“6 (1) Staffing within the Mental Health In-reach team impacting the timely undertaking of…”
Dated 18 Jul 2025, from the coroner for Inner West London. Sent to 5 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 12 Sep 2025. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated18 Jul 2025
- Deadline12 Sep 2025
- Published on judiciary.uk23 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| HMPPS | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Minister of State for Prisons | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Ministry of Justice/HMP Wandsworth | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Secretary of State for Health and Social Care | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Oxleas NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 6 (1) Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments. (2) Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme. (3) Knowledge of prison staff of the heightened risk of foreign nationals in custody, despite a higher proportion of foreign nationals being detained at HMP Wandsworth. (4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals. (5) Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges. (6) First Aid refresher training is not up to date for all healthcare staff.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0364
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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