Prison ACCT process flaws
Insufficient multi-disciplinary input at Assessment, Care in Custody and Teamwork (ACCT) reviews, and over-reliance on the process.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
99match
Reggie John
Concerns included insufficient communication between prisons regarding the prisoner's constant watch status, a lack of robust multi-disciplinary ACCT review processes, and instances where the Prison Service Order 2700 policy was not followed, impacting healthcare documentation.
Matched on
terms: acct, prison, proces
IMB recommendation
95match
Bedford (2020)
Initiate a fundamental review of the assessment, care in custody and teamwork (ACCT; the care planning process for prisoners identified as being at risk of suicide or self-harm) process – is it ‘fit for purpose’?
Matched on
terms: acct, prison, proces
Committee recommendation
94match
#19 - Set out complementary work being done alongside ACCT to prevent over-reliance on the process.
Although many witnesses have welcomed the revised ACCT process, we note the concern expressed by some that there may be an over-reliance on ACCT, and a perception that it is seen as an outcome in itself. Whilst the ACCT should be seen as a means to achieving a successful outcome for women in prison, the Ministry of Justice...
Matched on
terms: acct, prison, proces
PFD report
93match
Stuart Baumber
The coroner identified that many prison cell doors lack current anti-ligature strips due to no national retrofit programme. There is also an absence of a national pro forma for the ACCT process, leading to over-reliance on current risk assessment.
Matched on
terms: acct, prison, proces
PFD report
93match
Steven May
The coroner identified insufficient mental health training and medical note review by reception staff, alongside deficiencies in the ACCT process. Further concerns included inadequate First Aid training and emergency response by prison staff, and limited weekend healthcare access for inmates.
Matched on
terms: acct, prison, proces
PFD report
93match
Matthew Sargent
The coroner noted insufficient processes for sharing and reviewing historical prisoner information and risks between staff and healthcare departments. Specifically, healthcare staff were not consistently informed of prisoners with an ACCT history or provided with Prisoner Escort Records upon arrival.
Matched on
terms: acct, prison, proces
IMB recommendation
93match
Bedford (2021)
We echo the concerns of Her Majesty’s Inspectorate of Prisons (HMIP) regarding the implementation of the assessment, care in custody and teamwork (ACCT) process and would hope that the new version might lead to improvements. We can also see real value in involving prisoners in assessing the effectiveness of the ACCT system.
Matched on
terms: acct, prison, proces
Committee recommendation
92match
#18 - Set out clear evaluation methods for the new ACCT process's success in reducing self-harm.
The increasing level of self-harm in the female estate over the last decade is alarming and while the number of self-inflicted deaths is low, even one death is one too many. We recognise that the MoJ and HMPPS are working to address self-harm levels across the female estate and welcome the ongoing work to improve the Assessment, Care...
Matched on
terms: acct, proces
IMB recommendation
90match
Erlestoke (2024)
Just over 60% of first Assessment Care in Custody and Teamwork (ACCT) reviews do not have the benefit of healthcare input. This negates the multidisciplinary ethos behind the intended strategy of the ACCT process and which impacts on the safety of prisoners – how will this important issue be addressed?
Matched on
terms: acct, prison, proces
PPO recommendation
90match
The Deputy Director of Immigration Prison Teams (North and South)
The Deputy Director of Immigration Prison Teams (North and South) should ensure that HOIE staff: are involved in the ACCT process, including reviews, if there are concerns about a prisoner’s immigration or deportation status, and
Matched on
terms: acct, prison, proces
PFD report
89match
John Betteridge
Insufficient or absent ACCT training for healthcare and prison staff meant mandatory provisions of the ACCT process were not being adhered to. This indicated a clear training need within the system.
Matched on
terms: acct, prison, proces
PFD report
89match
Dean Saunders
The coroner identified lacunas in the admissions protocol for transferring mentally disordered individuals from police custody and a lack of clarity in hospital transfer processes. Concerns were also raised regarding ACCT process training, family involvement, and the resilience of psychiatric cover at Chelmsford prison.
