Lack of access to NOMIS by clinical staff
Department of Health and Social Care received 2 coroners' reports about this hazard between 10 Sept 2021 and 18 Jul 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Department of Health and Social Care was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“(4) Whilst all prison staff were trained in the use of this system and were able to access it, only some clinical staff are able to access NOMIS.”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 3 years 10 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“(b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and”
Original on judiciary.uk ↗ Repeated from the earlier report:accessNOMISprisonstaff
Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“I understand your concerns about staffing shortages within the mental health in-reach team at HMP Wandsworth, and how that may have impacted the quality of mental health assessments. I understand from NHS England that, at the time of Mr [name redacted] death, the team had a vacancy for one whole time equivalent staff member, and that this has now been filled. In addition, the internal patient safety investigation into Mr [name redacted] death carried out by Oxleas NHS Foundation Trust, as the healthcare”
Stated timescale: late 2024
“Staffing within the Mental Health In-reach team”
Stated timescale: 15 October 2025
- All reports to Department of Health and Social Care
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.
2021 → 2025Patryk Gladysz3 years 10 months after Lee Thrumble · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with healthcare staff's ability to access and use the Prison NOMIS system. The earlier report focuses on lack of mandatory training limiting access, while the later report notes inconsistent understanding and account de‑activations affecting access.
Lee Thrumble · 10 Sept 2021
“(4) Whilst all prison staff were trained in the use of this system and were able to access it, only some clinical staff are able to access NOMIS.”
Original on judiciary.uk ↗ Patryk Gladysz · 18 Jul 2025
“(b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care was found for this report.
Stated action · timescale: late 2024
“I understand your concerns about staffing shortages within the mental health in-reach team at HMP Wandsworth, and how that may have impacted the quality of mental health assessments. I understand from NHS England that, at the time of Mr [name redacted] death, the team had a vacancy for one whole time equivalent staff member, and that this has now been filled. In addition, the internal patient safety investigation into Mr [name redacted] death carried out by Oxleas NHS Foundation Trust, as the healthcare”
Stated action · timescale: 15 October 2025
“Staffing within the Mental Health In-reach team”
- 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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2021 → 2025 | 0.82 | 0.18 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
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.