Inadequate information sharing between police and mental health services
Essex Police received 2 coroners' reports about this hazard between 14 Aug 2017 and 26 Nov 2025.
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 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.”
Original on judiciary.uk ↗ Essex Police responded, stating 7 specific actions.Response (PDF) ↗Response (PDF) ↗
“All health-based place of safety calls are directed now through the new Trust's call centre. This means that all calls are recorded and documented on a call-log by trained call-handlers.”
“All patients admitted to health-based places of safety have individual patient records detailing potential risks, assessment of presentation and copies of documentation from other agencies. Further work is continuing on electronic record-keeping processes in regard to this issue.”
5 more stated actions in the Promises tab.
- 8 years 3 months laterClosely relatedConfidence 0.85 · higha different coroner
“Essex Police were aware that [the deceased] was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime.”
Original on judiciary.uk ↗ Essex Police responded.Response (PDF) ↗
- All reports to Essex Police
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.
2017 → 2025Aminata Coulibaly8 years 3 months after Terence Pimm · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight shortcomings in information sharing and coordination between Essex Police and mental health services.
Terence Pimm · 14 Aug 2017
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.”
Original on judiciary.uk ↗ Aminata Coulibaly · 26 Nov 2025
“Essex Police were aware that [the deceased] was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.”
Stated action
“All health-based place of safety calls are directed now through the new Trust's call centre. This means that all calls are recorded and documented on a call-log by trained call-handlers.”
Stated action
“All patients admitted to health-based places of safety have individual patient records detailing potential risks, assessment of presentation and copies of documentation from other agencies. Further work is continuing on electronic record-keeping processes in regard to this issue.”
Stated action
“The new Trust has taken steps to reinforce to staff the importance of family involvement and ongoing communications. A detailed debrief in this respect was undertaken with the staff involved in Mr [name redacted] care. Additionally, audits on this issue are being undertaken via the new Trust's staff supervision process.”
Stated action
“The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.”
Stated action
“The new Trust has launched a new street-triage team in which mental health practitioners work together with dedicated police officers. We anticipate that this initiative will also help significantly to improve information-sharing and coordination between our services.”
Stated action
“A new flowchart is in place now for staff, which details clearly which actions to take in situations where people are subject to a warrant. Training on this is underway for all our staff working in mental health accident and emergency teams and mental health criminal justice teams.”
Stated action · timescale: 1° September
“Essex Police have taken the following action; e Essex Police has written to the Essex and Essex Community Rehabilitation Company concerning the outcome of the Inquest;”
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 Essex Police 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 |
|---|---|---|---|---|
| 2017 → 2025 | 0.73 | 0.04 | Closely related · 0.85 | 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.