Inmate with schizophrenia died after lack of care

Daniel Ayers was found dead at HMP Winchester in 2021

An inmate with severe mental illness took his own life after being deprived of medication and care in prison, an investigation has found.

Daniel Ayers, 43, from Dorset, was found dead in his cell at HMP Winchester on 25 July 2021.

He was withdrawn and dishevelled and had taken to wearing only a blanket in the weeks before he died, the Prisons and Probation Ombudsman said.

The Prison Service has been approached for comment.

Mr Ayers, from Dorchester, arrived at the jail on 30 June 2021 after being remanded on a charge of threatening a police officer with an imitation firearm.

He had schizophrenia and a history of suicide attempts, the ombudsman Adrian Usher said.

Previously, the prisoner had been prescribed the heroin substitute methadone, antidepressants, antipsychotics and the sedative diazepam in the community.

However, prison staff identified that the combination of drugs was "risky", Mr Usher reported.

"They stopped various medications without ever trying to establish why he had been prescribed them," the ombudsman found.

"As a result, Mr Ayers was not given any antipsychotic or antidepressant medication during his time at Winchester.

"His diazepam dose was reduced without any discussion with him or consideration of the potential impact this would have."

The ombudsman said Mr Ayers began to deteriorate about a week after arrival, but no-one considered monitoring him for potential self-harm.

The inmate never had a mental health assessment in prison despite being referred four times, Mr Usher recorded.

Each time a nurse, who formerly worked for prison healthcare contractor PPG, closed the referrals despite no action being taken, he said.

The nurse has been referred to regulators for a full investigation, the report added.

An inquest in January 2025 found the death was "exacerbated by the infection control measures and the reduced staffing levels imposed by COVID", the ombudsman said.

As the result of the death, the prison has improved staff training and procedures, Mr Usher concluded.