Independent investigation: Philip Silverstone, Belsize Park (2014)

The Governor should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including that: • ACCT assessors do not chair the first ACCT case review; • Multidisciplinary case reviews are held with … Read more The Governor should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including that: • ACCT assessors do not chair the first ACCT case review; • Multidisciplinary case reviews are held with all relevant people involved in a prisoner’s care; • Case reviews are held on the day they are scheduled or reasons given to explain the delay; • ACCTs should not be closed by one member of staff acting alone. Show less

The Governor and Head of Healthcare should ensure that staff open an ACCT whenever a prisoner has significant risk factors or potential triggers.

The Governor should ensure that prisoners assessed as at risk of suicide or self-harm are not held in the segregation unit unless all other options have been considered and excluded and there are fully documented reasons, including at segregation reviews, … Read more The Governor should ensure that prisoners assessed as at risk of suicide or self-harm are not held in the segregation unit unless all other options have been considered and excluded and there are fully documented reasons, including at segregation reviews, to explain the exceptional circumstances. Segregated prisoners on an ACCT should have an urgent mental health assessment and effective care plans to help prevent deterioration in mental health. Show less

The Governor and Head of Healthcare should ensure that all staff understand that, subject to a personal risk assessment, they should enter a cell at night when there are serious concerns about the health of a prisoner.

The Governor and Head of Healthcare should ensure that all prison staff fully understand PSI 03/2013 and their responsibilities during medical emergencies and that the control room calls an ambulance as soon as an emergency medical code is received.