Cancellation of hospital appointments for prisoners
NHS England received 2 coroners' reports about this hazard between 16 Aug 2019 and 4 Apr 2021.
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 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits.”
Original on judiciary.uk ↗ NHS England responded, stating 6 specific actions.Response (PDF) ↗Response (PDF) ↗
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”
Stated timescale: end of December 2019
“a clinical review of any appointments which are postponed. This includes a review by the GP to assess Clinical need and risk. Where the demand for external escorts exceeds availability, the GP will prioritise appointment attendance based on clinical need and any appointment cancelled is to be automatically re-booked with the hospital trust. This revised process including clinical review will suitably prioritise and prevent future failings to re-arrange cancelled appointments. The monitoring of this”
Stated timescale: monthly Contract Review Meetings (CRM)
4 more stated actions in the Promises tab.
- 1 year 8 months later
Raised again · 1st time
Imre Thomas↗
4 Apr 2021 · Nicholas Rheinberg · Lancashire and Blackburn with Darwen
Identical hazardConfidence 0.90 · higha different coroner“Cancelled hospital appointments putting vulnerable prisoners at risk. As the commissioning body you are asked to investigate the possibility of organising special prison clinics for visiting hospital consultants.”
Original on judiciary.uk ↗ Repeated from the earlier report:Cancelledhospitalappointments
The most recent report. A response may not be due or published yet.
- 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 → 2021Imre Thomas1 year 8 months after Justin Gallagher · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight cancelled hospital appointments for prisoners due to insufficient resources and lack of a coordination system. The later report builds on the same issue by suggesting special prison clinics.
Justin Gallagher · 16 Aug 2019
“A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits.”
Original on judiciary.uk ↗ Imre Thomas · 4 Apr 2021
“Cancelled hospital appointments putting vulnerable prisoners at risk. As the commissioning body you are asked to investigate the possibility of organising special prison clinics for visiting hospital consultants.”
Original on judiciary.uk ↗
Stated action · timescale: end of December 2019
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”
Stated action · timescale: monthly Contract Review Meetings (CRM)
“a clinical review of any appointments which are postponed. This includes a review by the GP to assess Clinical need and risk. Where the demand for external escorts exceeds availability, the GP will prioritise appointment attendance based on clinical need and any appointment cancelled is to be automatically re-booked with the hospital trust. This revised process including clinical review will suitably prioritise and prevent future failings to re-arrange cancelled appointments. The monitoring of this”
Stated action · timescale: ongoing
“the running of a regular report via SystmOne to ensure that healthcare records have been requested; and e © anominated member of staff checking that all newly arrived prisoners have been offered a full general health assessment to include the drafting of a care plan within 7 days of arrival. The checks to be noted on an internal document which is shared with all healthcare staff”
Stated action · timescale: ongoing
“New prisoners with chronic conditions are assigned to a named clinician. Depending upon the condition this may be a GP, [name redacted] or Primary Care Nurse”
Stated action · timescale: end of December 2019
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”
Stated action
“The Governor of HMP Lewes is committed to providing resources for external escorts to medical appointments. Currently, sufficient escorting staff are made available for three external hospital escorts each weekday, and appointments are prioritised by the healthcare team. In the event that there are inadequate resources because of other operational pressures and it is necessary to consider the cancellation of an external appointment, the Duty Governor contacts the healthcare team for advice on”
No published response from NHS England was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 → 2021 | 0.69 | 0.22 | 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.