Source · Prevention of Future Deaths

Adam Clark

Ref: 2026-0379 Date: 27 Jul 2026 Coroner: David Reid Area: Worcestershire 1 response identified · 1 indexed addressee View PDF

Response deadline: 23 November 2026 (estimated from the Judiciary.uk publication date).

Date 27 Jul 2026
56-day deadline 23 Nov 2026 est. estimated from the Judiciary.uk publication date
Responses identified 1 of 1

Coroner's concerns

Coroner's Concerns (source excerpt)
During the inquest, it became apparent that a maths tutor at HMP Hewell, who had noted significant concerns about the deceased’s mental health at the end of November 2024 ( only a week before he died ), had not received any training about (a) the risk of suicide and/or self-harm in prisoners, or (b) the...
View full coroner's concerns
During the inquest, it became apparent that a maths tutor at HMP Hewell, who had noted significant concerns about the deceased’s mental health at the end of November 2024 ( only a week before he died ), had not received any training about (a) the risk of suicide and/or self-harm in prisoners, or (b) the Assessment, Care in Custody and Teamwork ( ACCT ) process which is designed to protect those prisoners at increased risk of self-harm, since she had started working at the prison in June 2024. Her line manager within the education department at the prison had not herself received any such training when she worked at the prison between December 2022 and September 2025.

I heard evidence from the Head of Safety at the prison that there were still staff working at the prison who had not received this training, that he was “reasonably confident” that those staff members had been identified, and that measures had been put in place to address this “training deficit” within the next 4 weeks ( i.e. by 19.8.26 ).

This has been a recurring issue in inquests into deaths in custody in Worcestershire, and it is of considerable concern that it has still not been resolved.

Responses

1 respondent

HM Prison Probation Service

Central Government
PDF
AI-classified response stance Action Planned
AI-generated response summary

HMP Hewell has reviewed its suicide and self-harm (SASH) and ACCT training arrangements. To strengthen oversight, a comprehensive training log will be maintained, and training records will be reviewed monthly at safer custody meetings. Additionally, more staff are being trained to deliver ACCT and SASH training.

View full response
Dear Mr Reid, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR ADAM CLARK Thank you for your Regulation 28 report of 27 July 2026 addressed to the Governor of HMP Hewell following the inquest into the death of Adam Clark at the prison on 1 December 2024. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Interim Director General of Prisons. I know that you will share a copy of this response with Mr Clark’s family, and I would first 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 have raised concerns regarding the provision of suicide and self-harm prevention training, including Assessment, Care in Custody and Teamwork (ACCT) training, for all staff working within the prison. The prison safety policy framework places clear responsibility on Governors and Directors to ensure staff are appropriately trained for the roles they perform. Establishments are required to assess their local safety training needs and maintain training plans to ensure staff have access to the training, support and development necessary to effectively identify, manage and respond to risks of self-harm and suicide. HMPPS recognises the importance of ensuring that all staff are equipped to identify, respond to, and manage risks relating to self-harm and suicide. Staff training forms a key part of the wider approach to supporting vulnerable individuals and ensuring effective delivery of care OFFICIAL - FOR PUBLIC RELEASE

