Prevention of Future Deaths reports · 2023

Andrew Shirley

Regulation 28 report to prevent future deaths, reference 2023-0063, written 27 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Jan 2023
Reference2023-0063
DeceasedAndrew Shirley
CoronerDavid Reid
Coroner areaWorcestershire
CategoryState Custody related deaths · Mental Health related deaths
Sourcejudiciary.uk record · original PDF
Responses published3

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATIO  28:  REPORT TO PREVE  T FUTURE DEATHS (1) 

NOTE: This form is to be used dtol' an inqU6st. 

REGULA1il 

211  REPORT ii'C IP 

IFlUTUR!E DEATHI 

THDI Rlc!PORT 8  BED G SIE  'ii' 11'0: 

i. 

Govemc!I', Iii ·  P Hli1m!IDI,  ~Bl Ull'll3, ~Sddltch, mf@~irahDl'IS ISllllf 

@QS. 

1 

I am David Donald Wllllam Reid, HM Senior Coroner for the coroner ar&& of 
Worcestershire 

2 

CO  O  ER'S LEGAL PO 

R.S 

I make this report under paragraph 7, Schedule 5, of the Coroners end Justice Ad 
2009 and ragulatlons 28 and 29 of the Coroners (Investigations) Ragulelfons 2013. 

3 

INVESTI 

On 31.3.21  an investigation wes commenced Into the death of Andrew Paul 
SHIRLEY, e prisoner at HMP Hewell who died In his cell at the prison on 23.3.21 
having daUberately suspended himself by a ligature. He was 25 years of age at the 
tlm& C;>f his death. 
This lnvestlgetion concluded st the end of the inquest on 20.1.23. 

The medical cause of death was: 
1a external net:k compression ( hanging ). 

The conclusion of the inquest was ss follows: 

· 

nAr1drew Shirley died as the result of deDbsrately suspending himself by a ligature. It 
Is not possible to determine what his intention was et the time he did this. 
Sea questionnaire. 
Questionnaire: 
1. Did healthcare and mental haalthcsre staff at HMP Hewell: 
(a) take sufficient steps to Identify and reeord Ar1drew"s risk.of suicide and/or self-
hann? 
NO 
(b) put In place sufficient measures to try to reduce thet risk of suicide and/or self-
hann, whether ( for example ) by locating Andrew on the Targeted Care Pethwey, 
opening an ACCT docum&nt, recording concerns on the Initial Segregation Health 
Screen dooument, formul&tlng· e mental health care plan, or otherwise ? 
NO 
(c) share sufficient lnfomt~n about Andrew's risk of suicide and/or self hann with 
prison staff, so as to.enable prison staff to make approprtate decisions themselves 
about reducing thet risk? 
NO 

2. If any of your answers to Questions 1(aHc) above Is NO 
(a) did that failure/those faUures probably cause or contribute to Andrew's death on 23 
March2021? 
YES 

1 

 3. 
(a} on 20.3.21  should the Duty Govemor, after reading the Initial Segregation Health 
Screen document before making the decision that Andrew should remain on the 
Segregation Unit, have made any more enquiries about the answers given on that 
document? 
YES 

If YES to Question 3(a}: 
(b) would those enquiries prob.11bly have lad to furihe  infonnsition being provided 
about sn Increased risk of Andrew committing en act of suicide or self-herm? 
YES 

If YES to Quest!on 3(b}: 
(c) should the Duty Govemor have taken eny action to try to reduce that risk ( e.g. by 
opening an ACCT document)? 
YES 

4. If YES to Question 3(c):  · 
(a) Old the failure to take such actioo probably cause or contribute to Andr&W's death? 
CANNOT SAY 

(b) If NO or CANNOT SAY to Question 4(&), did that failure possibly cause or 
contribute to -Andrew's death on 23 March 2021? 
YES 

Neglect 
5. Was Andrew's death contributed to by neglect? 
YES 

4  CIRCUMSTANCES OF THE DEAntl 

In answering the questions "when, where, how and in what ctrcurnstences did Andrew 
come by tiis deathr, the jury found as follows: 

"On 23.3.21 Mr. Andrew Shirley was found unresponsh[e in cell 14 afthe Segregation 
Unit at HMP Hewa/1 suspsnd8d by a ligature. Advanced life ssvlng measu,es were 
undertaken but he was pronounced deed st the scene st 1944hrs." 