Matched on
terms: acct, prison, proces
PFD report
89match
Callum Smith
The coroner identified a possible conflict between healthcare staff's risk assessment methods and ACCT policy requirements for prisoners. Concerns were raised that healthcare staff required clearer training on the ACCT process and its lower threshold for intervention.
Matched on
terms: acct, prison, proces
Article 2 learning point
89match
Mr Quartz — HMP Doncaster - LP 5
We recommend that there should be modifications to the ACCT process nationally. In particular, there should be a comprehensive suicide risk assessment for all prisoners and young offenders on ACCT, with recognition of risk factors, appropriate interventions and contingency planning. The triggers and risk factors should be reviewed utilising the CAREMAP process and the ACCT should not be...
Matched on
terms: acct, prison, proces
PFD report
87match
Adrian Johnson
The coroner identified gaps in the assessment and management of tobacco withdrawal by healthcare professionals during initial prison screenings, which elevated the prisoner's vulnerability. Concerns also included insufficient healthcare input into ACCT reviews and inconsistent information sharing.
Matched on
terms: acct, prison
PFD report
87match
Cherylin Norrell-Goldsmith
The coroner raises concerns about open pipe work in cells as potential ligature points for vulnerable prisoners. Additionally, there are concerns regarding insufficient multi-disciplinary input at ACCT reviews and a lack of accessible recording of significant medical events on non-medical records for prison staff.
Matched on
terms: acct, prison
PFD report
87match
John Delahaye
The coroner identified confusion over a risk assessment question for in-possession medication, potentially leading to incorrect authorisations. Further concerns included unreliable 'read coding' in prison healthcare records and insufficient healthcare attendance at ACCT reviews.
Matched on
terms: acct, prison
PFD report
85match
Liam Lambert
The ACCT document process was incomplete, with information not fully used and appropriate individuals not always invited to reviews. Additionally, resourcing pressures were noted to affect officers' ability to ensure prisoner safety from self-harm.
Matched on
terms: acct, prison, proces
PFD report
85match
Roy Hoey
The coroner noted ambiguity in the interpretation of national and local safer custody guidance regarding the conditions and process for initiating an ACCT plan when a prisoner is identified as being at risk of suicide or self-harm.
Matched on
terms: acct, prison, proces
PFD report
85match
Carl Newman
Prison staff did not have ready access to current training records, specifically for ACCT and SASH, leading to officers working with outdated or absent training in safer custody processes.
Matched on
terms: acct, prison, proces
PPO recommendation
85match
The Governor
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with national instructions. In particular, staff should: • hold multidisciplinary ACCT reviews; and • set effective caremap objectives which are specific, time-bound, meaningful, aimed at reducing risk and updated at each case review.
Matched on
terms: acct, prison
PPO recommendation
85match
The Governor of HMP Holme House
The Governor should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines. In particular, staff should: ▪ hold multi-disciplinary ACCT reviews which take place within the set timescales. ▪ set effective caremap objectives which are specific, time-bound and meaningful, aimed at reducing risk and updated at each case review. ▪ carry...
Matched on
terms: acct, prison
PPO recommendation
85match
The Operational Manager and the Head of Healthcare
The Operational Manager and the Head of Healthcare should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including: reviewing and update the prisoner’s caremap at every case review; involving the prisoner’s family in the ACCT process when appropriate, and including family contact issues in the caremap; recording all relevant...
Matched on
terms: acct, prison, proces
PPO recommendation
85match
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that staff manage prisoners at risk of suicide or self-harm in line with policy, and in particular, staff should: ensure relevant staff involved in the prisoner’s care, including healthcare staff where appropriate, are invited to all case reviews; and involve a prisoner’s next-of-kin in the ACCT process when appropriate.
Matched on
terms: acct, prison, proces
PPO recommendation
83match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidance, including that: • ACCT case reviews are multidisciplinary and include all relevant people involved in the prisoner’s care, including healthcare staff and those providing through the gate services where relevant; • A named case co-ordinator...
