Recurance · prevention of future deaths reports
Pre-inquest brief
Recurring hazard (see the quoted concerns)
The earlier warning
Tomasz Nowasad · 20 Dec 2019 · Nigel Meadows, Manchester (City)
“It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide”
judiciary.uk/prevention-of-future-death-reports/tomasz-nowasad
What was promised
Stated action 1 · response to Tomasz Nowasad (20 Dec 2019) · stated timescale: none stated
“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”
judiciary.uk/…/2019-0445-Response-from-NHS-England-Redacted.pdf
What recurred
- 7 Feb 2025 · Anthony Binfield, David Richards and Rolandas Karbauskas · Laurinda Bower · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Tomasz Nowasad · 20 Dec 2019
“It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide”
Later · Anthony Binfield, David Richards and Rolandas Karbauskas · 7 Feb 2025
“a failure by prison and healthcare staff to read the incoming prisoner's core file. This hard copy file contains valuable information such as previous ACCT documents and SASH warning forms”
What happened next
No web check of the stated actions has been published for this chain.