An NHS Trust has been urged to take action after a man with "longstanding" mental health issues died in HMP Hewell. 

Oliver Davies, aged 41, died by suicide in his prison cell on December 31, 2022, following a deterioration in his mental health. 

Oliver had been an inmate in HMP Hewell since October 20, 2022, and the coroner noted that it was his first experience of custody. 

Following an inquest that lasted 10 days, a jury found that neglect contributed to Oliver's death due to a failure to "take sufficient steps to ensure a proper and timely review by a GP of Oliver’s mental health needs" as well as failings around mental health assessments. 

In particular, the coroner advised that there needs to be reinforced teaching for staff to ensure that all staff carrying out mental health assessments are aware of all the circumstances.

Coroner David Reid has now sent a prevention of future deaths report to the Chief Executive of the Midlands Partnership University NHS Foundation Trust as there is a "risk that future deaths will occur unless action is taken".  

In the report, the coroner said that: 

  • During Oliver’s time at HMP Hewell, sufficient steps were not taken to ensure a proper and timely review by a GP of his mental health needs and whether mental health medication should be re-prescribed to him.
  • Information relevant to Oliver’s recent and current mental state was not shared sufficiently between prison staff, healthcare staff and mental healthcare staff at HMP Hewell, such that Oliver’s ongoing risk of self-harm or suicide could be properly assessed.
  • Oliver was not kept sufficiently informed of progress regarding his applications for a doctor to review his mental health needs and to consider whether mental health medication should be re-prescribed to him.
  • Oliver was not kept sufficiently informed of his allocation to, and forthcoming appointments with, a mental health care coordinator.

The report also states that the ACCT case review on December 30, 2022, did not sufficiently consider all information relevant to Oliver’s ongoing risk of self-harm or suicide.

Oliver’s mother gave evidence at the inquest, and the Coroner remarked that he hoped her happy memories of Oliver would sustain her in the future.

In a statement after the inquest, Oliver’s mum Lynne Bullar said: "Oliver was an extremely unwell and vulnerable young man, who was very fearful of the prison regime.

"It is extremely distressing to learn that his frequent requests for mental health treatment and medication were repeatedly ignored, which led to a deterioration in his mental health.

"As a family, it was our expectation that Oliver would be looked after and kept safe, which sadly did not happen. Oliver was a very much loved only child, who will be forever missed by his family. 

“We would like to thank the Coroner, and the jury for their careful consideration and conclusions.

"We hope that procedures will be immediately put into place to prevent other families having to endure the devastating loss of their child in these circumstances." 

Alice Wood of Farleys Solicitors said: "Lynne has felt throughout this process that Oliver had been failed and to now have that on record is very important.

"We are grateful to the Coroner and the jury for their care and attention throughout the inquest."

Copies of the PFD report were received by all interested parties including HM Prison and Probation Service, Practice Plus Group, West Mercia Police and GEOAmey.

In response to the PFD report, Liz Lockett, Chief Nurse and Deputy Chief Executive at Midlands Partnership University NHS Foundation Trust today, said: "First and foremost I would like to express my sincere condolences to the family and friends of Mr Davies at this difficult time.

"The Trust accepts the coroner’s findings into the inquest of Oliver Davies. Our priority is to implement the learning from the coroner’s report.

"This process has begun, and we will continue to make the necessary improvements in line with the recommendations made by the coroner in a timely manner." 

A spokesperson from Practice Plus Group said: "We send our heartfelt condolences to Oliver Davies’ family.

"There were a number of lessons learned from the inquest and we will continue to work with all agencies involved to improve the care provided to those with complex needs in prison, and to identify anyone who needs additional support at the earliest opportunity."