AN investigation into the death of a Powys man in prison has concluded that staff relied too heavily on an incomplete assessment of his mental health, while others were not sufficiently trained on suicide and self-harm procedures.

Shane Davies, 33, died in hospital on August 28, 2022, having been found unconscious in his cell at HMP Cardiff late in the evening of August 17.

Mr Davies, who had lived in both Rhayader and Llandrindod Wells, had been sentenced to a custodial period of just over two years at Merthyr Tydfil Crown Court for drug offences weeks earlier, and was moved to Cardiff having previously been on remand in Bristol.

His was the eighth self-inflicted death at Cardiff prison since August 2019.

After concerns for Mr Davies following odd behaviour – including barricading his cell – earlier in the evening, staff were instructed to complete welfare checks every half hour, to monitor Mr Davies’ unusual behaviour.

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It was during one check, at 11.30pm, that an officer saw him unconscious in his cell and raised the alarm. Ambulance staff were on the scene by 11.38pm.

The independent investigation revealed that prison staff worked hard to resuscitate Mr Davies once he was discovered, but that there had been a delay requesting an ambulance.

He was resuscitated and transferred to an intensive care unit on August 18, but never regained consciousness, and died 10 days later.

The report author stated that although Mr Davies’ risks were appropriately managed, not all staff had received Assessment, Care in Custody and Teamwork (ACCT) training – including the nurse who was responsible for identifying risks.

While the night operational manager at the prison was concerned about Mr Davies’ behaviour and put wellbeing checks in place on August 17, neither prison staff nor the nurse assessed that Mr Davies was in crisis or at increased risk of suicide or self-harm – although the report author deemed this appropriate.

(Image: NQ)

Adrian Usher, Prisons and Probation Ombudsman, who conducted the report, said: “The clinical reviewer found that overall, the clinical care provided to Mr Davies was equivalent to that which he could have expected to receive in the community.

“However, he found that the mental health team relied too heavily on an incomplete assessment of Mr Davies’ mental health from his previous prison, instead of completing their own.

“On July 23, when Mr Davies was assessed by the mental health team at Cardiff, he should have been referred for a full mental health assessment.”

He added: “Our interviews revealed that several staff at Cardiff had not received training on suicide and self-harm procedures in line with national policy.

“Following Mr Davies’ death and other self-inflicted deaths at Cardiff, managers had been supported by the regional safety team to increase the number of trainers within the prison.”

The report also noted that when Mr Davies moved cells on August 16, it had not been cleaned and a significant amount of religious material belonging to another inmate was stuck to the walls, and religious text made into the shape of a large cross.

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It is not clear if the condition of the cell had any impact on Mr Davies’ mental health, but he should never have been placed in such an environment.

Additionally, it was reported that the prison did not contribute to Mr Davies’ funeral costs. The report said the prison accepted it should have done more to ensure Mr Davies’ mother had understood the offer of a financial contribution and agreed to make a retrospective contribution towards the costs.

An action plan following publication of the report in October said the head of healthcare at HMP Cardiff should ensure that decisions on mental health referrals are based on a review of a prisoner’s current mental health and previous mental health history - a recommendation that was accepted.

The action plan also stated that a review of the referral process to the mental health team will be undertaken, and criteria and guidance be specifically designed, to ensure this is aligned with equivalent services within the community and under the Mental Health (Wales) Measure 2010. This will also be done in conjunction with a review of similar process in other similar prisons.

To read the full report, click here.

Helplines

If you would like any help with bereavement, loss or mental wellbeing, here are some helpline numbers

You can call the Samaritans on 116 123

Papyrus Hopeline on 0800 068 4141

Campaign Against Living Miserably (CALM) on 0800 58 58 58

Survivors of Bereavement by Suicide (SOBS) 0300 111 5065 uksobs.org