Mother’s Outcry After Vulnerable Son’s Prison Suicide Linked to Neglect

Following an inquest that determined neglect played a role in her son’s death, a mother has asserted that the occurrence of suicides in prisons will persist unless the entire institutional culture undergoes transformation. Oliver Davies, described as a vulnerable individual with chronic mental health conditions, was held on remand at HMP Hewell in Worcestershire due to a breach of his bail conditions. The 41-year-old, whose mental health medication was not re-prescribed, died by suicide on New Year’s Eve 2022, having been incarcerated for a period of 10 weeks. Lynne Bullar, his mother, stated that personnel at HMP Hewell significantly failed him. Separately, two healthcare providers operating within the prison indicated they were implementing enhancements as recommended by the coroner. Mrs. Bullar, a resident of Hereford, conveyed to the BBC: “My life is very badly damaged by not having Oliver here, and it could have so easily been prevented. There were so many opportunities to help Oliver and they didn’t happen. And Oliver would not want this happening to anybody else.” Reflecting on the profound impact of her only child’s passing, she remarked: “I’m half the person I was. I feel like my whole purpose in life has gone. I’m glad I am the age I am now because I believe maybe it won’t be that long before we’re reunited.” An inquest conducted this year concluded that Mr. Davies’s death was partly attributable to neglect, leading to a prevention of future deaths report being dispatched to the Midlands Partnership NHS Trust. Senior coroner David Reid determined that adequate measures were not implemented to guarantee a thorough and prompt assessment of his mental health requirements, nor regarding the necessity of re-prescribing his mental health medication. Furthermore, he ascertained that information pertinent to Mr. Davies’s mental health was not adequately disseminated among prison, healthcare, and mental healthcare personnel within the facility. Additionally, Mr. Davies was not kept adequately apprised of the status of his requests for a medical review of his mental health needs. Mr. Reid concluded that these combined elements likely caused or contributed to Mr. Davies’s demise. The Midlands Partnership University NHS Foundation Trust, which was responsible for providing mental health services at the prison, issued a statement saying: “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 representative for Practice Plus Group, a private entity that delivers healthcare services, including GP care, at the prison, stated: “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.” Mr. Davies had faced charges of assault and coercive control, entering a guilty plea for the former and a not guilty plea for the latter; however, his detention at Hewell stemmed from a violation of his bail conditions. Adrian Usher, the Prisons and Probation Ombudsman, determined that Mr. Davies was vulnerable and presented at the prison with evident indicators for suicide and self-harm, yet no personnel in the reception or induction unit took action based on this information. Furthermore, his designated mental health worker failed to attend two scheduled appointments with him, and when staff eventually initiated suicide and self-harm prevention protocols, referred to as ACCT, he was housed in a solitary cell. Mr. Usher commented: “No-one considered whether this was suitable because everyone believed it to be someone else’s decision.” Mr. Davies had submitted a request form to consult a doctor, stating that he was “extremely depressed” and that he was “not coping at all, please help”. The inquest jury also received testimony from another inmate at HMP Hewell, who indicated he had become acquainted with Mr. Davies and observed a decline in his mental health. This inmate informed the jury that he approached a prison officer while in distress, only to be sworn at and instructed to leave. When questioned, he affirmed his belief that prison staff regarded Mr. Davies as a nuisance. Mr. Davies’s death marked the sixth suicide at Hewell since December 2019, with an additional suicide occurring in 2023. Mrs. Bullar contends that without systemic changes, numerous further deaths will ensue. “It will continue unless the whole culture in these prisons change,” she stated. She further questioned: “Will lessons ever be learned in these places? I don’t know whether they will but if I can expose it in any way and get change then Oliver’s death won’t have been in vain.” For further updates, follow BBC Hereford & Worcester on BBC Sounds, Facebook, X, and Instagram. Copyright © 2024 BBC. All rights reserved. The BBC disclaims responsibility for the content found on external websites. Information regarding our external linking policy is available.