Daniel Akam
PFD Report
Historic (No Identified Response)
Ref: 2019-0461
No published response · Over 2 years old
Response Status
Responses
0 of 5
56-Day Deadline
12 Mar 2020
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
Failure_to_carry out ACCT observations recorded in the ACCT loq (1-CCTV evidence in the inquest established that 18 observations on Mr Akam were not carried ut (2) The same 18 missed observations were recorded in the ACCT document as having_been carried out,when they had not been from days put day
(3) Five different prison officers purportedly signed various of these entries Whilst the above missed observations occurred 24 hours to Daniel Akam's death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner: If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase_ (5) The fact that the five separate officers did not carry out observations when recorded that they did, indicates that the problem is systemic ACCI training for prison officers (6) In addition, the evidence revealed that the prison officers did not appear to know what their own obligations and responsibilities were in relation to the ACCT procedure and processes. The general evidential picture was that of inadequate ACCT training for officers, who universally indicated that it would be helpful to have refresher training_ Unless adequate and repeated ACCT training is provided for all officers, particularly for those junior and more inexperienced officers, the lives of vulnerable prisoners will not be safeguarded in accordance with the purpose of the ACCT procedure
(3) Five different prison officers purportedly signed various of these entries Whilst the above missed observations occurred 24 hours to Daniel Akam's death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner: If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase_ (5) The fact that the five separate officers did not carry out observations when recorded that they did, indicates that the problem is systemic ACCI training for prison officers (6) In addition, the evidence revealed that the prison officers did not appear to know what their own obligations and responsibilities were in relation to the ACCT procedure and processes. The general evidential picture was that of inadequate ACCT training for officers, who universally indicated that it would be helpful to have refresher training_ Unless adequate and repeated ACCT training is provided for all officers, particularly for those junior and more inexperienced officers, the lives of vulnerable prisoners will not be safeguarded in accordance with the purpose of the ACCT procedure
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
Report Sections
Investigation and Inquest
On 18th October 2019 commenced an investigation into the death of Daniel AKAM; 43 years_ The investigation concluded at the end of the inquest on 4th December 2019. The jury determined that the medical cause of death was 1a Hanging: 4_ The jury returned a combined conclusion of Suicide and Narrative Conclusion in the following terms: 'namely that the lack of an adequate third ACCT Case Review was considered to have possibly contributed to Daniel Akam's death
Circumstances of the Death
Daniel Akam had some_history of depression and self-harm when aged in the community Whilst in prison; he had a history of low mood and anxiety. From 4th October 2018, Daniel Akam expressed that he was receiving threats other inmates, and was suffering acute anxiety as a result: An ACCT was opened and he was subsequently moved to a different wing on 8th October 2018_ 3_ Three prior to his death on 10th October 2018,he made superficial cuts to his wrists and forehead, at which point he was onto twice hourly ACCT observations This frequency was to continue until further amendment; save a further stipulation was added following a third and final ACCT review the before his death, on 12th October 2018, that no observation should be more than 35 minutes after the preceding observation
4. However; this third ACCT review only lasted for between 5-7 minutes no member of health care was present_ and the assessment wrongly concluded that Daniel Akam posed a risk of harm to others rather than to himself. This was contrary to all his prison records, with which staff conducting the review had not sufficiently familiarised themselves Furthermore his worsened mental state was not sufficiently conveyed to health care post review [The jury concluded that the inadequacy of this third and final ACCT review possibly contributed to death]: 5_ Daniel Akam was last seen alive on an ACCT observation at approximately 8.45am on 13th October 2018. 6_ The next ACCT observation due at approximately 9.15/9.20a.m_ was not performed [Although it was left as possibly contributory, the jury did not find that this factor possibly contributed to death]: Daniel Akam was found unresponsive on the floor of his prison cell with a rope ligature around his neck at 9.45a.m; and declared deceased at 10.30a.m. He was no longer attached to the ligature upon his discovery, and it was not possible, then or subsequently, to identify the ligature point in the cell; nor how he was able to have a rope in his cell at a time when he was vulnerable to self-harm.
4. However; this third ACCT review only lasted for between 5-7 minutes no member of health care was present_ and the assessment wrongly concluded that Daniel Akam posed a risk of harm to others rather than to himself. This was contrary to all his prison records, with which staff conducting the review had not sufficiently familiarised themselves Furthermore his worsened mental state was not sufficiently conveyed to health care post review [The jury concluded that the inadequacy of this third and final ACCT review possibly contributed to death]: 5_ Daniel Akam was last seen alive on an ACCT observation at approximately 8.45am on 13th October 2018. 6_ The next ACCT observation due at approximately 9.15/9.20a.m_ was not performed [Although it was left as possibly contributory, the jury did not find that this factor possibly contributed to death]: Daniel Akam was found unresponsive on the floor of his prison cell with a rope ligature around his neck at 9.45a.m; and declared deceased at 10.30a.m. He was no longer attached to the ligature upon his discovery, and it was not possible, then or subsequently, to identify the ligature point in the cell; nor how he was able to have a rope in his cell at a time when he was vulnerable to self-harm.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.