Absence of fitness to transfer assessment
NHS England received 2 coroners' reports about this hazard between 20 Jun 2014 and 24 Oct 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from NHS England was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“There must be a robust and clearly documented process in place when assessing a detainee's fitness to transfer, together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison's care.”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 9 years 4 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There was also no evidence that Mr [name redacted] had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.”
Original on judiciary.uk ↗ Repeated from the earlier report:fitnesstransfer
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.
2014 → 2023Jonathan McCarthy9 years 4 months after Redmond Johnson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of a proper fitness-to-transfer assessment for detainees before movement. They share the concern that without such assessment, risks to health are not managed.
Redmond Johnson · 20 Jun 2014
“There must be a robust and clearly documented process in place when assessing a detainee's fitness to transfer, together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison's care.”
Original on judiciary.uk ↗ Jonathan McCarthy · 24 Oct 2023
“There was also no evidence that Mr [name redacted] had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.”
Original on judiciary.uk ↗
No published response from NHS England was found for this report.
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 |
|---|---|---|---|---|
| 2014 → 2023 | 0.77 | 0.25 | Identical · 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.