“Oliver had been at HMP Hewell since 20.10.22”

The coroner’s concerns

– 1) Oliver had been at HMP Hewell since 20.10.22. He was a man with longstanding mental health issues, for whom this was a first experience of custody. After a steady deterioration in his mental state, a mental health referral on 17.11.22 led to a belated mental health examination conducted by a registered learning disability nurse on 6.12.22. In the week leading up to the nurse’s assessment: (a) A prison officer had made an urgent TAG mental health referral on 30.11.22, citing concerns that Oliver was experiencing active thoughts of self-harm or suicide, and that he ( the officer ) had “mild concerns” about intentional self-harm, and there were “definite indicators” of unintentional self-harm; and (b) Oliver himself had submitted a healthcare application form asking to see a doctor, saying that he was “extremely depressed”, his anxiety was “really high” and he was “not coping at all, please help”; These important events were not highlighted on Oliver’s SystmOne medical record, and so the nurse conducting the assessment 6.12.22 was not aware of either of these important recent events, and did not take them into account when assessing Oliver; 2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s assessment. An appointment was fixed for Oliver to meet the care coordinator for the first time on 14.12.22. Due to workload pressures, the care coordinator was unable to fulfil that appointment before he went on leave from 1628.12.22. Shortly before he went on leave, the care coordinator conducted a “RAG rating” exercise to determine whether he should prioritise seeing Oliver, and determined that Oliver’s case merited the lowest priority RAG rating ( green ). When conducting that RAG rating exercise, the care coordinator did not take into account: (a) The prison officer’s urgent TAG mental health referral of 30.11.22 ( above ); and (b) A further TAG mental health referral made by a prison paramedic which cited “mild concerns” about both deliberate and unintentional self-harm on Oliver’s part, the details of which had been entered onto Oliver’s SystmOne medical record. In addition, the care coordinator did not raise in the mental health team’s daily forum.the fact that he was unlikely to have time to see Oliver before he went on leave. Had the care coordinator taken into account the referrals at (a)-(b) above, and raised at the daily forum his difficulty in being able to see Oliver, it may well have been that Oliver’s case would have merited a more urgent response from the care coordinator or someone else in his stead. 3 Having heard evidence at the inquest from your Trust’s Clinical Director, , I was not satisfied that the Trust has fully recognized the above shortcomings, and taken action to ensure that they are not repeated for other mental health patients in custody at HMP Hewell.

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, 2024-0541

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