Missing escort records during reception screening
His Majesty's Prison and Probation Service received 3 coroners' reports about this hazard between 18 Dec 2014 and 13 Jul 2017.
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 1 of the 2 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“That there is a need for the Prisoner Escort Record to be reviewed and redesigned”
Original on judiciary.uk ↗ No published response from His Majesty's Prison and Probation Service was found for this report.
- 2 years laterClosely relatedConfidence 0.90 · higha different coroner
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
Original on judiciary.uk ↗ Repeated from the earlier report:escortrecord
His Majesty's Prison and Probation Service responded.Response (PDF) ↗
- 7 months laterIdentical hazardConfidence 0.95 · higha different coroner
“During the course of the inquest into the death of [name redacted] (Ned) O'Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.”
Original on judiciary.uk ↗ Repeated from the earlier report:nursereceptionscreeningEscortReportaccompanied
His Majesty's Prison and Probation Service responded, stating 4 specific actions.Response (PDF) ↗
“The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to the healthcare member of staff based there, ensuring that they have access to all the relevant information.”
“The SystmOne record is also available to the receiving establishment on a terminal in the reception area. We are therefore confident that the system that has been introduced at Liverpool ensures that the relevant information is routinely available, shared with healthcare staff and recorded.”
Stated timescale: 2078
2 more stated actions in the Promises tab.
- All reports to His Majesty's Prison and Probation Service
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.
2014 → 2016Tedros Kahssay2 years after John Stabler · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the Person Escort Record (PER) failing to convey necessary information during prisoner intake.
John Stabler · 18 Dec 2014
“That there is a need for the Prisoner Escort Record to be reviewed and redesigned”
Original on judiciary.uk ↗ Tedros Kahssay · 6 Dec 2016
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
Original on judiciary.uk ↗ 2016 → 2017Edwin O'Donnell7 months after Tedros Kahssay · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports describe that nurses performing initial health reception screening did not receive the Prisoner Escort Report (PER) accompanying the prisoner.
Tedros Kahssay · 6 Dec 2016
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
Original on judiciary.uk ↗ Edwin O'Donnell · 13 Jul 2017
“During the course of the inquest into the death of [name redacted] (Ned) O'Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.”
No published response from His Majesty's Prison and Probation Service was found for this report.
No specific action could be extracted with a verified quote.
Stated action
“The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to the healthcare member of staff based there, ensuring that they have access to all the relevant information.”
Stated action · timescale: 2078
“The SystmOne record is also available to the receiving establishment on a terminal in the reception area. We are therefore confident that the system that has been introduced at Liverpool ensures that the relevant information is routinely available, shared with healthcare staff and recorded.”
Stated action · timescale: shortly
“the Head of Healthcare at Liverpool and a member of the prison's senior management team are meeting shortly to re-evaluate current practices and implement revised procedures to ensure that second health screenings take place within 24-48 hours.”
Stated action · timescale: twice monthly
“At Liverpool the training is being delivered at the 'Academy Training Days' which take place twice monthly.”
- 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 His Majesty's Prison and Probation Service 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 |
|---|---|---|---|---|
| 2014 → 2016 | 0.74 | 0.26 | Closely related · 0.90 | different |
| 2016 → 2017 | 0.76 | 0.28 | Identical · 0.95 | 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.