Gary McDonald
20 Sept 2022 · Coroner David Reid · Worcestshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of follow-up on mental health history
“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. His community GP records were 1 requested and were received by the prison on 30.3.21; these showed a previous history of depression, and two previous drug overdoses, the most recent of which had been only 7 months earlier”
Linked reports
Raised again laterAdam Clark - Prevention of future deaths report (2)27 Jul 2026 · 3 years 10 months later
Closely relatedConfidence 0.90 · high
This 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.”
Later 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.”
Responses
2022-0291-Response-Practice-Plus-Group-.pdf ↗· Practice Plus Group
Stated action · Day 5 - Initial Management Review and key word search undertaken by a Seniorurse
“the Head of Healthcare has consulted with other stakeholders within the team about the concern raised and have considered ways this concern can be alleviated. The healthcare team have introduced an updated version (V4) of the EDiC pathway and passport. This”