Inadequate medical information transfer between custodial healthcare providers
NHS England received 2 coroners' reports about this hazard between 16 Aug 2019 and 22 Oct 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 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body.”
Original on judiciary.uk ↗ NHS England responded, stating 5 specific actions.Response (PDF) ↗
“The Ministry of Justice will respond directly to the Coroner on this.”
“Partnership NHS Foundation Trust (SPFT) undertook a Root Cause Analysis Investigation following Mr [name redacted] death and three recommendations were made: a. healthcare staff should be trained in how to detect diabetes and hypertension; b. long term conditions such as diabetes and hypertension are managed in line with National Institute for Care Excellence (NICE) guidelines; and c. reviews of repeat medication comply with NICE”
Stated timescale: end of 2018
3 more stated actions in the Promises tab.
- 6 years 2 months laterClosely relatedConfidence 0.85 · higha different coroner
“There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare”
Original on judiciary.uk ↗ Repeated from the earlier report:healthcarebetween
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.
2019 → 2025Amy Cross6 years 2 months after Martin Haines · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight a lack of effective communication or information transfer between separate healthcare providers involved in custodial settings. The earlier report notes missing protocols between prison health teams, while the later report describes no system for passing medical details during transfers between police, court, and prison.
Martin Haines · 16 Aug 2019
“There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body.”
Original on judiciary.uk ↗ Amy Cross · 22 Oct 2025
“There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare”
Original on judiciary.uk ↗
Stated action
“The Ministry of Justice will respond directly to the Coroner on this.”
Stated action · timescale: end of 2018
“Partnership NHS Foundation Trust (SPFT) undertook a Root Cause Analysis Investigation following Mr [name redacted] death and three recommendations were made: a. healthcare staff should be trained in how to detect diabetes and hypertension; b. long term conditions such as diabetes and hypertension are managed in line with National Institute for Care Excellence (NICE) guidelines; and c. reviews of repeat medication comply with NICE”
Stated action · timescale: 31 March 2020
“An on-going action plan remains in place and will continue to be monitored closely for the remainder of the trust's contract which ends on 31 March 2020. To support · this, and ensure a reduction in any risk to patients, commissioners have appointed a clinical reviewer (previously Director of Nursing”
Stated action
“The Prison and Healthcare providers have reminded staff of the protocols in relation to responding to an unresponsive body, including the need for prison staff to elicit a verbal or non-verbal response from each prisoner when cells are unlocked. Further reminders have been issued on the need to immediately call an ambulance when a Code RED or Code BLUE is called, including a new poster in the control room.”
Stated action
“Electronic Patient Records All healthcare providers are given access to electronic healthcare software, SystmOne. Substance misuse services have their own database which records performance and on which payment is based. Clinical information is recorded on SystmOne.”
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 |
|---|---|---|---|---|
| 2019 → 2025 | 0.76 | 0.12 | Closely related · 0.85 | 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.