[Page 2] OFFICIAL - FOR PUBLIC RELEASE planning and risk management processes. All new prison officers receive training on suicide and self-harm prevention as part of Initial Prison Officer Training, with a range of related training available. Staff who undertake specific responsibilities within the ACCT process, including assessment, case management and coordination roles, receive additional training relevant to those duties. Dedicated suicide and self-harm training is also available to staff who work in prisons but do not undertake prison officer training. This includes both directly employed prison staff in non-operational roles and staff employed by partner organisations, such as education providers and healthcare services, who may identify concerns about a prisoner during the course of their work. Safety Support Skills training also includes dedicated learning on self-harm, suicide prevention and mental health. These modules are designed to provide staff the knowledge and skills required to recognise signs of vulnerability, understand risk factors, contribute effectively to assessment and care planning processes, and provide appropriate support to those at risk of self-harm. HMP Hewell recognises that staff of all grades and roles have an important part to play in the safety of those residing within the prison. A full review of all suicide and self-harm (SASH) and ACCT training arrangements has been undertaken to ensure the provision, frequency, and quality of training are appropriate and effective. As set out above all operational staff receive training in suicide and self-harm awareness and ACCT processes as part of their mandatory national training programme, and while there is no formal requirement for this training to be repeated once completed, HMP Hewell remains committed to identifying ongoing learning opportunities and addressing any skills gaps through additional training and targeted support. Non-operational staff including staff from external education providers and other personnel who are not directly employed by the prison, have access to ACCT and SASH training through dedicated local trainers, with weekly sessions scheduled to ensure all staff can be accommodated. Partner agencies support this process by notifying the establishment of new staff members, enabling prompt identification of those requiring training. In addition, weekly ACCT training sessions are delivered by the new colleague mentor, alongside monthly SASH training sessions designed to reinforce knowledge and maintain competence. To strengthen oversight and assurance, a comprehensive training log will be maintained to record all staff who have completed training, ensuring that no individual is overlooked. The log will also be used to monitor five-year refresher dates and support ongoing compliance. Training records and any outstanding requirements will be reviewed as a standing agenda item at monthly safer custody meetings, providing oversight of progress and identifying areas requiring further attention. Furthermore, additional staff are being trained to deliver ACCT and SASH training, increasing resilience, sustainability, and future training capacity across the establishment. OFFICIAL - FOR PUBLIC RELEASE

[Page 3] OFFICIAL - FOR PUBLIC RELEASE Thank you for bringing these matters to my attention. I trust that this response provides assurance that action is being taken to address the concerns identified.

