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HMP Hewell death: Inmate's Birmingham transfer probed

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HMP Birmingham's failure to provide a satisfactory handover and write a care plan may have contributed to Saul Thomas's death, a report states

A failure to alert a prison about a transferring inmate's mental health may have contributed to his death, a coroner has said.

Saul Thomas died at HMP Hewell, Worcestershire, after being transferred from HMP Birmingham where he was undergoing psychiatric assessment.

The coroner said HMP Birmingham's handover was "unsatisfactory", and it had failed to put a care plan in place.

The Prison Service said it was considering the coroner's findings.

In a report to prevent future deaths, Coroner David Reid said Mr Thomas, 42, was found dead in his HMP Hewell cell on 19 May 2019.

The month before, he had arrived at HMP Birmingham where he was sent to the mental health ward for formal assessment.

During his time there, Mr Thomas "continued to express paranoid thoughts", the report said. He was moved to HMP Hewell on 16 May.

Entrance to HMP Hewell
Mr Thomas died at HMP Hewell in May 2019

An inquest into Mr Thomas's death concluded on 10 December, having looked at circumstances surrounding an Assessment, Care in Custody and Teamwork (ACCT) plan - the care-planning process for prisoners identified as being at risk of suicide or self-harm.

The report said that jurors found an ACCT should have been opened for Mr Thomas at HMP Birmingham. It added failure to do so "probably" caused or contributed to his death.

Jury members also found an "unsatisfactory handover" provided by HMP Birmingham "possibly" caused or contributed to his death, the report stated.

The report does not give the cause of death. The coroner's office has been contacted for clarification.

In his report, Mr Reid asks HMP Birmingham to conduct an investigation into failings and ensure staff are appropriately trained.

A Prison Service spokesperson said: "We will consider the coroner's findings and respond in due course.

"We have trained more than 25,000 staff in suicide and self-harm prevention as part of our drive to tackle these issues, and the number of self-inflicted deaths has fallen across the prison estate over the last year."

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