Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate weekend mental health provision at prison
The earlier warning
Kevin Dermott · 13 Jun 2016 · Nicholas Rheinberg, Cheshire
“At HMP Haverigg there was inadequate mental health cover with at times only one mental 1 health nurse and no provision for psychiatric referral”
judiciary.uk/prevention-of-future-death-reports/kevin-dermott
What was promised
Stated action 1 · response to Bradley Brown (30 Nov 2018) · stated timescale: none stated
“the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded.”
judiciary.uk/…/2018-0374-Response-by-HM-Prison-and-Probation-Se…
What recurred
- 30 Nov 2018 · Bradley Brown · Lisa Hashmi
- 13 May 2026 · Nigel Keenan · Robert Cohen · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Bradley Brown · 30 Nov 2018
“Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted.”
Later · Nigel Keenan · 13 May 2026
“Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends.”
What happened next
No web check of the stated actions has been published for this chain.