Recurring hazard (see the quoted concerns)
His Majesty's Prison and Probation Service received 2 coroners' reports about this hazard between 20 Dec 2019 and 7 Feb 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 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide”
Original on judiciary.uk ↗ His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”
- 5 years 2 months later
Raised again · 1st time
Anthony Binfield, David Richards and Rolandas Karbauskas↗
7 Feb 2025 · Laurinda Bower · Nottingham City and Nottinghamshire
Identical hazardConfidence 0.90 · higha different coroner“a failure by prison and healthcare staff to read the incoming prisoner's core file. This hard copy file contains valuable information such as previous ACCT documents and SASH warning forms”
Original on judiciary.uk ↗ Repeated from the earlier report:staffreadfileACCT
His Majesty's Prison and Probation Service responded, stating 6 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Trust has established enhanced Executive led oversight and assurance reviews for Offender Health. This comprises a weekly meeting where progress against the Transformation Plan is reviewed with individuals held to account.”
“A new national template for prison reception screening for the male prison estate was launched on the 1 April 2025. Staff are in the process of receiving the Nationally delivered Highbury Hospital, Highbury Road, Nottingham, NG6 9DR training for this and the benefits include a standardised and simplified model of screening which enable the understanding and recording of previously documented clinical risk which needs to be further considered as part of the reception and induction process.”
Stated timescale: 1 April 2025
4 more stated actions in the Promises tab.
- All reports to His Majesty's Prison and Probation Service
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 → 2025Anthony Binfield, David Richards and Rolandas Karbauskas5 years 2 months after Tomasz Nowasad · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the failure of prison and healthcare staff to read and act upon the prisoner's ACCT/core file containing self‑harm and suicide risk information. The earlier report stresses reading the ACCT file on arrival, while the later report notes that the core file with ACCT documents was not reviewed.
Tomasz Nowasad · 20 Dec 2019
“It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide”
Original on judiciary.uk ↗ Anthony Binfield, David Richards and Rolandas Karbauskas · 7 Feb 2025
“a failure by prison and healthcare staff to read the incoming prisoner's core file. This hard copy file contains valuable information such as previous ACCT documents and SASH warning forms”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”
Stated action
“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”
No specific action could be extracted with a verified quote.
Stated action
“The Trust has established enhanced Executive led oversight and assurance reviews for Offender Health. This comprises a weekly meeting where progress against the Transformation Plan is reviewed with individuals held to account.”
Stated action · timescale: 1 April 2025
“A new national template for prison reception screening for the male prison estate was launched on the 1 April 2025. Staff are in the process of receiving the Nationally delivered Highbury Hospital, Highbury Road, Nottingham, NG6 9DR training for this and the benefits include a standardised and simplified model of screening which enable the understanding and recording of previously documented clinical risk which needs to be further considered as part of the reception and induction process.”
Stated action
“The Head of Safer Custody has introduced a new Early Days in Custody (EDIC) booklet along with colleagues from Reception and the Induction wing.”
Stated action
“We have worked with Prison colleagues to ensure that SIMs are attended on a weekly basis by a member of the Mental Health Team. This meeting is to discuss any patients of concern and highlight any specific issues relating to that individual.”
Stated action · timescale: June 2025
“CSIP: Patients can also be referred to CSIP (Challenge, Support and Intervention Plan). This is a prison risk management system and process that will enable information sharing on risk in the prison estate and also support the development of cross professional relationships. Healthcare staff are currently accessing the training for this, and full compliance is aimed to have been achieved by June 2025.”
Stated action · timescale: July 2025
“Training - Healthcare staff have arranged to attend the Prison staff induction programme so that they can deliver health training to the Prison Officers. Initially this will be focused on emergency response but will later include Mental Health awareness training. This was agreed at the Local Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was very positive. Healthcare staff will continue to receive clinical risk, self-harm and suicide training, which is”
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 His Majesty's Prison and Probation Service 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 | 0.69 | 0.23 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for His Majesty's Prison and Probation Service
- Obscured observation panels hinder monitoring3 reports · 2024–2026
- Lack of basic first aid training and CPR among prison officers12 reports · 2015–2026
- Inadequate ACCT training leading to incomplete documentation16 reports · 2014–2026
- Lack of certified safer cells outside segregation unit4 reports · 2023–2025
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.