Insufficient nighttime staffing leading to missed healthcare involvement in ACCT
Birmingham and Solihull Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 3 Sept 2014 and 18 Dec 2018.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards.”
Original on judiciary.uk ↗ Birmingham and Solihull Mental Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“The night staffing level for HMP. Birmingham was reviewed. when responsibility for its Operation was transferred to G4S, and NOMS is ste that it is acceptable. G4S has chosen to deploy a Prison Custody Officer (PCO) to patro] the healthcare centre at night, and this is beyond the public sector benchmark which would require the use. an Operational Support Grade (OSG) for this purpose. This allows extr: flexibility, as a PCO is trained and authorised to perform additional dutles, such-as to unoch”
- 4 years 3 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Original on judiciary.uk ↗ Birmingham and Solihull Mental Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”
Stated timescale: 1% February 2019
- All reports to Birmingham and Solihull Mental Health NHS Foundation Trust
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 → 2018John Delahaye4 years 3 months after Yohannes Kidane · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures that prevent appropriate healthcare involvement in ACCT processes, putting prisoners at risk. The earlier report cites insufficient night staffing limiting observation capacity, while the later report notes a breakdown in communication that leaves healthcare unaware of ACCT reviews.
Yohannes Kidane · 3 Sept 2014
“The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards.”
Original on judiciary.uk ↗ John Delahaye · 18 Dec 2018
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The night staffing level for HMP. Birmingham was reviewed. when responsibility for its Operation was transferred to G4S, and NOMS is ste that it is acceptable. G4S has chosen to deploy a Prison Custody Officer (PCO) to patro] the healthcare centre at night, and this is beyond the public sector benchmark which would require the use. an Operational Support Grade (OSG) for this purpose. This allows extr: flexibility, as a PCO is trained and authorised to perform additional dutles, such-as to unoch”
Stated action
“The night staffing level for HMP. Birmingham was reviewed. when responsibility for its Operation was transferred to G4S, and NOMS is ste that it is acceptable. G4S has chosen to deploy a Prison Custody Officer (PCO) to patro] the healthcare centre at night, and this is beyond the public sector benchmark which would require the use. an Operational Support Grade (OSG) for this purpose. This allows extr: flexibility, as a PCO is trained and authorised to perform additional dutles, such-as to unoch”
No specific action could be extracted with a verified quote.
Stated action · timescale: 1% February 2019
“The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”
- 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 Birmingham and Solihull Mental Health NHS Foundation Trust 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 → 2018 | 0.68 | 0.10 | Closely related · 0.80 | 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.