Missed mental health observations not communicated to healthcare staff
Home Office received 2 coroners' reports about this hazard between 18 Sept 2014 and 28 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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.”
Original on judiciary.uk ↗ Home Office responded.Response (PDF) ↗
- 4 years 11 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“A GP who had seen Mr [name redacted] during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the document as a custody officer process.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to Home Office
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 → 2019Amir Siman-Tov4 years 11 months after Brian Dalrymple · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that important information observed or documented by detention/custody staff is not effectively communicated to healthcare personnel, putting detainees at risk. The earlier report concerns missed mental‑health observations; the later report concerns unawareness of ACDT documents and lack of healthcare staff participation in that process.
Brian Dalrymple · 18 Sept 2014
“Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.”
Original on judiciary.uk ↗ Amir Siman-Tov · 28 Aug 2019
“A GP who had seen Mr [name redacted] during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the document as a custody officer process.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No published response from Home Office was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 Home Office 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 → 2019 | 0.70 | 0.11 | 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.