Source · Prevention of Future Deaths
John Betteridge
Ref: 2016-0238
Date: 30 Jun 2016
Coroner: Andrew Tweddle
Area: County Durham and Darlington
Responses identified: 0 / 4
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Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
Date
30 Jun 2016
56-day deadline
25 Aug 2016 est.
Responses identified
0 of 4
Coroner's concerns
Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
View full coroner's concerns
(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training: was told that ACCT training is now part of Healthcare staff induction training: A prison GP with 11 years' experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs_ A Senior Officer who chaired the first review of the his The him: May
ACCT (at which the ACCT was closed) believed it was practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT system has been in existence for a number of years, some staff were working without having received any training and some either had not had sulficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to. The inquest has indicated a clear training need.
ACCT (at which the ACCT was closed) believed it was practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT system has been in existence for a number of years, some staff were working without having received any training and some either had not had sulficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to. The inquest has indicated a clear training need.
Report sections
Investigation and inquest
On 02.06.2015 | commenced an investigation into the death of John Brandon Betteridge, 43 years. The investigation concluded at the end of the inquest 0n28.06.2016. The conclusion of the inquest Suicide including a medical cause of death of 1a) Pressure on the Neck due to 1b) Hanging: The jury also concluded that the fact that the deceased did not have his prescription medication during his time of imprisonment during time at HMP Durham possibly contributed more than minimally to his death jury concluded that the deceased should have been subject to an open ACCT at the time of his death The jury also concluded that the fact that the deceased was not on an open ACCT at the time of his death probably contributed more than minimally to his death.
Circumstances of the death
The deceased was remanded to HMP Durham on Friday 22" May 2015. At an initial health screening it was recorded that he had a history of drug use and that he was taking prescribed medication for depression and anxiety but did not have any medication with He had self-harmed a long time previously but it was said had no current thoughts of suicide He tested positive for the use of opiates He was told that he would not be able to receive any prescribed medication until the prison GP could check the situation with his community GP which would not be until the following Tuesday as this was a bank holiday weekend On the night of 23/24" May the deceased self-harmed. An ACCT was opened. Some 9 hours after the ACCT was opened the ACCT was closed. Healthcare staff were not present at the ACCT closure. The jury found that the deceased hung himself as an act of suicide on the night of Monday 25"h and was found dead at roll call in his cell at 4.55 am on the morning of Tuesday 26"" May:
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power to take such action: Your RESPONSE You are under a duty to respond to this report within 56 of the date of this report, namely by 25"h August 2016 !, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
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Report details
- Reference
- 2016-0238
- Date of report
- 30 June 2016
- Coroner
- Andrew Tweddle
- Coroner area
- County Durham and Darlington
Responses identified
Responses identified
0 of 4
4 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Aug 2016 (estimated).
Sent to
- G4S
- National Offender Management Service
- NHS England
- Spectrum Community Health