With regard to my first concern, I would request that consideration be given to make the requirement for attendance by someone from healthcare, who has knowledge of the prisoner/patient mandatory at first reviews and when the decision is made to close the ACCT. In addition if they do not attend the review should be postponed. In terms of the ACCT, I would ask for consideration to be given to a local policy whereby if an ACCT has been opened for a particular prisoner and subsequently closed, if there is a subsequent event requiring the protection of an ACCT the previous one should be reopened rather than an entirely different document. This would go some way to ensure continuity and would make the first Care Map available to the staff. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1st January 2020. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mr Williams Central North West London NHS Foundation Trust I have also sent a copy to the Independent Monitoring Board, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Tom OSBORNE Senior Coroner for Milton Keynes Dated: 06 November 2019