Recurance · prevention of future deaths reports
Pre-inquest brief
Duplicate records leading to missing healthcare data
The earlier warning
Mark Doyle · 18 Dec 2017 · Heather Williams, London Inner (North)
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 23 Jan 2019 · Tyrone Givans · ME Hassell · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Mark Doyle · 18 Dec 2017
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
Later · Tyrone Givans · 23 Jan 2019
“A past spelling error meant that there were two sets of NOMIS prison records for Mr [name redacted]. This meant that there were then two sets of SystmOne healthcare records.”
What happened next
No web check of the stated actions has been published for this chain.