Delayed staff training on cell entry and emergency communications
Ministry of Justice received 2 coroners' reports about this hazard between 16 May 2024 and 8 Jul 2025.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency”
Original on judiciary.uk ↗ Ministry of Justice responded.Response (PDF) ↗
- 1 year 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“The evidence of OSG [REDACTED] did not appear to demonstrate familiarity with the processes set out in this policy at the time of [the deceased]'s death”
Original on judiciary.uk ↗ Ministry of Justice responded.Response (PDF) ↗
- All reports to Ministry of Justice
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.
2024 → 2025George Emmett1 year 2 months after Luke Pearce · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that staff lack sufficient training or familiarity with procedures for entering cells and using Code Blue/Red communications during medical emergencies. This gap could delay appropriate emergency response and endanger prisoner safety.
Luke Pearce · 16 May 2024
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency”
Original on judiciary.uk ↗ George Emmett · 8 Jul 2025
“The evidence of OSG [REDACTED] did not appear to demonstrate familiarity with the processes set out in this policy at the time of [the deceased]'s death”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
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 Ministry of Justice 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 |
|---|---|---|---|---|
| 2024 → 2025 | 0.69 | 0.17 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.