'Inequity' in prison mental health care - coroner

Frazer Williams, 28, took his own life while awaiting a transfer from prison to a psychiatric unit

Prisoners with mental health emergencies face "inequity" in the way they are treated, a coroner has said.

Dorset senior coroner Rachael Griffin said there were delays in sending inmates to hospital, while members of the public were given NHS care straight away.

In a Prevention of Future Deaths Report, she said an inmate at HMP Guys Marsh, Frazer Williams, died after waiting for a hospital transfer for more than three weeks in a prison without a healthcare unit.

The Prison Service said it would consider the report.

Mr Williams, 28, was found dead in his cell at the prison near Shaftesbury on 7 March 2022.

An inquest jury previously concluded he took his own life following "inadequate assessment and monitoring".

His mental health deteriorated to the point where he had delusions that flushing the toilet or watching television would harm his family, the inquest heard.

Ms Griffin recorded: "His cell was in an extremely poor state, littered with rubbish, an unflushed toilet and a bucket which was used for him to urinate and defecate in... was found to be full in his cell at the time of his death."

Mr Williams' mother previously said she was trying to come to terms with his death and what he endured

The coroner said there was evidence transfers to hospital within the legal timeframe of 28 days were unusual.

She concluded: "There is inequity in the system in that if a person is deemed detainable under the Mental Health Act 1983 in the community, they will be admitted to hospital straight away."

Writing to the Prison Service and other authorities, she also highlighted failures in the handover process from Mr Williams' previous jail, HMP Winchester.

She said the Hampshire prison had 24-hour health care while HMP Guys Marsh did not, and there was a "lack of a national directory" of the facilities available.

Previously, Mr Williams' mother, Tracey Fitter, said: "We are trying to come to terms with the circumstances surrounding his death and what he endured in the months leading up to it.

"There is a huge hole in our lives that can’t be filled and we miss him every single day.”

Her solicitor Maya Grantham previously said: "Frazer’s inquest has shone a light on just how unsafe prison is for someone as unwell as Frazer.

“The current process of referral and transfer from prison to psychiatric hospital urgently requires reform. "

In February, an Inspectorate of Prisons report found the average wait for a hospital transfer was 85 days, while one inmate waited 462 days.

A Prison Service spokesperson said: “Our thoughts remain with Frazer Williams’ friends and family.

“We will consider the coroner’s findings carefully and respond... in due course.”