On 15 March 2024, after a three-week inquest into the death of Alan Davies, a jury returned a conclusion with critical findings, including a neglect rider.

Mr Davies was in HMP Cardiff when he died in September 2021. The jury heard evidence that he had undergone a period of food and fluid refusal prior to his transfer into prison from a previous clinic, and continued to deteriorate whilst in prison. A clinical decision to send Mr Davies to hospital on 10th September 2021 was reversed on the basis of an apparent misunderstanding about the length of time he had been refusing food, which came about during the course of discussions about staffing levels at the prison which would be impacted by the hospital transfer. The nursing and healthcare staff responsible for monitoring Mr Davies over the weekend of 11-12th September were not aware of anything in particular to look out for in respect of his presentation. Despite being on hourly observations, and in a cell with a CCTV camera, Mr Davies was not given emergency medical attention or taken to hospital in the early hours of 12th September 2021, despite laying unclothed on the floor for a number of hours. At times whilst on the floor he was asking for help and trying to get attention by various means including banging things, slapping his body and waving in his cell. Footage shows that during this time Mr Davies was told to cover himself up and put himself back into bed.

The jury found:

  • Mr Davies died from an equal combination of misadventure, self-neglect and neglect.
  • Mr Davies contributed to his death by deliberately refusing food and fluid, but he did not intend to end his life. It was an unintended consequence of such refusal.
  • There were missed opportunities regarding the transfer of Mr Davies to hospital.
  • The management, co-ordination and planning, including the handover of information within the prison and healthcare was unsatisfactory.
  • The level and adequacy of observations was insufficient in noticing Mr Davies signs of deterioration.
  • The events between the 10th and 12th of September were highly unacceptable.

The Coroner indicated at the end of the hearing that he would be issuing a Preventing Future Deaths report to Cardiff & Vale University Health Board, HMP Cardiff and Swansea Bay University Health Board. The PFD report can be found here.

The family of Mr Davies was represented by Angelina Nicolaou, instructed by Craig Court and Kay Evans of Harding Evans.

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