Adam Clark - Prevention of future deaths report (2)
27 Jul 2026 · Coroner David Reid · Worcestershire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. risk of suicide/self-harm
“During the course of the inquest I heard evidence giving rise to concern.”
2. drug overdose
“The most recent attempt at self-harm was a drug overdose only 6 weeks before his arrival at HMP Hewell”
3. lack of mandatory training on PER review
“agency nurses working in prisons throughout England and Wales are provided to Practice Plus Group ( PPG ) by one agency”
4. inflexible template design
“any changes to the template can only be made nationally, and not locally”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“During his initial healthcare screening appointment on the evening he arrived at HMP Hewell ( 25.3.21 ) and his secondary healthcare screening appointment the following day, Mr [name redacted] denied any mental health issues, and denied any current thoughts of suicide or self-harm.”
This report
“the agency nurse who conducted the deceased's initial healthcare screening appointment on his arrival at HMP Hewell may not have looked at his PER, either because he did not have access to a copy of it, or because he had not been trained to ensure that he looked at it.”