To clarify, at the time of these events Andrew was a diagnosed paranoid 
schizophrenic who had been receiving a monthly depot injection of anti-psychotic 
medication. He ~lso hed a documented history of eelf-hann end suicide attempts. 
Andrew hed bean In poUce custody from 25.2.21  until 1.3.21, during which time he 
had undergone a fonnal Mental Health Ad essessment at the Celudon Centre, 
Coventry because of concems about his mental health. Those conducting that 
assessment concluded that he did not require treatment in a psychiatric hospital, 
whether as e detained or voluntary Inpatient. 
Following e court hearing on 1.3.21, Andrew was remanded Into custody to await trlal, 
end was taken to HMP Hewell. 
At the prison, Andrew's me~I health history was noted and he was allocated a 
mantal health care coordinator. During the three weeks that Andrew was at the prison, 
his care-coordinator failed to carry out any In-depth mental health assessment of him, 
failed even to begin to formulate a mental health c;are plan for him, end faU&d proparly 
to assess and menage his risk of suicide and/or self-hann. The overall failings of the 
healthcare end mental healthcare teams eit the prison are reflected In the answers of 
the Jury to Questions 1, 2 and 5 In the Jury Questionnaire (above]. 
Throughout his time at the prison, Andrew said on several occasions thet he felt that 
his medication was not worklna. 

2 

 .. 

On 20.3.21  Andrew was placed In the Segiragation Unit et the prison, following sin 
Incident In which he epat at two prison officers. 
In order to assist the Duty Governor In deciding whsthsr Andrew could be held safely 
on the Sagregstlon Unit, a nurss completed ein Initial Se;regation Health Scresn 
document. in which she recorded thiit Andrew was currently on anti-psychotic 
medlCS1tion. In addition, during the cou 'S8 of her assessment of Andrew, he told her 
that he was haal"ling voices which were telling him to kill himself, and that h8 wanted a 
radio so that he could drown those voices out. That infonnation wss not releiyed to the 
Duty Governor, but the Duty GOV8mor accepted in his evidence thet, In llght of the 
lnformllltion that Andrew wsis on anti;>sychotlc medication, ha should heive spoken to, 
end sought further Information from the nurse. 
In their answers to Questions 3 end 4 In the Jury QuesUonnalrs, the Ju,y found that, 
had the Duty Governor sought this further Information, ha would probably have taken  . 
~ctlon to reduce Andrew's risk of suicide and/or self-hann ( e.g. by opening an ACCT 
document ), and his failure to do so possibly caused or contributed to Andrew's death 
on 23.3.21. 
Two further Initial Segregation Health Screen documents were completed on 22.3.21, 
by a paramedic end mental heelt.ti nurse respactlvely. 
In the first of th088, the paremedlc concemed concluded that there were no 
"healthcare reasons• not to segrsgete Andrew at that time. Thet conclusion WES 
based on two wrong answers In the algorithm contained within that document. The 
paramedic conceded that she had neither sesn Andrew, nor looked at his medical 
reool"ds before complstlng this document. 
The mental health nurse who completed the second Initial Segregation Health Screen 
document also conceded that he had not seen Andrew beforehand, and accept.ad in 
evidence that he might have raached a dlfferant conclusion If he had read entries 
contained within Andrew's medlcal notes. 
Andrew was found collapsed and unresponsive in his cell on the following evening of 
23.3.21, suspended by & Dgeture. He wss confirmed deceased et the scene later thEJt 
1hetday. 

5 

During the course of the inquest the evidence revealed matters giving rise to concem. 
In my opinion there Is a risk that future deaths will occur uni~ action Is taken. In the 
cfrcumstances It is my statutory duty to report to you. 

