Healthcare staff absent during ACCT reviews
Ministry of Justice received 2 coroners' reports about this hazard between 18 Dec 2018 and 16 May 2023.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Original on judiciary.uk ↗ Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”
Stated timescale: 1% February 2019
- 4 years 5 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending.”
Original on judiciary.uk ↗ Repeated from the earlier report:teamACCTreviews
Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“The policy requires that healthcare staff are always invited to attend, or otherwise contribute, to the first case review, allowing the case review team to consider the need for any additional mental health support for the individual, including referral to the mental health team, and their attendance at subsequent case reviews.”
- All reports to Ministry of Justice
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.
2018 → 2023Stuart Robinson4 years 5 months after John Delahaye · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that essential professional input is missing during ACCT reviews, putting prisoners at risk. The earlier report notes absent healthcare staff, while the later report stresses the need for mental health team attendance.
John Delahaye · 18 Dec 2018
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Original on judiciary.uk ↗ Stuart Robinson · 16 May 2023
“question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending.”
Original on judiciary.uk ↗
Stated action · timescale: 1% February 2019
“The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”
Stated action
“The policy requires that healthcare staff are always invited to attend, or otherwise contribute, to the first case review, allowing the case review team to consider the need for any additional mental health support for the individual, including referral to the mental health team, and their attendance at subsequent case reviews.”
- 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 Ministry of Justice 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 |
|---|---|---|---|---|
| 2018 → 2023 | 0.76 | 0.35 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Ministry of Justice
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.