“To HMP Eastwood Park and The Ministry of Justice – training issues in relation to the…”
Dated 4 Dec 2024, from the coroner for Avon. 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.
The 56-day response deadline
Deadline passedReplies were due by 29 Jan 2025. 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.
- Report dated4 Dec 2024
- Deadline29 Jan 2025
- Published on judiciary.uk9 Dec 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| HMP Eastwood Park | Response publishedPublished on judiciary.uk in December 2024. |
| Practice Plus Group | Response publishedPublished on judiciary.uk in December 2024. |
| Avon and Wiltshire Mental Health Partnership NHS TrustNamed in the report as “Avon and Wiltshire Mental Health Partnership Trust” | Response publishedPublished on judiciary.uk in December 2024. |
| Ministry of Justice | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 Jan 2025. A reply may have been sent and not yet published. |
The coroner’s concerns
– To HMP Eastwood Park and The Ministry of Justice – training issues in relation to the following areas for new and existing staff: Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory; ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews; Little or no understanding of when constant supervision can be used and how is it used; Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken. To HMP Eastwood: the ligature point in Residential Unit 3 where the privacy screen meets the wall.
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, 2024-0672
- 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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