The 

TI'IERS Of CO  CERN are as follows.  -

ACCT v.6 training; and 
SASH ( suicide end self-hem, ) modal 3 training. 

(1)  I heard evidence thEJt v.8 of the ACCT document had been In place at prisons 
throughout England and Waiss since June 2021, and that training ralevsnt 
thereto conelS1& of: 
(I) 
(II) 
However, I silso h6Slrd that, as at 20.1.23 ( over 18 mon1he after the 
ln1roductlon of the latest ACCT document ), 280 out of 400·members of staff 
at the prison ( 70% ) were yet to have completed that training. llt le of 
coneldenibls concern thEt such a hlg  pa  n~ee of staff et the prleon 
may not be In a pcaltlon to nte0gnlu thra rtek 
lch a prGeoner presents 
a eppruprflette etaps to 
of suicide and/or eelf-henn, and thsrefo,s to 
nHluce that rlski 

· 

(2)  I also heard evidence that, despite the Introduction of e new Initial 
· Segregation Health screen algorithm documsnt for prisoners In the 
Segregation Unit, Duty Govemors at the prison hed not yet received eny 
training about the steps they should take In order to complete that document 
appropriately. 

6 

ACTDO  SHOULD BE TA 

3 

 In my opinion action should be taken to prevent future deaths and I believe you have 
the power to take such action by conducting an Investigation Into the deficiencies and 
failures outlined above, and ensuring that appropriate training Is provided to all 
relevant staff. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 dsiys of the date of this report. 
namely by 24.3.23. I, the coroner, may extend the psriod. 

Your rasponse must contain details of action taken or proposed to be taken, setting 
out the timeteibla for action. Otherwise you must explain why no action Is proposed. 
i------,.~--,.---,---------------------------------

COPllES End ~  BUCATDON 

8 

I heva sent e copy of my 1'19l()Ort to the Chief Coroner end to the following: 

B5mberg Peirce eollcltors, who represent Andrew's family; 

 Chief Executive of HM Prison end Probetlon Seivlce; 

 HM Chl&f Inspector of Prtsons; 

 chair of the Independent Advisory PBnel on Deaths In Custody; 

Practice Plus Group; 
Midlands Pa~ership NHS Foundation T11.1st; 
The Prison end Probation Ombudsman. 

I am also under e duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both In a complete or redacted or summary 
fonn. He may send e copy of this report to any person who he believes may find It 
useful or of intereet. You may make represent&Uons to me, the coroner, at the time of 
your response, about the release or the publication of your respons~ by th19 Chief 
Coroner. 

9 

819111ed 

D. D. 

• Reid  . 

2-ri January 2023 

H.  • Senior Coroner for Worcesterehlre 

4

Responses

3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Hm Prison and Probation Service (PDF)
Director General of Operations 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London 
SW1H 9AJ 

23 March 2023 

Mr David D W Reid 
HM Senior Coroner for Worcestershire 
The Civic 
Martins Way 
Stourport-on-Severn 
DY13 8UN 

Dear Mr Reid, 

Thank you for your Regulation 28 report of 27 January 2023, addressed to the Governor of HMP 
Hewell. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as 
Director General of Operations. 

I know that you will share a copy of this response with Mr Shirley’s family, and I would first like to 
express my condolences for their loss. Every death in custody is a tragedy and the safety of 
those in our care is my absolute priority. 

You have expressed concerns regarding the number of staff that have not yet received the 
updated Assessment, Care in Custody and Teamwork (ACCT) version 6 (v6) and Suicide and 
Self-Harm Prevention (SASH) training.  

It is essential that ACCT procedures are utilised by all members of staff working within prisons, 
including healthcare colleagues, and that staff feel confident in recognising risk and in making the 
decision to open an ACCT in order to support prisoners when it is needed. ACCT v6 and SASH 
training includes guidance on understanding and assessing the risks and triggers of self-harm, 
the ACCT v6 process and supporting individuals who self-harm while they are under ACCT 
monitoring and during the post closure period. HMP Hewell is currently delivering training 
sessions that incorporate both ACCT v6 and SASH training to all staff with the expectation that 
this will be completed by July 2023. 

