Lack of relevant information sharing during ACCT reviews
Care UK received 2 coroners' reports about this hazard between 10 Dec 2014 and 18 Dec 2017.
They came from 2 different coroners in 2 coroner areas. 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 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews.”
Original on judiciary.uk ↗ Care UK responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
“From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model .The National Health Service Commissioning Board has procured seven services - GP Services including Pharmacy, Dental, Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services.”
Stated timescale: April 2015
- 3 years laterClosely relatedConfidence 0.90 · higha different coroner
“Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner's ACCT in relation to matters that could bear on risk, 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 and the infrequent occasions that Care UK staff made entries on Mr [name redacted] ACCT daily record.”
Original on judiciary.uk ↗ Repeated from the earlier report:ACCTinformation
Care UK responded, stating 2 specific actions.Response (PDF) ↗
“Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”
Web search (Tavily): No evidence found either way
Prisoner Wellbeing (Safer Custody) - POPS ↗“We agree that the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows. All prisoners who are deemed necessary to be admitted to the Substance Misuse Unit will remain on the unit for a period of stabilisation and until it is deemed safe for them to be moved off this unit and to be placed on normal location. By default, prisoners should not be”
Stated timescale: immediate effect
- All reports to Care UK
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 → 2017Mark Doyle3 years after Geraldine Kilborn · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in sharing relevant information during ACCT reviews, specifically concerning mental health input and record entries.
Geraldine Kilborn · 10 Dec 2014
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews.”
Original on judiciary.uk ↗ Mark Doyle · 18 Dec 2017
“Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner's ACCT in relation to matters that could bear on risk, 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 and the infrequent occasions that Care UK staff made entries on Mr [name redacted] ACCT daily record.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
Stated action
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
Stated action · timescale: April 2015
“From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model .The National Health Service Commissioning Board has procured seven services - GP Services including Pharmacy, Dental, Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support Services.”
Stated action
“Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”
What happened next: No evidence found either way
The organisation did not specify a completion timeframe for embedding LOPs or conducting audits.
“When a loved one is sent to prison, it's natural to feel concerned about their well-being, especially in the unfamiliar environment of a custodial setting. One of the key priorities of the prison service is **safer custody**, which refers to the systems and procedures in place to protect individuals from harm, ensure their physical and mental well-being, and prevent self-harm or incidents of violence”
No evidence found does not mean the action did not happen.
Stated action · timescale: immediate effect
“We agree that the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows. All prisoners who are deemed necessary to be admitted to the Substance Misuse Unit will remain on the unit for a period of stabilisation and until it is deemed safe for them to be moved off this unit and to be placed on normal location. By default, prisoners should not be”
- 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 Care UK 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 → 2017 | 0.70 | 0.09 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Care UK
- Inadequate investigation documentation and delayed safety disclosure2 reports · 2023–2024
- Missing follow up of non attendance at reception healthcare screening3 reports · 2016–2019
- Inadequate ACCT document review and agency input documentation3 reports · 2014–2017
- Lack of depression management documentation and screening2 reports · 2016–2016
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.