“There was limited communication between the Caswell clinic and HMP Cardiff following the…”

The coroner’s concerns

(1) There was limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr Davies’ discharge. In particular, information that Mr Davies had commenced food refusal following the s 117 meeting and that it had not been possible to assess him physically prior to transfer was not clearly communicated to HMP Cardiff before the transfer occurred (2) Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format to manage the known risks associated with the transfer of Mr Davies to prison (3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff. Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner (4) Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP Cardiff. (5) Mr Davies was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc. Insufficient consideration was given as to whether Mr Davies’ needs were better met at an alternative specialist institution. (6) No clear plan to promote Mr Davies’ engagement with prison medical services, or the assessment of his mental or physical condition was devised or implemented at HMP Cardiff (7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP Cardiff (8) No food and fluid refusal policy was in place to guide healthcare staff. 3 (9) The number of GPs working in HMP Cardiff was insufficient to meet the demands upon them. (10) The Nurse and Health care assistant responsible for Mr Davies on the night of his collapse were working an 11.5 hour night shift without rest breaks, which they identified as being overly fatiguing (11) The Nurse, Health care assistant and Custodial manager responsible for Mr Davies on the night of his collapse were not provided with clear information regarding the duration of his fluid and food refusal or the warning signs to consider in the context of the known risk of sudden collapse (12) The Health care assistant caring for Mr Davies overnight overheard more senior prison staff stating that they would not return to assist Mr Davies in healthcare, and felt unable to challenge this.

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, 2024-0160

Added to Minute Book

8 Oct 2026

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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