Bradley Brown
30 Nov 2018 · Coroner Lisa Hashmi · Manchester (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate mental health assessment leading to death
“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. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays.”
2. lack of coordinated mental health service commissioning
“Commissioning of Mental Health/Healthcare Services: As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“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 report
“Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends.”
Responses
2018-0374-Response-by-HM-Prison-and-Probation-Service.pdf ↗· Ministry of Justice
Stated action
“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.”