“The failures to open an ACCT (assessment care in custody and teamwork) on 26 August and 2…”

The coroner’s concerns

The failures to open an ACCT (assessment care in custody and teamwork) on 26 August and 2 September 2026 recorded by the jury in their conclusion had already been identified by the PPO (Prisons and Probation Ombudsman) and I heard evidence that NLFT has undertaken remedial work to avoid this happening in the future. I write to you now concerning the failure of the NLFT mental health nurse who conducted an assessment of Mr Nuth two days before Mr Nuth’s death, to read his medical records. This meant that the mental health nurse did not know that Mr Nuth had disclosed to another mental health nurse that he had heard voices telling him to tie a ligature and jump off a landing, and he did not know that there had been a failure on two occasions since to open an ACCT. The mental health nurse and the then service manager both readily accepted at inquest that the medical records should have been read before an assessment was conducted. However, both were candid that, in a busy prison, without immediate access to the records on the wing (mobile devices are not permitted in prison), it may well be the case that an assessing mental healthcare professional will not necessarily do that. Aside from the individual, this seems to be a systems issue. 10 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every interested person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I have sent the report to: the family of Stephen Nuth HM Prison Pentonville the Ministry of Justice (MoJ) Practice Plus Group (PPG) Phoenix Futures HM Inspectorate of Prisons (HMI Prisons) HM Prison and Probation Service (HMPPS) Prisons and Probation Ombudsman (PPO) Independent Advisory Panel on Deaths in Custody (IAPDC). I also have a duty to send a copy of the report to the Chief Coroner. 3 You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 5 above for additional information relating to the publication of reports and responses. SIGNATURE ME Hassell 4

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0401

Added to Minute Book

14 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0