoey

Ref: 2016-0360 Date: 13 Oct 2016 Coroner: Andre Rebello Area: Liverpool and Wirral Responses identified: 1 / 1 View PDF

Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.

Date 13 Oct 2016
56-day deadline 30 Dec 2016
Responses identified 1 of 1
State Custody related deaths

Coroner's concerns

AI summary
Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.
View full coroner's concerns
During the course of this investigation inquest a considerable amount of time was taken up with the detailed questioning of witnesses around the meaning of local and national safer custody guidance. The court was taken to Noms PSI 64/2011 and the apparent discrepancy between chapter 1 and chapter 5 was highlighted. Chapter 1 Page 10 -This related to the entire document “Management of prisoners at risk of self harm to self, others and from others (Safer Custody) All staff who receive information, including from concerned family members, or observe changes in a prisoner’s behaviour which indicates a change in the risk they pose to themselves, to others and/or from others must communicate their concerns immediately to the Residential, Daily or Night Operational Manager, and/or consider opening an ACCT Plan and make a record in an appropriate source e.g. observation book, NOMIS, Security Information Report, ACCT Plan.

The court ruled that this general catch-all chapter covers everything covered by the policy, self-harm, violence and bullying of others and protection from others – so that is why there are alternative solutions.

Chapter 5 Page 26 - This chapter only related to the operation of the ACCT Process – Assessment, Care in Custody and Teamwork Any member of staff who receives information, including that from family members or external agencies, or observes behaviour which may indicate a risk of suicide/self-harm must open an ACCT by completing the Concern and Keep Safe form.

HMP Altcourse – safer custody Document “All prisoners suspected of being at risk of suicide or self-harm are placed onto an ACCT Plan – All Mandatory actions in PSI 64/2011 must be followed.”

Admissions Policy at HMP Altcourse “All prisoners will be assessed for risk of suicide or self-harm during reception process. Upon arrival into admissions a prisoner’s documentation, PER or other documents received from courts, such as suicide warning forms will be checked for risks of suicide or self-harm Prisoners will be asked about this.”

And then

“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”

I ruled

I direct you that there is no internal conflict in PSI 64/2011 chapter 1 and chapter 5 are referring to different things - And in any event the Altcourse policy properly embraces national guidance in full.

The mandatory actions in the policy are italicised and I read again – “Any member of staff who receives information, including that from family members or external agencies, or observes behaviour which may indicate a risk of suicide/self-harm must open an ACCT by completing the Concern and Keep Safe form.” This does not mean that every contact from family members or external agencies or observed behaviour requires an ACCT to be opened. There needs to be investigation, assessment and evaluation of the issue – which may indicate a risk of suicide /self harm – and thereafter it is mandatory to open an ACCT.

The reason I make this ruling is not only that it common sense and the plain English meaning of the paragraph - but also we have heard expert and experienced evidence from a MOJ/ NOMs trained ACCT trainer that that is the cascaded training down from NOMS – to each Prison and that is what is trained to ACCT assessors and to all those who have basic ACCT training. So in each scenario that has been raised was there assessment and evaluation of the presenting issue which may indicate a risk of suicide and self-harm?

I am reporting this matter to NOMS as there was confusion for the witnesses when different parts of the guidance were put to them and this may lead to confusion as to what is required to apply the best practices of safer custody within prisons. It may be that clarification of the updated policy will improve safer custody, notwithstanding what the court was advised about the national training. Clarification would have certainly reduced the length of time for the inquest hearing considerably.

Responses

1 respondent
HM Prison and Probation Service Central Government
17 Jan 2017 PDF
Action Planned

NOMS acknowledges potential confusion regarding ACCT guidance and will resolve this in the revision of PSI 64/2011, due for completion by the end of April 2017; the revised version will be easier for staff to read and understand. (AI summary)

View full response
Dear Mr Rebello Thank you for your Regulation 28 report dated 13 October 2016 addressed to the National Offender Management Service concerning the recent inquest into the death pf Hoey on 4 September 2014 at HMP Altcourse: You have raised concerns about the confusion for the witnesses when different parts of the ACCT guidance were put to them and that this may lead to confusion as tolwhat is required to apply the best practices of safer custody within prisons. Chapter details the circumstances in which you may open an ACCT such as a member pf staff receives information or observes behaviour that indicates a change in risk The policy states that the concerns should be reported and recorded in the appropriate documents Chapter 5 states that the member of staff must open an ACCT if there are these concerns_ NOMS acknowledges the potential for confusion regarding the opening of a ACCT and this will be resolved in the revision of PSI 64/2011 due for completion by the endlof April 2017 . It is not the intention of the policy to require staff to open an ACCT automatically in every circumstance where a risk may be indicated but it is expected that they communicate their concerns immediately to the Residential, Daily or Night Operational Manager, consider opening an ACCT plan and make record of their decision in an appropriate source, for example the observation book and PNOMIS. have passed on your concerns to the policy lead responsible for the revision of the policy_ and they assure me that the revised version will be much easier for the Istaff to read and understand. hope that you find this information helpful.

Report sections

Investigation and inquest
On 4th September 2014 I commenced an investigation into the death of Roy Patrick HOEY, Aged 20. The investigation concluded at the end of the inquest on 4th October 2016. The conclusion of the inquest was

Ia Compression of the Neck Ib Hanging

Roy Patrick Hoey committed suicide
Circumstances of the death
The jury found after seven days of inquest hearing:-

Roy Patrick Hoey died at 05.22 hours on 04/09/14 at Altcourse, Brookfield Drive, Fazackerley, Liverpool in Meeling Brown Wing, cell 14. He died by compression of the neck from hanging by using a curtain as a ligature. We are sure that he put himself in the position in which he was found with the intention of ending his life.

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Report details

Reference
2016-0360
Date of report
13 October 2016
Coroner
Andre Rebello
Coroner area
Liverpool and Wirral

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: 30 Dec 2016.

Sent to

National Offender Management Service

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