You were also concerned that Duty Governors had not yet received any training about the steps 
they should take in order to complete the Initial Segregation Health Screen algorithm document 
for prisoners in the Segregation Unit. 

HMP Hewell has developed Duty Governor guidance for managing the risk of segregation and  
delivered a training session to all Duty Governors in March 2023. The training included 
information on the policy requirements, how to review periods of increased risk and the process 
of the Initial Segregation Health Screen. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Since Mr Shirley’s death, a number of supporting tools have also been published by HMPPS  
to assist prisons in ensuring segregation is managed appropriately. This has included a learning 
guide on how to effectively collate, analyse and share data to enhance local decision-making and 
multidisciplinary practice. 

Thank you again for bringing your concerns to my attention. I trust that this response provides 
assurance that action is being taken to address this matter. 

Yours sincerely, 

Director General of Operations
Response from Midlands Partnership NHS Foundation Trust (PDF)
Chief Executive 
Trust Headquarters 
St George’s Hospital 
Corporation Street 
Stafford 
ST16 3SR 

Mr D.D.W Reid 
His Majesty’s Senior Coroner for Worcestershire 

Dear Mr Reid 

RE:

 Andrew Paul Shirley (deceased) 

Report to Prevent Future Deaths 

Thank you for your letter dated 27th January 2023, reporting a matter to us, in accordance 
with Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

May I take this opportunity to reassure you that following Mr Shirley’s death, we undertook 
a thorough investigation into the care delivered by the Midlands Partnership Foundation 
Trust. 

MATTER OF CONCERN: 
The three areas of concern were; 

1.  You heard evidence that, following concerns raised in the inquest about failures by 
the mental healthcare staff at the prison to complete documentation  in a timely 
fashion or, (on occasions) at all, a “rigorous” 2 day training package for all mental 
healthcare  staff  at  the  prison  has  now  been  implemented.  However,  as  at 
20.01.2023  no  data  could  be  provided  which  showed  how  many  of  the  current 
mental healthcare staff at the prison had actually received this training. 

2.  You heard  evidence that v.6 of  the ACCT  document had  been  in  place at prisons 
throughout England and Wales since June 2021, and that training relevant thereto 
consists of; 

Together we are making life 
better for our communities 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i) 
ii) 

ACCT v6 training; and 
SASH (suicide and self-harm) model 3 training 

However,  you  also  heard  that,  as  at  20.01.2023  (over  18  months  after  the 
introduction of the latest ACCT document): 
a)  42%  of  mental  healthcare  staff  at  the  prison  had  not  received  the  ACCT  v6 

training (but would be receiving it that very day); and 

b)  SASH training for all mental healthcare staff had been booked for February and 

March 2023. 

It is of considerable concern that such a high percentage of mental healthcare staff 
at  the  prison  may  not  be  in  a  position  to  recognise  the  risk  which  a  prisoner 
presents of suicide and/or self-harm, and therefore to take the appropriate steps 
to reduce that risk. 

3.  You also heard evidence that, despite the introduction of a new Initial Segregation 
Health Screen Algorithm document for prisoners in the Segregation Unit, there has 
been no training for mental healthcare staff in how to complete these documents 
appropriately; and 
It is of particular concern that members of the mental healthcare staff at the prison 
are  expected  to  have active involvement  in the  completion  of these important 
documents, which aim to identify prisoners who may be at risk of suicide and/or 
self-harm if placed in the Segregation Unit, without any suitable training to qualify 
them to do so. 

Following discussions within the mental health services in the Specialist Services Care Group 
and  with corporate services, I am now in a position to respond to the specific concerns 
raised during the course of the inquest. 

4.  You heard evidence that, following concerns raised in the inquest about failures 
by the mental healthcare staff at the prison to complete documentation  in a 
timely fashion or, (on occasions) at all, a “rigorous” 2 day training package for all 
mental healthcare staff at the prison has now been implemented.  However, as 
at 20.01.2023 no data could be provided which showed how many of the current 
mental healthcare staff at the prison had actually received this training. 

