Inadequate mental health team attendance at ACCT reviews
Oxleas NHS Foundation Trust received 2 coroners' reports about this hazard between 18 Jul 2025 and 24 Mar 2026.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
Original on judiciary.uk ↗ Oxleas NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“Staffing within the Mental Health In-reach team”
Stated timescale: 15 October 2025
- 8 months laterClosely relatedConfidence 0.85 · higha different coroner
“There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews.”
Original on judiciary.uk ↗ Oxleas NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Oxleas 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.
2025 → 2026Thomas Ruggiero (2)8 months after Patryk Gladysz · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with ensuring mental health staff are adequately involved in prison care processes. The earlier report cites staffing shortages affecting mental health assessments, while the later report notes failures to meet the policy requirement for mental health team attendance at ACCT reviews.
Patryk Gladysz · 18 Jul 2025
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
Original on judiciary.uk ↗ Thomas Ruggiero (2) · 24 Mar 2026
“There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Staffing within the Mental Health In-reach team”
Stated action · timescale: 15 October 2025
“Staffing within the Mental Health In-reach team”
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 Oxleas 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 |
|---|---|---|---|---|
| 2025 → 2026 | 0.66 | 0.08 | Closely related · 0.85 | 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.