Missing follow up of non attendance at reception healthcare screening
Care UK received 3 coroners' reports about this hazard between 6 Sept 2016 and 16 May 2019.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The lack of a process for following up non- attendance at the Reception Healthcare first night screening”
Original on judiciary.uk ↗ Care UK responded, stating 1 specific action.Response (PDF) ↗
“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House.”
Stated timescale: within 72 hours
- 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There was no second reception screen conducted. If Mr [name redacted] was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.”
Original on judiciary.uk ↗ Repeated from the earlier report:receptionhealthcare
Care UK responded, stating 1 specific action.Response (PDF) ↗
“The nurse has been reminded of the process of giving evidence at an inquest and to listen carefully to the question that is being and to take time in considering her answer. Enquiries have been made by the Interim Head of Healthca re who is satisfied that the nurse in giving evidence at the inquest was confused and made a mistake in response to your question.”
- 2 years 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews.”
Original on judiciary.uk ↗ Care UK responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Care UK
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.
2016 → 2017John Williams7 months after Warren Sampson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of a reliable process to ensure that a second reception health screen occurs and that any missed attendance is followed up. They describe the same gap in follow‑up procedures for healthcare screening.
Warren Sampson · 6 Sept 2016
“The lack of a process for following up non- attendance at the Reception Healthcare first night screening”
Original on judiciary.uk ↗ John Williams · 28 Mar 2017
“There was no second reception screen conducted. If Mr [name redacted] was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House.”
2016 → 2019Daniel Davey2 years 8 months after Warren Sampson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with healthcare staff participation in ACCT reviews, noting inconsistent attendance and lack of reliable processes.
Warren Sampson · 6 Sept 2016
“The lack of a process for following up non- attendance at the Reception Healthcare first night screening”
Original on judiciary.uk ↗ Daniel Davey · 16 May 2019
“It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews.”
Original on judiciary.uk ↗
Stated action · timescale: within 72 hours
“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House.”
Stated action
“The nurse has been reminded of the process of giving evidence at an inquest and to listen carefully to the question that is being and to take time in considering her answer. Enquiries have been made by the Interim Head of Healthca re who is satisfied that the nurse in giving evidence at the inquest was confused and made a mistake in response to your question.”
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 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 | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2016 → 2017 | 0.72 | 0.10 | Identical · 0.90 | different |
| 2016 → 2019 | 0.68 | 0.09 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Care UK
- Inadequate investigation documentation and delayed safety disclosure2 reports · 2023–2024
- Lack of relevant information sharing during ACCT reviews2 reports · 2014–2017
- Inadequate ACCT document review and agency input documentation3 reports · 2014–2017
- Lack of depression management documentation and screening2 reports · 2016–2016
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.