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recurance

Lack of meaningful family involvement in care process

Closely relatedConfidence 0.90 · high2 reports · 2017–2019 One-page brief (print or PDF)

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.

2
reports
2
different coroners
2017–2019
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Dean Saunders↗

    17 Feb 2017 · Caroline Beasley-Murray · Essex

    “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. 2 years 6 months later

    Raised again · 1st time

    Justin Gallagher↗

    16 Aug 2019 · Alan Craze · East Sussex

    Closely 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.

  3. All reports to NHS England

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error