Oliver Davies: Mum's tribute to son who died in HMP Hewell

Oliver Davies 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. 

Oliver's mum Lynne Bullar, who attended the inquest every day, has now spoken out about the turmoil she has faced since losing her son and the devastating impact his tragic death has had on the family and all that knew and loved him. 

Oliver Davies died in HMP Hewell (Image: Family Handout) She said: "Oliver was a kind, sensitive and compassionate young man who struggled with a mental health condition. He was quite a lonely lad and found it difficult to make friends. 

"His one true friend was his beloved dog Jake. When he sadly passed away, Oliver was heartbroken and his mental health deteriorated significantly. He never came to terms with the loss.

"There were many happy times that Oliver and I spent together. He enjoyed helping me in the garden, DIY and when he was well, he had a great sense of humour."

At the inquest, the coroner found 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.

This meant Oliver's ongoing risk of self-harm and suicide could not be properly assessed. 

Ms Bullar said: "Oliver's vulnerabilities and suicide risk were clearly flagged but were largely ignored. Oliver made several written applications pleading for help. 

"He must have felt completely abandoned." 

Portrait of Oliver with his dog Jake (Image: Handout) Recalling the days after she received the news of Oliver's death, Ms Bullar said they were "very dark" and she will forever miss her "beautiful" son. 

She said: "I have cried an ocean full of tears. It is only with the help of my wonderful family and friends, the crisis team, my counsellor and my doctor that I have got through this. 

"With the help of Ally and Pete from Golden Valley Funeral Services, we arranged a beautiful and dignified funeral service for Oliver which was full of music and memories. 

"Oliver's dog Jake, made out of flowers, was placed at the front of his coffin. A memory bear was made for me out of Oliver's clothes which has been a great comfort." 

In memory of Oliver, Ms Bullar continues to run a cat visiting service to nursing homes which her son named 'Cats for Comfort'. 

Any donations received are given to The Dogs Trust and Herefordshire Mind. 

Oliver's garden memorial with a statue of Jake by the side (Image: Handout) Ms Bullar added: "Oliver was my only child. A much-loved son who will be forever missed. I am half the person I was before he died. 

"Oliver was badly let down. How many other families will have to endure the death of their child in prison before lessons are learned?" 

Coroner David Reid has since 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".  

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."