Lack of meaningful family involvement in care process
NHS England received 2 coroners' reports about this hazard between 17 Feb 2017 and 16 Aug 2019.
They came from 2 different coroners 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 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner's family.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Web search (Tavily): Evidence found that the action was carried out
Health and Justice Commissioning Intentions 2015/16 ↗- 2 years 6 months laterClosely relatedConfidence 0.90 · higha different coroner
“There was no involvement of the family and so a source of important information was missed.”
Original on judiciary.uk ↗ Repeated from the earlier report:involvementfamily
NHS England responded, stating 6 specific actions.Response (PDF) ↗Response (PDF) ↗
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”
Stated timescale: end of December 2019
“a clinical review of any appointments which are postponed. This includes a review by the GP to assess Clinical need and risk. Where the demand for external escorts exceeds availability, the GP will prioritise appointment attendance based on clinical need and any appointment cancelled is to be automatically re-booked with the hospital trust. This revised process including clinical review will suitably prioritise and prevent future failings to re-arrange cancelled appointments. The monitoring of this”
Stated timescale: monthly Contract Review Meetings (CRM)
4 more stated actions in the Promises tab.
- All reports to NHS England
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.
2017 → 2019Justin Gallagher2 years 6 months after Dean Saunders · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the lack of family involvement in the care process as a safety concern. The earlier report focuses on the ACCT process in prison settings, while the later report notes missed family input in general healthcare provision.
Dean Saunders · 17 Feb 2017
“The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner's family.”
Original on judiciary.uk ↗ Justin Gallagher · 16 Aug 2019
“There was no involvement of the family and so a source of important information was missed.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Stated action
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
What happened next: Evidence found that the action was carried out
The document indicates that NHS England is involved in commissioning healthcare for police custody, including plans to transfer responsibility by 2016.
“The commissioning of Healthcare for Police Custody Suites is to transfer to NHS England by 2016. This work will continue to be developed and”
Stated action · timescale: end of December 2019
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”
Stated action · timescale: monthly Contract Review Meetings (CRM)
“a clinical review of any appointments which are postponed. This includes a review by the GP to assess Clinical need and risk. Where the demand for external escorts exceeds availability, the GP will prioritise appointment attendance based on clinical need and any appointment cancelled is to be automatically re-booked with the hospital trust. This revised process including clinical review will suitably prioritise and prevent future failings to re-arrange cancelled appointments. The monitoring of this”
Stated action · timescale: ongoing
“the running of a regular report via SystmOne to ensure that healthcare records have been requested; and e © anominated member of staff checking that all newly arrived prisoners have been offered a full general health assessment to include the drafting of a care plan within 7 days of arrival. The checks to be noted on an internal document which is shared with all healthcare staff”
Stated action · timescale: ongoing
“New prisoners with chronic conditions are assigned to a named clinician. Depending upon the condition this may be a GP, [name redacted] or Primary Care Nurse”
Stated action · timescale: end of December 2019
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”
Stated action
“The Governor of HMP Lewes is committed to providing resources for external escorts to medical appointments. Currently, sufficient escorting staff are made available for three external hospital escorts each weekday, and appointments are prioritised by the healthcare team. In the event that there are inadequate resources because of other operational pressures and it is necessary to consider the cancellation of an external appointment, the Duty Governor contacts the healthcare team for advice on”
- 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 NHS England 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 |
|---|---|---|---|---|
| 2017 → 2019 | 0.70 | 0.26 | Closely related · 0.90 | different |
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.