Mark Vagnoni

Michael Spurr 

                                                                                                             Chief Executive 

        HM Prison & Probation Service 

            8th Floor 102 Petty France 

            London 

            SW1H 9AJ 

            E-mail: ceohmpps@noms.gsi.gov.uk 

Ian Pears 
Acting Senior Coroner 
HM Coroners Office 
The Court House 
Woburn Street 
Ampthill 
Bedfordshire, MK45 2HX 

E-mail: 

20 November  2017 

Dear Mr Pears 

Inquest into the death of Mark Daniel Vagnoni 

Thank  you  for  your  Regulation  28  Report  of  11  October  2017  following  the 
conclusion  of  the  inquest  into  the  death  of  Mark  Vagnoni.  I  am  responding  to  the 
matters  of  concern  that  you  have  raised  for  Her  Majesty’s  Prison  and  Probation 
Service (HMPPS).  

I  know  that  you  will  be  sharing  a  copy  of  this  response  with  Mark’s  mother,  and  I 
would  like  first  to  express  my  sincere  condolences  for  her  loss.  Every  death  in 
custody is a tragedy and the safety of those in our care is my absolute priority. 

I  am  grateful  to  you  for  bringing  these  matters  of  concern  to  my  attention.  I  will 
address the issues that you have raised in the order that they appear in your report. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ACCT observations during the night state 
Your  first  concern  is  about  the  potential  for  prisoners  to  be  particularly  vulnerable 
during  night  state,  and  the  need  for  greater  observations  or  other  strategies  to  be 
undertaken,  when staff resources  are  limited,  and  until  the first  ACCT  case review 
can take place and mental health input is available.  

Prison  Service  Instruction  64/2011  Safer  Custody  states  that  the  level  of  ACCT 
observations needs to be set on the basis of a consideration of the level of risk, and 
with particular regard to any factors which may increase risk, and this would include 
an inability to undertake a full ACCT case review with mental health input during the 
night  state.  National  policy  also  states  that  observation  levels  must  be  clearly 
documented  on  the  front  cover  of  the  ACCT  document,  with  observations  made  at 
unpredictable times.  

In July 2017 HMPPS issued a learning bulletin entitled ‘ACCT - Conversations and 
Observations’ to all prisons, reminding staff of the importance of setting appropriate 
observation  levels  for  prisoners  supported  by  the  ACCT  process.  HMP  Bedford 
additionally issued a staff notice in October 2017 to remind all ACCT case managers 
about assessing risk and setting appropriate observation levels, and the importance 
of undertaking a full ACCT case review within 24 hours of an ACCT being opened. It 
also  reminded  staff  that  if  a  prisoner’s  level  of  risk  changes,  especially  during  the 
night  state,  they  must  immediately  inform  the  night  orderly  officer  who  will  ensure 
the  ACCT  is  reviewed  and  observation  levels  increased  if  necessary.  Additional 
support, including consideration of use of Samaritans phones or access to Listeners, 
may also be given depending on the needs of the prisoner.  

All  relevant  staff  at  HMP  Bedford  have  received  training  in  setting  the  appropriate 
level of ACCT observations for a prisoner at risk. An improved assurance check on 
completed  ACCT  documentation  was  introduced  at  the  establishment  in  October 
2017. Senior managers now complete weekly checks on documentation, as well as 
providing feedback and guidance to ACCT case managers and staff.  

You  may  find  it  helpful  to  know  that  the  ACCT  is  currently  being  redesigned  and 
there  are  plans  to  roll  out  a  revised  version  of  the  document.    As  part  of  this 
redesign,  a  summary  sheet  of  ACCT  observations  and  conversations  will  be 
included to improve information sharing. 

NOMIS layout and ACCT Alerts  
You  express  concern  that  the  layout  of  NOMIS,  the  prisoner  electronic  record 
system, is not helpful to staff as they need to drill down beyond the initial screen to 
be alerted to past ACCTs.  

The current layout of NOMIS contains alerts on the home screen which allow staff to 
see  important,  current  information  on  a  prisoner,  including  whether  they  are  on  an 
open  ACCT.  Past  information  is  easily  accessible  through  the  prisoner’s  history 
section, and all prison staff who need to access NOMIS are trained in its use before 
being  given  access  to  the  system.  The  course  is  designed  to make  staff  aware  of 
where and how the information about a prisoner is recorded.  

 
 
 
 
 
 
 
 The  investigations  into  the  death  of  Mr  Vagnoni  brought  to  the  attention  of  the 
Governor the fact that  some  staff  at  Bedford  were  not fully  familiar  with  the  use  of 
NOMIS. In light of this, a Notice to Staff was published in October 2017 reminding 
them  of the  importance  of  refreshing  their knowledge  by  completing  the e-learning 
course.  Any  staff  identified  as needing  additional  support  in  the  use of  NOMIS  will 
have this included in their staff learning and performance review. The Notice to Staff 
set out where important information regarding a prisoner’s ACCT history is located, 
and  the  importance  of  clearly  recording  information  on  NOMIS.  HMP  Bedford  is 
currently  developing  a  standardised  induction programme for  all  new  staff  who  will 
be using NOMIS to ensure that they have the knowledge required to use the system 
effectively. The new induction programme will come into effect by December 2017.  

Wing transfer documentation 
Your final concern is that there was no wing transfer documentation which included 
information about past ACCTs and risk factors about Mr Vagnoni,  

As  you  may  be  aware,  PS1  75/2011  Residential  Services  requires  that  any 
information  regarding  the  needs,  risks  or  behaviours  of  prisoners  who  are  showing 
signs of distress or self-harm must be properly recorded in the wing occurrence book 
or equivalent, and shared appropriately with other teams.  

In October 2017 all staff at HMP Bedford were reminded through a Notice to Staff of 
the importance of ensuring that all available information, including any identified risk 
factors, must be considered prior to changing a prisoner’s location, and shared with 
staff responsible for their care at the receiving location. Information must be shared 
both verbally and on NOMIS, with entries also  made in the  wing observation book. 
Residential managers are required to undertake monthly checks on wing observation 
books  and  NOMIS  to  ensure  that  information  is  being  recorded  accurately  and 
comprehensively.  

Thank  you  again  for  bringing  these  matters  of  concern  to  my  attention.  Please  be 
assured that learning from the circumstances of Mr Vagnoni’s tragic death is shared 
widely across the prison estate.  

Yours sincerely 

Michael Spurr