Inadequate ACCT document review and agency input documentation
Care UK received 3 coroners' reports about this hazard between 10 Dec 2014 and 28 Mar 2017.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
Original on judiciary.uk ↗ Care UK responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
“From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model .The National Health Service Commissioning Board has procured seven services - GP Services including Pharmacy, Dental, Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services.”
Stated timescale: April 2015
- 1 year 9 months laterClosely relatedConfidence 0.70 · moderatea different coroner
“The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare.”
Original on judiciary.uk ↗ Repeated from the earlier report:ACCTinput
Care UK responded, stating 1 specific action.Response (PDF) ↗
“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House.”
Stated timescale: within 72 hours
- 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
Original on judiciary.uk ↗ Care UK responded, stating 1 specific action.Response (PDF) ↗
“The nurse has been reminded of the process of giving evidence at an inquest and to listen carefully to the question that is being and to take time in considering her answer. Enquiries have been made by the Interim Head of Healthca re who is satisfied that the nurse in giving evidence at the inquest was confused and made a mistake in response to your question.”
- All reports to Care UK
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.
2014 → 2016Warren Sampson1 year 9 months after Geraldine Kilborn · different coronerClosely relatedConfidence 0.70 · moderate
Closely relatedConfidence 0.70 · moderateBoth reports highlight problems with how information from other agencies is incorporated into ACCT reviews, either through insufficient reading of documents or lack of written evidence of input.
Geraldine Kilborn · 10 Dec 2014
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
Original on judiciary.uk ↗ Warren Sampson · 6 Sept 2016
“The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare.”
Original on judiciary.uk ↗ 2014 → 2017John Williams2 years 4 months after Geraldine Kilborn · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that staff do not adequately read or engage with the ACCT document, relying instead on others' input or lacking familiarity with its contents.
Geraldine Kilborn · 10 Dec 2014
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
Original on judiciary.uk ↗ John Williams · 28 Mar 2017
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
Original on judiciary.uk ↗
Stated action
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
Stated action · timescale: April 2015
“From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model .The National Health Service Commissioning Board has procured seven services - GP Services including Pharmacy, Dental, Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services.”
Stated action · timescale: within 72 hours
“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House.”
Stated action
“The nurse has been reminded of the process of giving evidence at an inquest and to listen carefully to the question that is being and to take time in considering her answer. Enquiries have been made by the Interim Head of Healthca re who is satisfied that the nurse in giving evidence at the inquest was confused and made a mistake in response to your question.”
- 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 Care UK 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 |
|---|---|---|---|---|
| 2014 → 2016 | 0.66 | 0.10 | Closely related · 0.70 | different |
| 2014 → 2017 | 0.63 | 0.12 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Care UK
- Inadequate investigation documentation and delayed safety disclosure2 reports · 2023–2024
- Missing follow up of non attendance at reception healthcare screening3 reports · 2016–2019
- Lack of relevant information sharing during ACCT reviews2 reports · 2014–2017
- Lack of depression management documentation and screening2 reports · 2016–2016
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.