Michael Pugh
PFD Report
All Responded
Ref: 2025-0378
All 1 response received
· Deadline: 19 Sep 2025
Coroner's Concerns (AI summary)
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
View full coroner's concerns
(1) The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POELT training and the other 1 month experience. Both officers gave evidence that following their POELT training their understanding of the ACCT process was incomplete; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00.
Responses
Action Taken
HMPPS provides a full day of training on suicide and self-harm prevention during Prison Officer Entry Level Training (POELT), including the ACCT process. HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during induction and signpost it to all staff during the HMPPS annual national safety focus initiative. (AI summary)
HMPPS provides a full day of training on suicide and self-harm prevention during Prison Officer Entry Level Training (POELT), including the ACCT process. HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during induction and signpost it to all staff during the HMPPS annual national safety focus initiative. (AI summary)
View full response
Dear Ms Harding,
Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death of Michael Pugh at HMP Swaleside on 29 June 2024. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the interim Director General of Operations.
I know that you will share a copy of this response with Mr Pugh’s family, and I would firstly 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 expressed concern regarding the Assessment, Care in Custody and Teamwork (ACCT) training provided to new prison officers during their initial Prison Officer Entry Level Training (POELT).
I would like to assure you that HMPPS are committed to providing prison officers with the right support, training and tools to empower them to do their jobs.
All new members of staff receive a full day of training on suicide and self-harm prevention during their POELT training. This includes training on the ACCT process and the appropriate timings and intervals of when ACCT observations need to be carried out and recorded. Following completion of POELT training, new entry officers have a two week local induction before ‘going live’ and becoming fully operational. Part of this local induction programme at Swaleside includes ACCT upskilling and a session based on completion of ACCT documents and recording of ACCT observations. The local training team keep a record of these sessions. Any further training needs for staff would be identified and delivered locally.
Additionally, any member of staff who undertakes a key role relating to ACCT case management, for example ACCT assessors or case co-ordinators, receives training specific to these roles.
In addition to the training HMPPS has an online Safety Learning Reference Library which holds various guidance, templates and training material, all of which are accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT where staff can access a ‘Recording Observations’ video guide as well as a written guide, both of which
include examples of best practice for carrying out ACCT observations. Going forward HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during their induction and, furthermore, will signpost the Safety Learning Reference Library to all staff during the HMPPS annual national safety focus initiative being held next month.
I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken following Mr Pugh’s death.
Thank you for your Regulation 28 report of 25 July 2025 following the inquest into the death of Michael Pugh at HMP Swaleside on 29 June 2024. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the interim Director General of Operations.
I know that you will share a copy of this response with Mr Pugh’s family, and I would firstly 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 expressed concern regarding the Assessment, Care in Custody and Teamwork (ACCT) training provided to new prison officers during their initial Prison Officer Entry Level Training (POELT).
I would like to assure you that HMPPS are committed to providing prison officers with the right support, training and tools to empower them to do their jobs.
All new members of staff receive a full day of training on suicide and self-harm prevention during their POELT training. This includes training on the ACCT process and the appropriate timings and intervals of when ACCT observations need to be carried out and recorded. Following completion of POELT training, new entry officers have a two week local induction before ‘going live’ and becoming fully operational. Part of this local induction programme at Swaleside includes ACCT upskilling and a session based on completion of ACCT documents and recording of ACCT observations. The local training team keep a record of these sessions. Any further training needs for staff would be identified and delivered locally.
Additionally, any member of staff who undertakes a key role relating to ACCT case management, for example ACCT assessors or case co-ordinators, receives training specific to these roles.
In addition to the training HMPPS has an online Safety Learning Reference Library which holds various guidance, templates and training material, all of which are accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT where staff can access a ‘Recording Observations’ video guide as well as a written guide, both of which
include examples of best practice for carrying out ACCT observations. Going forward HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during their induction and, furthermore, will signpost the Safety Learning Reference Library to all staff during the HMPPS annual national safety focus initiative being held next month.
I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken following Mr Pugh’s death.
Sent To
- His Majesty’s Prison and Probation Service
Response Status
Linked responses
1 of 1
56-Day Deadline
19 Sep 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 3rd July 2024 I commenced an investigation into the death of Michael Pugh, 29 years. The investigation concluded at the end of the inquest on 21st July2025. The conclusion of the inquest was suicide; Mr. Pugh having suspended himself in his cell at HMP Swaleside .
Circumstances of the Death
Michael Pugh was found in his cell on 29th June 2024 having died. He was subject of an ACCT at the time of his death. It was determined at the last ACCT review before his death that he should be subject to hourly observations. Observations were carried out on the afternoon of 28th June 2024 but recorded incorrectly. No observations were carried out on 29th June 2024 between 07.22 and 09.57 when Mr. Pugh was discovered having died, but the ongoing record was completed retrospectively to show that they had been carried out
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.