Matched on
terms: acct, prison
Article 2 learning point
83match
JL — HMYOI Feltham - LP 1
It is noted that the Internal Investigation, 2002, recommended attendance by the Chaplaincy at F2052SH (now ACCT – Assessment, Care in Custody and Teamwork) reviews both locally and nationally, and this recommendation is supported. In cases where drug abuse is involved a CARATS representative should also attend, and Education staff should be invited to attend or make a...
Matched on
terms: acct, prison
PFD report
81match
Alex Kelly
The coroner identified concerns regarding the absence of forensic psychiatric assessments for vulnerable children entering custody, deficiencies in the ACCT process regarding external agency input and interpretation of distress, and issues with social worker allocation and documentation practices.
Matched on
terms: acct, proces
PFD report
81match
Lee Rushton
The coroner raised concerns about the consideration given to ACCT care plans when a Cell Sharing Risk Assessment (CSRA) indicates a prisoner should be in a single cell for the protection of others, questioning if existing policy adequately covers this.
Matched on
terms: acct, prison
PFD report
81match
Kelvin Speakman
The coroner identifies inadequate ACCT documentation, absent healthcare input in reviews, and inconsistent staff communication, resulting in an incomplete understanding of the prisoner's condition at HMP Hewell. These issues have persisted despite prior assurances.
Matched on
terms: acct, prison
Article 2 learning point
81match
JL — HMYOI Feltham - LP 4
Where prisoners can be shown through review to have become dependent on the added support the ACCT process provides, consideration should be given to withdrawing the process more gradually as part of the closure plan.
Matched on
terms: acct, prison, proces
Article 2 learning point
81match
JL — HMYOI Feltham - LP 2
The CARATS teams should record information about their interviews with prisoners in unit history sheets, and share assessments with staff who are managing prisoners, particularly when an ACCT (formerly F2052SH) process has been opened. These records should be available when required for any future investigations.
Matched on
terms: acct, prison, proces
Article 2 learning point
80match
Mr Everest — HMP Altcourse - LP 5
A prisoner admitted as an in-patient to Healthcare should have a full assessment, with review of the case notes and a current mental state examination. Their needs and risks of self-harm and harm to others should be established and suitable care plans developed. This assessment should inform the ACCT process, including the provision of observations, frequency of reviews...
Matched on
terms: acct, prison, proces
IMB recommendation
78match
Erlestoke (2022)
Over 40% of first assessment, care in custody and teamwork (ACCT) reviews do not have the benefit of healthcare input, which impacts on the safety of prisoners – how will this issue be addressed?
Matched on
terms: acct, prison
IMB recommendation
78match
Stocken (2023)
The number of inappropriate transfers has risen over the last year. This includes prisoners who are transferred on open assessment, care in custody and teamwork (ACCT) documents and prisoners who have only been in prison for a few days or weeks. Hence, prisoner flow is still not working as it should.
Matched on
terms: acct, prison
IMB recommendation
78match
Erlestoke (2023)
Over 40% of first assessment, care in custody and teamwork (ACCT) reviews do not have the benefit of healthcare input, which impacts on the safety of prisoners – how will this issue be addressed?
Matched on
terms: acct, prison
IMB recommendation
78match
Belmarsh (2025)
Will the Governor continue to reinforce programmes across the prison to improve the quality of assessment, care in custody and teamwork (ACCT) plan reporting, as well as the procedures for managing prisoners who self-isolate?
Matched on
terms: acct, prison
PFD report
77match
Michael James Meyler
The coroner noted inadequate circulation of self-harm/suicide risk documents to healthcare and wing officers within the prison, alongside a failure to attach these to ACCT plans. There were also no clear procedures for logging that wing officers had reviewed relevant prisoner information.
Matched on
terms: acct, prison
PFD report
77match
Kevin Dermott
The report highlights inadequate mental health care, incomplete care planning, and significant communication deficits during multiple prison transfers, which led to a failure to recognise a relapse in the deceased's condition and properly observe ACCT procedures.