MPFT take the issue of record keeping very seriously. To support our Prison staff we 
provide a range of learning opportunities delivered in a variety of ways. 

Record keeping is included as a mandatory element within our Trust Induction during 
which new staff have to complete an online Data Security Awareness training module 
which covers Information Governance and General Data Protection Regulations (GDPR). 
The Trust Induction will be completed within the first 4 weeks. This is currently at 91% 
compliance for HMP Hewell, with outstanding training to be completed to achieve 100% 
by 31st March 2023. 

As part of the local Induction all new staff are given instruction on how to use SystmOne 
and what would be expected in regard to record keeping standards. These are detailed in 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the Inclusion Prisons Good Practice Guide. We have now introduced processes to ensure 
that the local induction will be completed within the first four weeks of commencement. 
Inclusion have developed a competency based local induction in which Team managers 
will sign off staff as competent to practice. Agency nurses complete the same Induction 
process as permanent staff. 

There is a Prison specific record keeping training provided for all staff on an annual basis. 
We will video record this session so it can be made available to people to watch as part of 
their induction pending completing the course face to face. Topics covered in this training 
include: 

  The importance of keeping good health records. 
  The requirement to record contacts contemporaneously 
  The requirement to gather relevant information from other parties involved in 

their care. 

Informed consent 

  Making a clinical formulation which directs decision making 
 
  Care coordination – roles and responsibilities 
  MPFT Risk Management processes 

The most recent training was delivered in June 2022 at which point we were 100% 
compliant. Due to staff turnover compliance is currently at 67%. Therefore a further 
record keeping training session has been planned for 25th April 2023 at which point 100% 
of all our staff will have completed the Prison Specific Record Keeping training. 
Attendance at the training will be recorded and monitored locally. 

Any new staff will view the recording of the training as part of their induction pending 
attending a face to face session. At the next training we will be using Mr Shirley’s case as a 
case study to demonstrate the importance of good record keeping. 

During supervision sessions we review two random case records to ensure that these 
meet the expected standards of record keeping. In cases where the records don’t meet 
expected standards an improvement plan will be developed with the individual. 
Supervision occurs at least 6 times a year. This is inclusive of agency staff. Where there are 
performance issues the frequency will be increased to monthly. 

As part of our mandatory training compliance process, service leaders receive monthly 
monitoring reports detailing current compliance in regard to supervision. If necessary this 
can also be checked on the live system. 

5.  You  heard  evidence  that  v.6  of  the  ACCT  document  had  been  in  place  at  prisons 
throughout  England  and  Wales  since  June  2021,  and  that  training  relevant  thereto 
consists of; 

iii) ACCT v6 training; and 
iv) SASH (suicide and self-harm) model 3 training 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 However, you also heard that, as at 20.01.2023 (over 18 months after the introduction 
of the latest ACCT document): 

a)  42%  of  mental  healthcare  staff  at  the  prison  had  not  received  the  ACCT  v6 

training (but would be receiving it that very day); and 

b)  SASH training for all mental healthcare staff had been booked for February and 

March 2023. 

It is of considerable concern that such a high percentage of mental healthcare staff 
at the prison may not be in a position to recognise the risk which a prisoner presents 
of suicide and/or self-harm, and therefore to take the appropriate steps to reduce 
that risk. 

ACCT training is provided by the Prison and it is expected that all MPFT Prison staff attend 
this training as part of their Induction. Attendance at ACCT training is recorded and 
monitored locally. 

An understanding of the ACCT process is part of the Inclusion Prison Induction and needs 
to be signed off by a manager/supervisor. 

As well as attendance at the training all MPFT staff are given a copy of the Inclusion Good 
Practice Guide to working in Prisons which includes information on ACCT processes. 
The use and function of the ACCT process is discussed in internal team meetings, MPCCC 
meetings and in specific ACCT meetings so new staff get the chance to familiarise 
themselves with how an ACCT is used. 

