HMP Hewell inmate died due to mental health neglect

Basic care was not given to Andrew Shirley at HMP Hewell in Worcestershire, an inquest finds

A remand prisoner took his own life due to failures in mental health care which amounted to neglect, an inquest found.

Andrew Shirley, 25, died while in segregation at HMP Hewell, Worcestershire, in March 2021.

Jurors were told there were a series of failures by health and prison staff to provide him with basic care.

Three reports will be shared nationally, reflecting the coroner's fears future deaths would occur due to failures across the prison estate.

Mr Shirley, from Nuneaton, who had ADHD and an established diagnosis of paranoid schizophrenia, was arrested by Warwickshire Police in February 2021.

Despite expressing suicidal thoughts and concerns his anti-psychotic medication wasn't working, he was assessed at the Caludon Centre, a mental health hospital in Coventry, and found fit to be detained in prison.

A mental health liaison nurse who saw him at a police station had intended to arrange a mental health act assessment but Mr Shirley was instead taken to court and remanded to HMP Hewell on 1 March 2021.

The inquest heard that despite a wealth of information available about the risk he posed to himself, the nurse assigned as his care co-ordinator in prison failed to read key entries in his medical notes, conduct any mental health assessment, or put any care plan in place during his time there.

Jurors were told healthcare staff took no steps to mitigate the risk he might pose to himself and despite displaying active symptoms of psychosis, and telling a nurse that voices were telling him to kill himself, Mr Shirley was placed into segregation, where he died on 23 March.

'Extremely distressing'

The coroner will be making three reports to prevent future deaths to the Governor of HMP Hewell, the chief executive of Practice Plus Group, which provides primary healthcare services at the prison, and the chief executive of Midlands Partnership NHS Foundation Trust.

In a statement, Mr Shirley's parents said: "Andrew was our son, we loved him and he was unwell. He needed help and support and we thought the prison would keep him safe.

"It has been extremely distressing to hear the extent of the failures by those responsible for keeping Andrew safe, to fulfil even their most basic responsibilities towards him. We can't put into words how much we miss him."

Parliament's justice committee highlighted this week that remand prisoners are at higher risk of suicide and the number of people being held in prison on remand is at the highest level it has been for 50 years.

The charity Inquest, which provides expertise on state-related deaths, said "urgent change" was needed to ensure "people in mental health crisis are diverted from prison and remand is only used as a last resort".