Staff failures might have contributed to prisoner death

Failures by staff might have contributed to the death of a vulnerable prisoner who took his own life on his first night at HMP Hewell, an inquest jury has concluded.

Mesut Olgun died in June 2018, six days after he was found hanging in his cell while on remand at the Worcestershire prison.

The inquest heard the 30-year-old had told prison staff he wanted to take his own life when he arrived, and he was duly categorised as at high-risk.

Despite a recommendation from one staff member to watch him at all times, prison officers instead decided to carry out checks every 15 minutes. In fact, only a third of these were actually carried out.

Giving evidence to the inquest, prison governor Joseph McFarlane, who took charge of the prison in April 2024, said there were only two ligature resistant cells at the prison, and both were in the segregation unit, in a different area of HMP Hewell.

Mr McFarlane said the prison had not installed any additional ligature resistant cells, or applied for funding to do so.

He said a review into the need for ligature resistant cells at the prison had been carried out.

Coroner David Read said he would be issuing a Prevention of Future Deaths Report to the prison's minister to ask if the use of the so-called safer cells had been properly reviewed.

"I am concerned that, unless that is done, there is a continuing risk that vulnerable prisoners like Mr Olgun will be denied an extra level of protection," he said.

The inquest also heard that Mr Olgun was not given unrippable bedding and clothing as he was not deemed to be at risk of using it to harm himself.

When he was found, the inquest jury heard there was a four-minute delay before prison staff called an ambulance, which the prison service has accepted as a failing, although Mr Read said he was satisfied that HMP Hewell had taken steps to address that.

Mr Olgun died in hospital on 14 June of a hypoxic brain injury caused by hanging.

Originally from Turkey, he had been living in Bristol before his death.

He was arrested on 6 June 2018 after a violent struggle in Bromyard, Herefordshire.

Local residents had called police after they reported seeing him throwing barrels of used cooking oil into the windows of shops.

The inquest jury heard he was holding a 10-inch knife, which he then used to attack PC Mike Davey and police dog Bacca before using it on himself.

The inquest was told a police officer used his uniform to try and stop Mr Olgun's bleeding before he was given medical treatment by paramedics.

He was then arrested on suspicion of causing grievous bodily harm and criminal damage.

Officers at Hereford Police Station were concerned about Mr Olgun's mental health, the inquest heard, so he was twice sent for treatment at the local hospital.

He was also given the highest level of observation in police custody, with his cell door kept open and a member of staff with him at all times.

The next day, he appeared at Kidderminster Magistrates' Court where he was remanded in custody without entering a plea.

Giving evidence, staff from prison transport firm GEO Amey said they contacted HMP Hewell in advance to warn prison staff that Mr Olgun was a suicide risk.

Prison staff decided to carry out 15-minute checks on Mr Olgun instead of constant monitoring, the inquest heard, but only 10 of the scheduled 33 checks were ever carried out, despite the logs suggesting otherwise.

Graham Evans was on duty as an operational support grade, an OSG, that night.

He told the inquest he later created false reports in the prison log to cover his mistakes, claiming he had made extra checks when he had not.

He said he was struggling with back pain at the time, and now accepted that he should not have gone to work.

"I thought I could cope," he told the inquest.

In November 2023, he was found guilty of misconduct in a public office after a separate trial at Worcester Crown Court.

In February 2024, he was sentenced to nine months in prison, suspended for 12 months, and 80 hours' of unpaid work.

His appeal against his sentence was later rejected by the court of appeal.

At the conclusion of the inquest, the coroner apologised to Mr Olgun's father for the delay in holding it.

His father, who was visibly upset, said that he had been diagnosed with cancer since his son's death, and that he hoped nobody else would have to endure what the family had been through.

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