As at March 2023 Mental Healthcare staff at HMP Hewell are 100% compliant with ACCT 
training. 

Suicide and Self harm Training 

Clinical Risk Management Training is one of MPFT’s mandatory training standards. This 
includes the identification and management of suicidality. As at March 2023 staff at HMP 
Hewell were 84% compliant with a plan to achieve 100% compliance by the end of March. 

In February 2023 MPFT launched a three level Suicide Mitigation Training which is detailed 
below. This will be part of the Prison Induction process and will be in place of the current 
two day training module. 

Training 

ESR Course 
Name 

Who For 

Delivery 
Method 

Duration 

Course Aims 

LEVEL 1 Zero 
Suicide 
Alliance 

LEVEL 2 
Suicide 

000 MPFT 
Zero Suicide 
Alliance 
Awareness 
(Level 1) 
301 Suicide 
Awareness 

All MPFT 
Staff 

E-
Learning 

30 
Minutes 

All Clinical 
Non 

MS 
Teams 

2 Hours 

To raise 
awareness of 
suicide 
prevention and 
mitigation 
To increase 
understanding 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
    
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Awareness 
for 
Professionals 

for 
Professionals 
(Level 2) 

LEVEL 3 
Suicide 
Response 
Part 1 & 2 

301 Suicide 
Response 
(Level 3) 

Registered 
& 
Registered 
Practitioners 
in ALL fields 
of practice 
All 
Registered 
Practitioners 
working in 
Mental 
Health & 
Learning 
Disability 
fields 

MS 
Teams 

1 Day 

and compassion 
and reduce the 
stigma associated 
with talking 
about suicide. 

To provide 
clinical tools to 
enhance the 
processes of 
suicide 
assessment and 
promote 
common 
language to 
improve 
prioritisation and 
referrals. 

Completing all three levels will be essential for all registered Clinical Prison staff and will 
be monitored via our Electronic Staff Record (ESR). 100% Mental Health staff have 
completed level 1 training and level 2 and 3 are booked to take place in June/July 2023. 

Staff continue to have access to the Inclusion Suicide Prevention and Awareness Toolkit. 
A HMP Hewell suicide prevention strategy is being developed as a partnership approach 
which includes the Prison, PPG, MPFT as well as other partner agencies such as education 
and Chaplaincy services. 

6.  You also heard evidence that, despite the introduction of a new Initial Segregation Health 
Screen  Algorithm document for prisoners in the Segregation  Unit, there  has been no 
training for mental healthcare staff in how to complete these documents appropriately; 
and 
It is of particular concern that members of the mental healthcare staff at the prison are 
expected to have active involvement in the completion of these important documents, 
which aim to identify prisoners who may be at risk of suicide and/or self-harm if placed 
in the Segregation Unit, without any suitable training to qualify them to do so. 

Health Screen Algorithm training is provided to MPFT staff by PPG. This is now in place 
and all registered nurses at HMP Hewell, inclusive of agency nurses, had completed the 
training by 3 February 2023. A new member of staff who started 2 weeks ago is the only 
member of staff not to have completed this but will do as part of their induction. 
This is part of the required training for staff working in prisons and is provided as part of 
and will monitored within our Induction process. We are in dialogue with PPG about how 
we can get our staff trained to also deliver this training. 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 While Segregation Health Screening is the responsibility of PPG, MPFT mental health staff 
will support this process and, where appropriate, contribute to the completion and review 
of the algorithm. 

All new staff will shadow an experienced member of staff supporting the completion of 
the Algorithm prior to doing so on their own. 

I hope this response helps to address your concerns. However, if you require any further 
information please do not hesitate to contact me. 

Yours sincerely 

Chief Executive 
Midlands Partnership NHS Foundation Trust 

6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex A 

Call Handlers Aide Memoire – Self referral 

To be used to gather relevant information when patients call to self-refer. 

