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recurance

Inadequate weekend mental health provision at prison

Closely relatedConfidence 0.90 · high3 reports · 2016–2026No published response to an earlier report One-page brief (print or PDF)

NHS England received 3 coroners' reports about this hazard between 13 Jun 2016 and 13 May 2026.

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 1 specific action.

3
reports
3
different coroners
2016–2026
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Kevin Dermott↗

    13 Jun 2016 · Nicholas Rheinberg · Cheshire

    “At HMP Haverigg there was inadequate mental health cover with at times only one mental 1 health nurse and no provision for psychiatric referral”
    Original on judiciary.uk ↗
  2. 2 years 6 months later

    Raised again · 1st time

    Bradley Brown↗

    30 Nov 2018 · Lisa Hashmi · Manchester (North)

    “Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted.”
    Original on judiciary.uk ↗

    NHS England responded, stating 1 specific action.Response (PDF) ↗

    “the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded.”
  3. 7 years 5 months later

    Raised again · 2nd time

    Nigel Keenan↗

    13 May 2026 · Robert Cohen · Cumbria

    Identical hazardConfidence 0.90 · higha different coroner
    “Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends.”
    Original on judiciary.uk ↗

    NHS England responded.Response (PDF) ↗

  4. All reports to NHS England

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error