In the Worcestershire Coroner’s Court

Before HM Senior Coroner Mr D D W Reid

Monday 30 September – Friday 11 October 2024

On Friday 11 October 2024, the inquest into the death of Oliver Davies concluded, with the jury finding his death was contributed to by neglect. The inquest was heard over 10 days at the Worcestershire Coroner’s Court.

Oliver died by suicide at HMP Hewell on 31st December 2022.

The jury found that the following issues probably contributed to Oliver’s death:

  1. During Oliver’s time at HMP Hewell, there were not sufficient steps 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.

  2. 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.

  3. 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.

  4. Oliver was not kept sufficiently informed of his allocation to, and forthcoming appointments with, a mental health care co-ordinator.

The jury found that Oliver’s death was contributed to by neglect because of the failure to take sufficient steps to ensure a proper and timely review by a GP of Oliver’s mental health needs and whether mental health medication should be re-prescribed to him.

The jury also found that the following issue possibly contributed to Oliver’s death:

  1. The ACCT case review on 30 December 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 relation to Oliver’s mental health assessment on 6 December, where the nurse did not know about Oliver’s healthcare application on 1 December or the TAG referral on 30 November, the Coroner directed that there needs to be reinforced teaching and instruction to staff to ensure that all staff carrying out mental health assessments are aware of all the circumstances. The Coroner will be preparing a Prevention of Future Deaths report to Midlands Partnership University NHS Foundation Trust and they will have to respond setting out what they propose to do to rectify the situation.

Oliver’s mother, 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. The neglect by healthcare staff at HMP Hewell to provide Oliver with the help he desperately needed sadly contributed to Oliver’s eventual suicide.

“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.

The jury’s findings show how Oliver was repeatedly failed at a time when he was vulnerable and in need of mental health support.

The Interested Persons were:

  • Oliver’s family

  • HM Prison and Probation Service

  • Practice Plus Group

  • Midlands Partnership NHS Foundation Trust

  • West Mercia Police

  • GEOAmey

Oliver’s family were represented by Alice Wood and Stevie Kelly at Farleys Solicitors, and Lucy McCann of 1 Crown Office Row.

If you’re looking for legal representation at the inquest into the death of a loved one, please get in touch with our highly experienced inquests team at Farleys on 0845 287 0939, contact us by email, or use the online chat below.