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recurance

Ministry of Justice

109
reports received
35
with a published response found
16
recurrence chains
39
reports in those chains
  • Coroner Mary Hassell · Inner North London · in 1 recurrence link

    No published response from this organisation found.

  • Coroner I M Cartwright · Leicester City and South Leicestershire · in 14 recurrence links

    Response · 1 stated action
    2024-0550-Response-from-HMPPS-received-by-CCO-24102025.pdf ↗
    “attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
  • Coroner Bronia Hartley · Greater Manchester West

    Response · 1 stated action
    2024-0485-Response-from-HMPPS.pdf ↗
    “HMP Forest Bank has advised that the induction is now split across two wings, which allows VPs and non-VPs to be housed separately, which means that the risks to VPs associated with co-location, including the cancelling of cell call bells by non-VPs, are no longer present.”
  • Coroner Patricia Harding · Mid Kent and Medway · in 2 recurrence links

    No published response from this organisation found.

  • Coroner Anton van Dellen · West London · in 4 recurrence links

    No published response from this organisation found.

  • Coroner Nadia Persaud · East London · in 2 recurrence links

    Response · 1 stated action
    2024-0409-Response-from-London-Borough-of-Redbridge.pdf ↗
    “The training for CCTV operators encompasses modules that cover behavioural body language training and are specifically designed to detect behaviours that would fall under the remit of 'suspicious'. The training is based on established principles and techniques outlined in Tavcom training programs - suspicious behaviours can include gestures, mannerisms, alone or in a group, time, location, how someone is acting (i.e. drunk/disorientated), approaching people, being aggressive etc. The training given”
    Response · 1 stated action
    2024-0409-Response-from-HMPPS-and-MoJ.pdf ↗
    “We accept that the Probation Delivery Unit (PDU) responsible for [name redacted] was understaffed at the time. Whilst at a national level, the staffing position of the Probation Service is improving, I acknowledge that raising staffing in this PDU to its full complement remains a significant challenge. Therefore, until such time as the situation improves, in this PDU and others with acute pressure remaining, staff will follow a Prioritisation Framework which we first implemented in January 2022”
  • Coroner Peter Nieto · Derby and Derbyshire · in 2 recurrence links

    Response · 1 stated action
    2024-0330-Response-from-HMPPS.pdf ↗
    “In April 2021, as part of a wider organisational change, HMP Foston Hall implemented ACCT version 6. The new version of the ACCT document was developed following a review of the previous version, and is designed to encourage a person-centred and multidisciplinary case management approach. In addition to the introduction of the new document, guidance documents that focus on various aspects including the ongoing record were produced to assist staff in conducting their duties. The ongoing record”
  • Coroner Alison Mutch · Manchester South · in 2 recurrence links

    Response · 1 stated action
    2024-0288-Response-from-DHSC.pdf ↗
    “The Trust recognises that, at the time of the incident the College did not have a clear written protocol in place to manage risk. As an educational establishment the College did not have plans or processes in place to communicate effectively with other teams within the Trust such as the clinical teams or externally to organisations such as the Probation Service about the risk of harm occurring to others. The College is bound by Trust policies in relation to safeguarding and the College team did”
    Response · 1 stated action
    2024-0288-Response-from-GMP.pdf ↗
    “the Head of Public Protection at Greater Manchester Police and the Head of Public Protection at Greater Manchester Probation service commenced monthly meetings in 2023.”
    Response · 1 stated action
    2024-0288-Response-from-HMPPS.pdf ↗
    “Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience”
  • Coroner Joanne Kearsley · Manchester North

    No published response from this organisation found.

  • Coroner Karen Dilks · Newcastle and North Tyneside

    No published response from this organisation found.

  • Coroner Charlotte Keighley · Cheshire

    No published response from this organisation found.

  • Coroner Kelly Dixon · Staffordshire and Stoke on Trent · in 2 recurrence links

    No published response from this organisation found.

  • Coroner Peter Nieto · Derby and Derbyshire

    No published response from this organisation found.

  • Coroner John Hobson · West Yorkshire (Eastern)

    No published response from this organisation found.

  • Coroner Clement Goldstone · Derby and Derbyshire

    Response
  • Coroner Peter Nieto · Derby and Derbyshire

    No published response from this organisation found.

  • Coroner Peter Nieto · Derby and Derbyshire

    Response · 6 stated actions
    2023-0467-Response-from-HM-Prison-and-Probation-Service.pdf ↗
    “We will issue new guidance for practitioners on NDelius recording of closed cases.”
    “We will update existing guidance in relation to recording, handling sensitive information and OASys help-text to address risk information received on closed cases.”
    “We will finalise and promote a new Senior Probation Officer (SPO) learning and development package, currently in development, to include support for SPOs on advising practitioners on handling sensitive information.”
    “We will conduct a review of Information Security Policy Framework to address closed cases.”
    “The new assessment service will continue to be designed as an open document, whilst facilitating a separate section for recording non-disclosable information. Current timelines aim for the 'Needs analysis' and 'Offence analysis' and sentence plan sections of the new service being available to pilot groups of staff by Summer/Autumn 2024.”
    “we will add to existing guidance for practitioners and court report writers on 'where to find risk related information on case records,' covering both OASys and NDELIUS.”
  • Coroner Hassan Shah · Northampton · in 1 recurrence link

    No published response from this organisation found.

  • Coroner Jenny Goldring · Inner South London · in 1 recurrence link

    No published response from this organisation found.

  • Coroner Jonathan Stevens · Hertfordshire · in 3 recurrence links

    No published response from this organisation found.

  • Coroner Jenny Goldring · Inner South London

    Response · 1 stated action
    2023-0269-Response-from-Serco-1-1.pdf ↗
    “We provide the following response on behalf of r the Prison, and we would like to take the opportunity to address you on each of your i f concerns in turn, for ease of reference”
  • Coroner Anna Loxton · Surrey

    No published response from this organisation found.

  • Coroner Kevin McLoughlin · West Yorkshire (Eastern) · in 1 recurrence link

    No published response from this organisation found.

  • Coroner Zak Golombeck · Manchester City

    No published response from this organisation found.

  • Coroner Kate Ainge · Liverpool and Wirral · in 1 recurrence link

    Response · 1 stated action
    2023-0161-Response-from-HM-Prison-Probation-Service.pdf ↗
    “The policy requires that healthcare staff are always invited to attend, or otherwise contribute, to the first case review, allowing the case review team to consider the need for any additional mental health support for the individual, including referral to the mental health team, and their attendance at subsequent case reviews.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error