State Custody related deaths

Action Taken (AI summary) HMP Ranby provides regular training and guidance to staff on the ACCT process, and guidance has been issued to staff to improve understanding of ACCT. A three-stage quality assurance process is in place to identify areas where individual or wider upskilling is required.

Action Taken (AI summary) The Trust has implemented several changes, including disseminating SIM meeting outcomes to care coordinators, documenting patient concerns on SystmOne, emphasizing risk mitigation in clinical supervision, and embedding a process for continuity of care during staff absences. A standing agenda item was added to daily meetings to address patient care during staff absence, with documented handover of responsibilities.

Action Taken (AI summary) Medway Maritime Hospital is working with system partners to co-create a written document setting out the process for effective and safe discharges of prisoners and has implemented twice-daily board rounds to discuss patient status. NHS England will share learnings with regional leads.

Action Taken (AI summary) HMP Wandsworth issued a notice in March 2021 to remind staff to have clear sight of prisoners and obtain signs of life during roll checks and have published further communications since. In 2024, they introduced a quality assurance process for roll checks and the Standards Coaching Team provided support to staff over the summer.

Action Taken (AI summary) HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality checks to ensure contemporaneous entries.

Action Taken (AI summary) The Department of Health and Social Care outlines national measures to improve urgent and emergency care, including funding increases for ambulance trusts, hospital beds, and discharge support. It also notes improved Category 2 ambulance response times nationally and in the NWAS region, and decreased patient handover times. Swansea Bay University Health Board has developed a Standard Operating Procedure for transferring individuals with mental/physical health needs into their care. They have also improved the service level agreement with a local GP practice, recruited additional GPs and implemented changes to the night shift pattern to alleviate staff workload. HMPPS has received assurance from the Governing Governor at HMP Cardiff that all staff are aware of emergency medical codes via the radio system. The Governor is also committed to encouraging staff to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so.

Action Taken (AI summary) HMPPS provides Introductory Suicide Prevention Training for probation staff and has developed a 7-minute briefing on suicide prevention. They are also working closely with other government departments to ensure prison leavers can access healthcare and support, and are drawing together a holistic staff IPP guide.

Action Taken (AI summary) Practice Plus Group details changes including medicines management policies reviewed and updated, a new audit tool for medication administration, new roles for nurses to oversee patients on wings, and a process in place if patient might be stockpiling medication. HMPPS has provided training to staff regarding the ACCT process, established a Safety Intervention Meeting (SIM) and a Multi-Disciplinary Complex Case Clinic (MPCCC) for complex cases. They encourage prison and healthcare staff to report intelligence through the Mercury intelligence system and undertake First Aid needs assessments and training.

Action Taken (AI summary) HMP Lewes reviewed record-keeping practices, clarified responsibilities for welfare checks and clinical observations, regularly briefs staff on emergency codes, and reviewed hospital escort procedures. Custodial managers now oversee Code Blue/Red incidents, and the policy on emergency escorts is being actively reviewed.

Action Taken (AI summary) HMPPS has implemented a revised ACCT case management approach across the prison estate to improve support for prisoners at risk of self-harm or suicide. They are also developing a safety training package for staff which will improve understanding of suicide and self-harm prevention.