 

Find patient on RiO. IF THEY ARE ALREADY OPEN TO A PATHWAY, AND ARE CALLING 
DURING THEIR WORKING HOURS, PROVIDE THE NUMBER FOR THEIR PATHWAY AND 
ADVISE THEM TO CALL THE PATHWAY DIRECTLY (END CALL). 

  Check demographics of caller and update contact details as required. Take tel. number 

caller is calling from. Check caller’s current location. Are they with anyone? 

MENTAL HEALTH CONCERNS 

  Ask the caller to explain in their own words why they are calling Access and what are 

their current Mental Health issues?  How do they feel this is affecting them? 
  Are they currently receiving / or have previously received support from any other 

Mental Health services? (i.e. counselling /IAPT/ Social Services etc.). 
Establish risks: 

 
RISKS 

  Have they ever Deliberately Self Harmed?  If yes, when was the last time? How do they harm 

themselves? 
If actively self-harming at the time of call then to go to Shift Co, or if OOH to relevant Crisis 
Team and consider calling Emergency Services (follow the UK Triage Tool) 

  Are they having any thoughts to harm others? 
  Are they having any suicidal thoughts? YES/N0 if Yes is there a plan? If Yes, is the plan 

imminent? 
(If Yes, call to go to Shift Co, if OOH’s this must be discussed with the relevant Crisis Team). 

Place caller on hold and ensure unvalidated progress note is inputted on RiO. Speak with 
Access shift co. who will advise how to proceed. 

Plan: 

Document next steps clearly in progress notes i.e. Referral opened to Access. Tracker sheet 
to Shift Co (document full name of Shift Co). Or Tracker sheet updated and passed to Shift 
Co etc. 

If OOH, discuss with / advice sought from CRHT Shift Co and include any advice given and 
steps to be taken either by Access or Client. 

7
Response from Practice Plus Group (PDF)
Practice Plus Group 
Hawker House 
5-6 Napier Court 
Napier Road 
Reading 
Berkshire 
RG1 8BW 

Tel. 0333 999 2570 
Fax 0333 200 4063 
practiceplusgroup.com 

H.M. Senior Coroner Mr D.D.W. Reid 
Coroner’s Court 
Martins Way 
Stourport-on-Severn 
Worcestershire 
DY13 8UN 

21 March 2023 

Dear Sir 

Regulation 28: Prevention of Future Deaths Report – Andrew Shirley 

I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice 

Plus  Group  on  27 January  2023  following  the  inquest  touching  upon the death of Mr Andrew 

Shirley at HMP Hewell. Practice Plus Group would like to express its sincere condolences to Mr 

Shirley’s family and friends. 

This response addresses the matters of concern in so far as they relate to Practice Plus Group 

Health & Rehabilitation Limited (“Practice Plus Group”), the lead provider of healthcare services 

at HMP Hewell since 1 April 2016. 

Matter of Concern: A high percentage of healthcare staff at the prison may not be in a position 

to recognise the risk which a prisoner presents of suicide and/or self-harm, and therefore to take 

appropriate steps to reduce that risk (due to not having received ACCT training). 

Response: The ACCT process is governed by the prison and to date Practice Plus Group have 

been reliant upon the prison to run the training required. Training on ACCT and SASH (suicide 

and self-harm) are done together as part of the same sessions. 

In  a new  joint  collaborative  initiative  between  our  prison colleagues,  Practice Plus  Group  and 

the Midlands Partnership NHS Foundation Trust (MPFT), a cohort of healthcare staff have been 

identified to be trained to deliver the ACCT training. This will significantly improve our ability to 

Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ensure training for our workforce as it enables Practice Plus Group and MPFT to train our staff 

on the ACCT process without the current reliance upon the prison. 

Following  a recent  period of focused training  activity,  including  a training session on  9 March 

2023, compliance for ACCT training for the healthcare team at HMP Hewell is now 76.8%.  Our 

aim is to have all staff at HMP Hewell trained by the end of April. 