Matched on
terms: acct, prison
PFD report
77match
Warren Sampson
The coroner noted inconsistent Healthcare attendance and documentation in ACCT reviews, a lack of process for following up missed first-night healthcare screenings, and no system to ensure officers are familiar with local directives.
Matched on
terms: acct, proces
PFD report
77match
Matthew Russell
The coroner noted insufficient monitoring of repeat prescriptions, a lack of structured care plans, and ineffective follow-up for missed appointments. Concerns also included inadequate staff training in the ACCT procedure and unclear procedures for prison gatehouse staff regarding prisoner safety alerts.
Matched on
terms: acct, prison
PFD report
77match
Mark Vagnoni
The coroner identified gaps in risk assessment for prisoners during the patrol state when an ACCT is opened, noting a lack of mental health input. Further concerns included the unhelpful NOMIS layout regarding past ACCTs and the absence of wing transfer documentation for risk factors.
Matched on
terms: acct, prison
PFD report
77match
Daniel Davey
The coroner noted it was not routine for healthcare staff to attend ACCT reviews, which was a concern relating to both prison and healthcare operations despite improvements introduced after the death.
Matched on
terms: acct, prison
Article 2 learning point
77match
Mr Atlantic — HMP Pentonville - LP 5
(a) We recommend that a single system be introduced at HMP Pentonville that records who has received ACCT training and when the training took place. This system should cover both staff in the main prison and those working on the Healthcare unit. It should also cover both temporary and permanent staff. We suggest that the same system be...
Matched on
terms: acct, prison
IMB recommendation
76match
Swaleside (2022)
The Board has concerns regarding the mental health of prisoners who have suffered long-term lockdown as evidenced by the high number of assessment, care in custody and teamwork (ACCTs) cases, self-harm cases and general violent incidents. The necessity for increased psychology and psychiatric services should be assessed.
Matched on
terms: acct, prison
IMB recommendation
76match
Bedford (2022)
The layout of the ACCT form does not facilitate care coordinators to summarise the prisoner’s story to bring together a description of triggers, coping strategies and other relevant factors into an individual ‘formulation’. We believe this remains a fundamental flaw in the ACCT process.
Matched on
terms: acct, flaw, prison, proces
IMB recommendation
76match
Brinsford (2023)
Challenge, support and intervention plans (CSIPs) are a good deterrent when they are working properly. Sadly, the Board recognises that they are often seen as less important as other processes & strategies such as assessment, care in custody and teamwork documents (ACCTs). Often the work involved is not completed within a timely manner. Some managers are totally on...
Matched on
terms: acct, proces
Article 2 learning point
76match
Mr Atlantic — HMP Pentonville - LP 13
(a) We recommend that more is done at HMP Pentonville to make it easier for staff conducting ACCT Case Reviews by clarifying for them what they are trying to achieve and how to fill in the form. We suggest this could be achieved by providing accompanying guidelines. Although it’s in a different context, a good example of this...
Matched on
terms: acct, prison, proces
Article 2 learning point
76match
AB — HMP Bedford - LP H
We recommend that a more detailed policy is developed about the allocation of cells. For prisoners subject to ACCT monitoring, any cell moves should be agreed as part of the reviewing process, other than in an emergency when they should be reported to the Case Review.
Matched on
terms: acct, prison, proces
PPO recommendation
76match
The Prison Group Director for Devon and North Dorset
The Prison Group Director for Devon and North Dorset should assure herself that meaningful action is being taken to ensure that ACCT procedures at Channings Wood improve.
Matched on
terms: acct, prison
PPO recommendation
74match
The Prison Group Director for Avon, South Dorset and Wiltshire
The Prison Group Director for Avon, South Dorset and Wiltshire should satisfy himself that meaningful improvements have been made to the management of ACCT procedures at Bristol.
Matched on
terms: acct, prison