Inquest finds failings in HMP Guys Marsh prisoner care

Frazer Williams, 28, died after taking his own life, and an inquest into his death has found that his mental health was deemed to be a ‘probable cause’ of his death, alongside the inadequacy of his healthcare diagnosis and treatment whilst at HMP Guys Marsh.

The management of Mr Williams' risk at the prison, and inadequate safeguarding measures taken after he was informed that he would be transferred to a psychiatric hospital for inpatient treatment were also cited as contributing factors in his death.

Mr Williams was from Andover and was initially imprisoned at HMP Lewes from ​June 4, 2021 until October 4, 2021 when he was released.

However, he was remanded back into custody at HMP Winchester just three days later.

He was transferred to HMP Guys Marsh, a category C training and resettlement prison for men near Shaftesbury, in January 2022

READ: Staff and prisoner safety concerns at HMP Guys Marsh Dorset

Frazer Williams of Andover died on Match 7 2022 at HMP Guys Marsh (Image: Supplied)

In their conclusions, the jury at the inquest identified missed opportunities to improve Mr Williams mental health including inadequacies in the prison system’s suicide and self-harm safeguarding process, known as Assessment, Care in Custody, and Teamwork (ACCT), and a multidisciplinary forum for discussing complex prisoners, known as Safety Intervention Meetings (SIM), which the jury described as inadequate in detail and lacking in documentation.

At the conclusion of the inquest hearing, the coroner confirmed that she would be sending a Prevention of Future Deaths report to the following recipients: Minister of State for Prisons; the Secretary of State for Health and Social Care; the Director General of HM Prison and Probation Service; the Chief Executive Officer of NHS England; the Governor of HMP Guys Marsh; and the Chief Executive Officer of Unilink Software Limited – the company which provides the prisoner email service to English and Welsh prisons. 

READ: 'Significant drug problem' at HMP Guys Marsh

HMP Guys Marsh is a category C prison in Shaftesbury (Image: Supplied)

The report, which will be sent within two weeks of the inquest concluding, will address a combination of national matters and issues specific to HMP Guys Marsh.

These include:

•          The systemic inequity between patients in the community and patients in prison when hospital admission is required for mental health treatment; 
•          The lack of joint national policy between NHS England and HMPPS on self-neglect in the prison system;
•          The lack of a national directory for use by prisons detailing healthcare provision available at each establishment; and 
•          The lack of national guidelines on prison-to-prison handover.

Speaking after the inquest, Mr Williams’ mum, Tracey Fitter, said: “For our family, the conclusion is bittersweet. While we are glad that the coroner will be writing a Prevention of Future Deaths report that could save other families the heartache we have experienced, sadly it has come too late for Frazer. 

READ: Prison officer left with broken jaw after attack by inmate

“Frazer was an incredibly loyal, protective, and loving member of our family. He was selfless and put others ahead of himself regardless of consequences or impact to himself. He was a unique and one-of-a-kind person that touched many hearts with his warmth.

“Frazer had so much to give, and it goes without saying our family are still devastated by his death. We are trying to come to terms with the circumstances surrounding his death and what he endured in the months leading up to it. There is a huge hole in our lives that can’t be filled, and we miss him every single day.”

A Prison Service spokesperson said: “Our thoughts remain with Frazer Williams’ friends and family.

“We will consider the coroner’s findings carefully and respond to the Prevention of Future Deaths report in due course.”