In  addition  to  the  above,  and  to  provide  further  assurance,  Practice  Plus  Group’s  Health  in 

Justice  service  has  identified  clinical  induction  as  one  of  its three  top  corporate  priorities  this 

year.  A  new  national  clinical  induction  is  being  developed,  which  will  incorporate  foundation 

training  in the ACCT  process,  ensuring  that  all  staff  receive  this  prior to  commencing  work in 

prison.  This will serve as an introduction to the full ACCT training, which will be delivered within 

the first six months of employment, once our healthcare professionals have acquired practical 

and contextual experience to support this.  It is intended that the Clinical Induction will have an 

implementation date of no later than 1 October 2023. 

There  are  no  requirements  or  national  standards  in  regards  to  ACCT  and  SASH  refresher 

training. However, to further embed understanding of the ACCT process, Practice Plus Group 

will  introduce  a  refresher  training  session  to  be  completed  at  2  yearly  intervals  following 

completion of initial training. This will be monitored on an ongoing basis via our organisational 

Learning Management System (LMS). 

Matter of Concern: Members of healthcare staff at the prison may be completing a document 

which aims to identify prisoners who may be at risk of suicide and/or self-harm if placed in the 

Segregation Unit, without any suitable training to qualify them to do so. 

Response: As part of the revision of Prison Service Order 1700 (Segregation) in June 2022, a 

new  Initial  Segregation  Health  Screen  (ISHS)  algorithm  document  for  prisoners  in  the 

Segregation Unit was introduced.  It is Practice Plus Group’s understanding that previously no 

healthcare  provider  within  the  Health  in  Justice  estate  has  provided  specific  training  to  staff 

around the completion of the algorithm document. In correspondence with 

, Head 

of  Healthcare  at  HMP  Hewell, 

  (Segregation  Policy  Lead  for  HMPPS)  has 

confirmed  that  there  is  “no  centrally  provided  training  available  to  healthcare  staff  on  the 

completion of the OT014”. OT014 is the Initial Segregation Health screen algorithm document. 

Page 2 of 4 

 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Practice  Plus  Group  has  taken  immediate  action  to  address  this  concern  and  our  Director  of 

Nursing & Quality has developed a comprehensive training session. The training incorporates 

an  overview  of  the  prison  processes  for  segregation,  clinical  assessment  (utilising  ISHS  and 

other  available  information  to  support  decision  making)  and  professional  accountability.  The 

session  includes  a  knowledge-based  test  and  scenario-based  learning.  The  training  session 

and associated resources are enclosed to support this response. 

The  training  was  delivered  at  HMP  Hewell  on  25  and  26 January 2023 and  was attended by 

, Regional Primary Care Lead, to enable her to deliver the same training face-

to-face  across  the  region.  Training  compliance  at  HMP  Hewell  is  currently  88%,  and  further 

dates have been arranged to ensure full compliance by 31 March 2023. 

Our  Director  of  Nursing  &  Quality  and  the  Head  of  Healthcare  at  HMP  Hewell  are  currently 

liaising with the governor of the prison (

) to ensure that the training is delivered 

as  a  collaborative  initiative  between  prison  and  healthcare  colleagues.  We  aim  to  promote 

shared  understanding  of  the  risks  associated  with  segregation,  and  the  requirement  for  joint 

care planning to ensure appropriate care for those who are segregated. We also intend to share 

this work more widely through prison and healthcare networks to encourage shared learning for 

safer segregation. 

I hope that the above response provides assurance that Practice Plus Group are committed to 

providing  a  high  quality  healthcare service  at HMP  Hewell  and  trust  this  response addresses 

the concerns you had. 

I would like to end this response by taking the opportunity of inviting you to visit the healthcare 

team at HMP Hewell should you wish to discuss and review first-hand the services that Practice 

Plus Group provide, as set out in this letter. 

Yours sincerely, 

Page 3 of 4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 National Medical Director, Health in Justice Practice Plus Group 

Enclosures: 

1.  The role of healthcare professionals in completing the Initial Segregation Health Screen 

(PowerPoint presentation) 
Initial Segregation Health Screen Scenarios 
Initial Segregation Health Screen Test 

2. 
3. 

Page 4 of 4

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