Inadequate weekend mental health provision at prison
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.
The story, report by report
Spacing grows with the time between reports.
“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 ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 2 years 6 months later
“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.”
- 7 years 5 months laterIdentical 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) ↗
- All reports to NHS England
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 → 2026Nigel Keenan7 years 5 months after Bradley Brown · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of mental health services for prisoners during weekends, which increases the risk of self‑harm and death.
Bradley Brown · 30 Nov 2018
“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 ↗ Nigel Keenan · 13 May 2026
“Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends.”
Original on judiciary.uk ↗ 2016 → 2026Nigel Keenan9 years 11 months after Kevin Dermott · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient mental health services at HMP Haverigg, noting gaps in staffing and availability.
Kevin Dermott · 13 Jun 2016
“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 ↗ Nigel Keenan · 13 May 2026
“Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends.”
Original on judiciary.uk ↗
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.
Stated action
“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.”
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 NHS England 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 → 2026 | 0.73 | 0.22 | Identical · 0.90 | different |
| 2016 → 2026 | 0.65 | 0.23 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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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.