Report sections

Investigation and inquest
On 03 December 2024 I commenced an investigation and opened an inquest into the death of Adam Eaton CLARK aged 36. The investigation concluded at the end of the inquest on 23 July 2026. The conclusion of the inquest was that: Narrative Conclusion – Mr. Clark died as a result of suicide. See Questionnaire:
1.       When Adam arrived at HMP Hewell on 30.10.24, should the Supervising Officer who spoke to him in reception have recorded in his NOMIS prison record: (a)      the fact that his Person Escort Record ( PER ) form contained a warning that he was at risk of suicide and self-harm? YES (b)      the fact that his Person Escort Record ( PER ) form contained details of his previous attempts at suicide and/or self-harm? YES (c)      the fact that he ( the Supervising Officer ) had decided not to open an ACCT for Adam, together with the reasons for that decision? YES If your answer to any of Questions 1(a)-(c) above is YES, go to Question 2. If all your answers to Questions 1(a)-(c) are either NO or CANNOT SAY, go to Question 3.
2.       If your answer to any of Questions 1(a)-(c) above is YES, did that failure or those failures together possibly cause or contribute to Adam’s death? YES
3.       Should the Supervising Officer in reception on 30.10.24 have opened an ACCT document for Adam at that point? NO If your answer to Question 3 is YES, go to Question 4. If your answer to Question 3 is NO or CANNOT SAY, go to Question 5.
4.       If your answer to Question 3 is YES, did the prison officer’s failure to open an ACCT possibly cause or contribute to Adam’s death? YES/NO/CANNOT SAY
5.       In relation to Adam’s initial healthcare screening appointment on his arrival at HMP Hewell on 30.10.24: (a)      did the nurse who conducted that appointment look at Adam’s PER document and the information within it set out at 1(a)-(b) above? CANNOT SAY If your answer to Question 5(a) is YES, go to Question 5(c). If your answer to Question 5(a) is NO or CANNOT say, go to Question 5(b). (b)      if your answer to Question 5(a) is NO or CANNOT SAY, should the nurse have looked at his PER document before or during that appointment? YES If your answer to Question 5(b) is YES, go to Question 5(c). If your answer to Question 5(b) is NO or CANNOT SAY, go to Question 7. (c)      If your answer to 5(a) or 5(b) is YES, should that nurse have opened an ACCT document for Adam at that point based on the information contained in the PER and the information provided during the healthcare screening appointment? NO If your answer to Question 5(c) is YES, go to Question 6. If your answer to Question 5(c) is NO or CANNOT SAY, go to Question 7.
6.       If your answer to Question 5(c) is YES, did the nurse’s failure to open an ACCT possibly cause or contribute to Adam’s death? YES/NO/CANNOT SAY
7.       In relation to Adam’s Cell Sharing Risk Assessment ( CSRA ) appointment on his arrival at HMP Hewell on 30.10.24: (a)      did the prison officer who conducted that appointment look at Adam’s PER document and the information within it set out at 1(a)-(b) above? CANNOT SAY If your answer to Question 7(a) is YES, go to Question 7(c). If your answer to Question 7(a) is NO or CANNOT say, go to Question 7(b). (b)      if your answer to Question 7(a) is NO or CANNOT SAY, should the prison officer have looked at his PER document before or during that appointment? YES If your answer to Question 7(b) is YES, go to Question 7(c). If your answer to Question 7(b) is NO or CANNOT say, go to Question 9. (c)      If your answer to 7(a) or 7(b) is YES, should that prison officer have opened an ACCT document for Adam at that point? NO If your answer to Question 7(c) is YES, go to Question 8. If your answer to Question 7(c) is NO or CANNOT SAY, go to Question 9.
8.       If your answer to Question 7(c) is YES, did the prison officer’s failure to open an ACCT possibly cause or contribute to Adam’s death? YES/NO/CANNOT SAY
9.       Should Adam’s behaviour on 21.11.24 and 26.11.24, which was witnessed by his maths tutor, have resulted in an ACCT being opened for him, whether by the tutor or by anyone else? YES If your answer to Question 9 is YES, go to Question 10. If your answer to Question 9 is NO or CANNOT SAY, go to Question 11.
10.      If your answer to Question 9 is YES, did the failure to open an ACCT possibly cause or contribute to Adam’s death? YES
11.      Had entries been made on Adam’s NOMIS prison record, ought the prison officers who decided to move Adam to Houseblock 4 on 30.11.24 have been aware of: (a)      his previous history of attempts at self-harm and/or suicide? YES (b)      his behaviour and comments to his maths tutor on 21.11.24 and 26.11.24? YES If your answer to either/both of Questions 11(a)-(b) above is YES, go to Question 12.
12.      If your answer to either/both of Questions 11(a)-(b) above is YES, did that failure or those failures together possibly cause or contribute to Adam’s death? Put another way, if the officers who decided to move Adam to Houseblock 4 on 30.11.24 had been aware of that information, are they likely to have taken action which may possibly have saved Adam’s life? YES
13.      Had entries been made on Adam’s NOMIS prison record, ought the prison officers who witnessed the deterioration in his mental health following his move to Houseblock 4 on 30.11.24 onwards have been aware of: (a)      his previous history of attempts at self-harm and/or suicide? YES (b)      his behaviour and comments to his maths tutor on 21.11.24 and 26.11.24? YES If your answer to either/both of Questions 13(a)-(b) above is YES, go to Question 14.
14.      If your answer to either/both of Questions 13(a)-(b) above is YES, did that failure or those failures together possibly cause or contribute to Adam’s death? Put another way, if officers witnessing the deterioration in Adam’s mental state following his move to Houseblock 4 on 30.11.24 had been aware of that information, are they likely to have taken action which may possibly have saved Adam’s life? YES
Circumstances of the death
On 1.12.24 Mr. Clark died after suspending himself by a ligature [REDACTED].
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
Copies sent to
I can confirm I have sent the report to4)  Practice Plus Group6)  The Independent Advisory Panel on Deaths in Custody

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Report details

Reference
2026-0379
Date of report
27 July 2026
Coroner
David Reid
Coroner area
Worcestershire

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: 23 Nov 2026 (estimated from the Judiciary.uk publication date).

Sent to

HMP Hewell

Part of a series

2 reports
2026-0380 All responses identified

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