Recurance · prevention of future deaths reports
Pre-inquest brief
Missing escort records during reception screening
The earlier warning
John Stabler · 18 Dec 2014 · Stuart Fisher, Central Lincolnshire
“That there is a need for the Prisoner Escort Record to be reviewed and redesigned”
judiciary.uk/prevention-of-future-death-reports/john-stabler
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 6 Dec 2016 · Tedros Kahssay · ME Hassell · Closely related · confidence 0.90 (high)
- 13 Jul 2017 · Edwin O'Donnell · Andre Rebello · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Tedros Kahssay · 6 Dec 2016
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
Later · Edwin O'Donnell · 13 Jul 2017
“During the course of the inquest into the death of [name redacted] (Ned) O'Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.”
What happened next
No web check of the stated actions has been published for this chain.