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recurance

Duplicate records leading to missing healthcare data

Closely relatedConfidence 0.85 · high2 reports · 2017–2019No published response to an earlier report One-page brief (print or PDF)

HMP Pentonville received 2 coroners' reports about this hazard between 18 Dec 2017 and 23 Jan 2019.

They came from 2 different coroners. 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 0 specific actions.

2
reports
2
different coroners
2017–2019
years
0.85
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Mark Doyle↗

    18 Dec 2017 · Heather Williams · London Inner (North)

    “I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
    Original on judiciary.uk ↗

    HMP Pentonville responded.Response (PDF) ↗

  2. 1 year 1 month later

    Raised again · 1st time

    Tyrone Givans↗

    23 Jan 2019 · ME Hassell · London Inner (North)

    Closely relatedConfidence 0.85 · higha different coroner
    “A past spelling error meant that there were two sets of NOMIS prison records for Mr [name redacted]. This meant that there were then two sets of SystmOne healthcare records.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:pastprisonrecords

    HMP Pentonville responded.Response (PDF) ↗Response (PDF) ↗

  3. All reports to HMP Pentonville

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