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Anger after vulnerable son's prison suicide

BBC A woman in a blue pinafore and white floral shirt is sat on a white leather chair, with green floral curtains behind her on the left. She is holding two large brown photo frames which are connected. In them are hand-painted portraits: on the left is a baby, surrounded by blue with a flower in the bottom-right corner, on the right is an adult man next to a black and white dog. Behind the woman on the right is a wooden unit with photos on it - many of a boy, but some of dogs. There are also animal sculptures on the unit.BBC
Lynne Bullar's son, Oliver Davies, killed himself while on remand in HMP Hewell. An inquest found neglect at the prison contributed to his death

A mother has said prison suicides will not stop unless the whole culture of prisons changes, after an inquest found neglect contributed to her son's death.

Oliver Davies, a vulnerable man with long-standing mental health issues, was on remand at HMP Hewell in Worcestershire for breaching his bail conditions.

The 41-year-old, who was not re-prescribed his mental health medication, took his own life on New Year's Eve 2022, after 10 weeks of being in the prison.

His mother, Lynne Bullar, said he was badly let down by staff at HMP Hewell. Two prison healthcare providers said they were working on improvements identified by the coroner.

Mrs Bullar told 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."

Speaking of the impact of her only child's death, she said: "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."

Family photo A man with blonde hair, wearing light blue jeans and a white t-shirt, squats over a path. He has a small white dog with light brown ears around his neck, and he is holding the dog's legs. The dog wears a black collar with a silver tag. The man and the dog are on a path, which is surrounded on both sides by grass and large green bushes.Family photo
Oliver Davies, a vulnerable man with long-standing mental health issues, killed himself while on remand at HMP Hewell

An inquest this year found Mr Davies's death was contributed to by neglect, and a prevention of future deaths report was sent to Midlands Partnership NHS Trust.

Senior coroner David Reid concluded sufficient steps were not taken to ensure a proper and timely review of his mental health needs and whether his mental health medication should be re-prescribed.

He also found information concerning Mr Davies's mental health was not shared sufficiently between prison, healthcare, and mental healthcare staff at the prison.

In addition that Mr Davies was not kept sufficiently informed of progress regarding his applications for a doctor to review his mental health needs.

All of these factors, Mr Reid concluded, probably caused or contributed to Mr Davies's death.

A woman in a blue pinafore and white floral shirt holds a black teddy bear on her lap: it is made of black and grey fabric and has orange patchwork ears, with an orange bow around its neck and Oliver embroidered on its chest in silver letters. She is sat on a white leather chair, with green floral curtains behind her on the left. On the right, behind her, is a wooden unit with lots of photos on it - many of a boy, but some of dogs. There are also animal sculptures on the unit.
Lynne Bullar had a teddy bear made out of Oliver's clothes, called Oliver Bear, which she took every day to the inquest

In a statement, the Midlands Partnership University NHS Foundation Trust, who provided mental health care at the prison, said: "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 spokesperson for Practice Plus Group, a private company providing healthcare such as GP care at the prison, said: "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."

'Please help'

Mr Davies had been charged with assault and coercive control, pleading guilty to the former and not guilty to the latter, but he was taken to Hewell for breaching bail conditions.

Prisons and probation ombudsman Adrian Usher, found that Mr Davies was vulnerable and arrived at the prison with clear markers for suicide and self-harm, but no-one in reception or the induction unit acted on this information.

His assigned mental health worker also missed two appointments to see him, and when staff eventually started suicide and self-harm prevention measures, known as ACCT, he was placed in a cell on his own.

Mr Usher said: "No-one considered whether this was suitable because everyone believed it to be someone else's decision."

Mr Davies had submitted a form asking to see a doctor, saying that he was "extremely depressed" and that he was "not coping at all, please help".

A black photo frame with 12 small boxes in it, all with different pictures of a boy in it. Some are of him as a young child, others as a teenager, and some as an adult. The frame is laid out on a carpet.
Lynne Bullar said her son was let down by staff at HMP Hewell

The jury at the inquest also heard evidence from another HMP Hewell prisoner, who said he had got to know Mr Davies and could see his mental health starting to deteriorate.

He told the jury he approached a prison officer while distressed and was sworn at and told to go away.

When asked, he confirmed he thought Mr Davies was seen as a nuisance by prison staff.

PA Media A red brick wall at the side of a road, saying 'Welcome to HMP Hewell' in white lettering. Wooden gates and grass are at the side of the road.PA Media
The trust providing mental health care at the prison accepted the findings and said: "Our priority is to implement the learning from the coroner’s report"

Mr Davies's death was the sixth suicide at Hewell since December 2019, with another suicide in 2023. Without change, Mrs Bullar believes there will be many more.

"It will continue unless the whole culture in these prisons change," she said.

"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."

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