Lack of depression management documentation and screening
Closely relatedConfidence 0.90 · highHow sure the judge model was that the two concerns are the same hazard, from 0 to 1. Links below 0.70 are never shown. High is 0.85 or more. A chain is only as strong as its weakest link, so the chain shows the lowest confidence of any of its links.2 reports · 2016–2016 One-page brief (print or PDF)
Care UK received 2 coroners' reports about this hazard between 19 May 2016 and 6 Dec 2016.
They came from 1 coroner. 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 8 specific actions.
“prison will continue to work with the healthcare provider f ensure that all staff are aware of the steps that they are required to take when responding to an emergency call.”
“we will collaborate with them to ensure that the action plan outlined in their response is implemented and that all healthcare staff are aware of the plan.”
“The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.”
Stated timescale: early December 2016
“consent for the obtaining of general practitioner records is now sought as part of the reception screen and it is also a mandatory field that needs to be completed by the member of healthcare prior to finishing the screen. When consent is taken, the screening tool requires a task be sent to the Administrative staff to make them aware that Care UK Clinical Services Limited - Registered in England No 03462881 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester”
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. Every quote shown was checked by code to appear word for word in the original report.
2016 → 2016Tedros Kahssay7 months after Samuel Blair · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · high
Both reports highlight failures to properly identify or act on a prisoner's depression history.
Samuel Blair · 19 May 2016
“There is no record from that meeting or any other time, of any consideration of or management plan for Mr [name redacted] depression.”
Stated action in the response to the earlier report
“in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start of the call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend. This training is in process and due to be completed in November 2016.”
“prison will continue to work with the healthcare provider f ensure that all staff are aware of the steps that they are required to take when responding to an emergency call.”
“we will collaborate with them to ensure that the action plan outlined in their response is implemented and that all healthcare staff are aware of the plan.”
“The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.”
Stated action · timescale: now
“consent for the obtaining of general practitioner records is now sought as part of the reception screen and it is also a mandatory field that needs to be completed by the member of healthcare prior to finishing the screen. When consent is taken, the screening tool requires a task be sent to the Administrative staff to make them aware that Care UK Clinical Services Limited - Registered in England No 03462881 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester”
Stated action · timescale: early December 2016
“The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk.”
Stated action · timescale: in development
“The scoring system in relation to the risk of self-harm and or suicide has now gone as this was found to be too prescriptive. The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and look into factors that may be relevant to suicide and or self-harm. To support this, a new risk assessment is currently in development by the national team and is based on learning from previous deaths in custody, concerns raised by the Learned Coroner,”
Stated action · timescale: end of March 2017
“We accept that the nurse could have explored the history of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment. The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside their physical health and substance misuse issues. Training, both online and face to face, has been developed to support the use”
Stated action · timescale: December 2016
“The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore, Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment”
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 TF-IDF compares shared words. Embedding compares meaning. Judge is the Nemotron Super verdict that decides whether a link is shown.
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.