Minute Book, home
Coroner’s reportPrevention of future deaths · 2021-0332

“The transfer and review of prisoners on an ACCT”

Dated 30 Sep 2021, from the coroner for Inner South London. Sent to 4 organisations or people.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

Read the full report on judiciary.uk

How this works

The 56-day response deadline

Deadline passed

Replies were due by 25 Nov 2021. A reply may have been sent and not yet published.

Organisations 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.

  1. Report dated30 Sep 2021
  2. Deadline25 Nov 2021
  3. Published on judiciary.uk13 Oct 2021
  4. Today27 Oct 2026

Watch this report

We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.

Next we ask your name, then send a link to confirm and create your free account. Already have an account? Sign in

Responses from each recipient

Responses from each recipient
Sent toResponse
Ministry of JusticeResponse 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.
Department of Health and Social CareResponse publishedPublished on judiciary.uk in October 2021.
HMP BelmarshResponse 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.
Oxleas NHS Foundation TrustResponse 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.

The coroner’s concerns

– (1) The transfer and review of prisoners on an ACCT. I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her. For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event. However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual. The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.

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, 2021-0332
Added to Minute Book
8 Oct 2026
Reuse
We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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

Ask about this report

AI

Summaries and questions, with page references. Pro and above.

Sign in to use