Inadequate support for autistic prisoners in crisis
Devon Partnership NHS Trust received 2 coroners' reports about this hazard between 23 Mar 2020 and 19 Mar 2025.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum”
Original on judiciary.uk ↗ Devon Partnership NHS Trust responded.Response (PDF) ↗Response (PDF) ↗
- 5 years laterClosely relatedConfidence 0.90 · higha different coroner
“The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally.”
Original on judiciary.uk ↗ Devon Partnership NHS Trust responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Devon Partnership NHS 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.
2020 → 2025Benjamin Compton5 years after Lewis Francis · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of appropriate services or understanding for autistic individuals experiencing crisis or needing mental health assessment.
Lewis Francis · 23 Mar 2020
“Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum”
Original on judiciary.uk ↗ Benjamin Compton · 19 Mar 2025
“The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- 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 Devon Partnership NHS 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 |
|---|---|---|---|---|
| 2020 → 2025 | 0.73 | 0.08 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Devon Partnership NHS Trust
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.