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recurance

Brian Dalrymple

18 Sept 2014 · Coroner Jeremy Chipperfield · West London

A similar concern from this report was raised again 2 times later. See the linked reports.

The coroner's concerns

  1. 1. lack of awareness of mental health indicators among detention staff

    “There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare”
  2. 2. relevant observations not communicated to healthcare staff

    “Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff”
  3. 3. medical practitioners lack necessary knowledge

    “Medical practitioners may be employed at Harmondsworth IRC without knowledge necessary to that role”
  4. 4. inadequate routine medical visits for segregated detainees

    “Routine medical visits to segregated detainees are inadequate properly to assess detainees' healthcare needs”
  5. 5. absence of comprehensive accessible clinical records

    “The absence of a comprehensive and accessible (computerised) clinical record relating to each detainee at IRCs Harmondsworth and Colnbrook”

Linked reports

Raised again laterTarek Chowdhury2 Apr 2019 · 4 years 6 months later
Closely relatedConfidence 0.85 · high

This report

“The absence of a comprehensive and accessible (computerised) clinical record relating to each detainee at IRCs Harmondsworth and Colnbrook.”

Later report

“That SystmOne is not operating adequately when new detainees arrive at IRCs.”
Original on judiciary.uk ↗
Full chain: Inadequate electronic health record availability for detainees
Raised again laterAmir Siman-Tov28 Aug 2019 · 4 years 11 months later
Closely relatedConfidence 0.80 · moderate

This report

“Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.”

Later report

“A GP who had seen Mr [name redacted] during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the document as a custody officer process.”
Original on judiciary.uk ↗
Full chain: Missed mental health observations not communicated to healthcare staff

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error