Lucy McCann appeared on behalf of the family of Oliver Davies, who died by suicide on 31 December 2022 at HMP Hewell.
The jury heard that Oliver had a long history of serious mental ill health, for which he received medication in the community. Oliver was arrested and taken to Hereford Police Station on 19 October 2022. During his time in police custody, and when transferred to HMP Hewell, Oliver was deemed to be at risk of suicide and self-harm. Oliver was remanded to HMP Hewell the following day. Throughout his ten weeks at HMP Hewell, Oliver was not prescribed any mental health medication despite numerous requests. Oliver’s mental health deteriorated. On 7 December 2022 he was allocated a mental health care coordinator, who he only met for the first time on 30 December 2022 as part of an ACCT case review the day prior to his death.
The two-week inquest heard evidence from 34 witnesses. The jury concluded that Oliver died by suicide, with a finding of neglect due to 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. In their narrative conclusion, the jury found failures by staff employed by the Midlands Partnership University NHS Foundation Trust, Practice Plus Group and HM Prison and Probation Service.
Senior Coroner David Reid issued a Regulation 28 report to the Midlands Partnership University NHS Foundation Trust (see here).
Lucy was instructed by Alice Wood, and assisted by Stevie Kelly, of Farleys Solicitors (see statement here).
