Lack of follow-up on mental health history and drug overdose
Practice Plus Group received 2 coroners' reports about this hazard between 20 Sept 2022 and 27 Jul 2026.
They came from 1 coroner in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“During his initial healthcare screening appointment on the evening he arrived at HMP Hewell ( 25.3.21 ) and his secondary healthcare screening appointment the following day, Mr [name redacted] denied any mental health issues, and denied any current thoughts of suicide or self-harm.”
Original on judiciary.uk ↗ Practice Plus Group responded, stating 1 specific action.Response (PDF) ↗
“the Head of Healthcare has consulted with other stakeholders within the team about the concern raised and have considered ways this concern can be alleviated. The healthcare team have introduced an updated version (V4) of the EDiC pathway and passport. This”
Stated timescale: Day 5 - Initial Management Review and key word search undertaken by a Seniorurse
- 3 years 10 months later
Raised again · 1st time
Adam Clark - Prevention of future deaths report (2)↗
27 Jul 2026 · David Reid · Worcestershire
Closely relatedConfidence 0.90 · high“the agency nurse who conducted the deceased's initial healthcare screening appointment on his arrival at HMP Hewell may not have looked at his PER, either because he did not have access to a copy of it, or because he had not been trained to ensure that he looked at it.”
Original on judiciary.uk ↗ Repeated from the earlier report:initialhealthcarescreeningappointmentHewell
Practice Plus Group responded.Response (PDF) ↗
- All reports to Practice Plus Group
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2022 → 2026Adam Clark - Prevention of future deaths report (2)3 years 10 months after Gary McDonald · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that prisoners' known mental‑health risk information (GP records or PER) was not reviewed during initial healthcare screening, leading to missed follow‑up.
Gary McDonald · 20 Sept 2022
“During his initial healthcare screening appointment on the evening he arrived at HMP Hewell ( 25.3.21 ) and his secondary healthcare screening appointment the following day, Mr [name redacted] denied any mental health issues, and denied any current thoughts of suicide or self-harm.”
Original on judiciary.uk ↗ Adam Clark - Prevention of future deaths report (2) · 27 Jul 2026
“the agency nurse who conducted the deceased's initial healthcare screening appointment on his arrival at HMP Hewell may not have looked at his PER, either because he did not have access to a copy of it, or because he had not been trained to ensure that he looked at it.”
Original on judiciary.uk ↗
Stated action · timescale: Day 5 - Initial Management Review and key word search undertaken by a Seniorurse
“the Head of Healthcare has consulted with other stakeholders within the team about the concern raised and have considered ways this concern can be alleviated. The healthcare team have introduced an updated version (V4) of the EDiC pathway and passport. This”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Practice Plus Group at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2022 → 2026 | 0.68 | 0.15 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.