“~ 4, At the conclusion of the inquest | expressed my concern in relation to assessing…”
Dated 7 Jun 2017, from the coroner for Avon. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 9 Aug 2017, after the 56 days for replies had ended (2 Aug 2017). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated7 Jun 2017
- Deadline2 Aug 2017
- Published on judiciary.uk9 Aug 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bristol Community Health | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Avon and Wiltshire Mental Health Partnership NHS TrustNamed in the report as “Avon and Wiltshire Mental Health NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
~ 4, At the conclusion of the inquest | expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners fo follow the requirements of PSI 64/2011. 2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PS! 64/2011. 3. {was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore | would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clearly an important and recognized policy in preventing a risk of self-harm or suicide. 4. | indicated that | would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff,
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, 2017-0185
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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