In a tragic incident at HMP Cardiff, prison staff ignored an inmate’s repeated pleas for medication, leading to his death in his cell. Shane Davies, a 33-year-old inmate with a history of mental health struggles, was found hanged in his cell after his requests for medication were ignored. The prisons ombudsman, Adrian Usher, highlighted several critical mistakes that were made leading up to Mr. Davies’ death.
Mr. Davies, who had a background of substance abuse and was diagnosed with psychosis and social anxiety disorder, had been requesting medication for his conditions while at HMP Bristol and later at HMP Cardiff. Despite his pleas, he was not prescribed any medication at either facility. On the night of his death, Mr. Davies alerted staff about breathing difficulties and swelling on his face, but his concerns were not adequately addressed.
At around 8.30pm on August 17, 2022, Mr. Davies requested to see a nurse due to his physical symptoms. However, when staff arrived, they found that he had blocked his cell door with furniture. Although a welfare check was conducted half an hour later, it was not until 11.30pm that an officer discovered Mr. Davies hanging in his cell. Despite resuscitation efforts and transportation to the hospital, Mr. Davies never regained consciousness and was pronounced dead on August 28, 2022.
An inquest into the incident revealed that Mr. Davies’ mental health assessment was incomplete and outdated, failing to account for his recent transfer to a new prison, which is a known risk factor for self-harm and suicide. The prisons ombudsman recommended that HMP Cardiff improve its mental health assessment processes and ensure staff receive adequate training on suicide and self-harm procedures.
Furthermore, the report highlighted deficiencies in response times, with a three-minute delay in calling an ambulance for Mr. Davies. The prison governor subsequently issued a notice emphasizing the importance of prompt action in medical emergencies. The report also noted the distress caused to Mr. Davies’ family upon discovering the state of his cell, which had religious material left by the previous occupant.
Following Mr. Davies’ tragic death, efforts were made to enhance staff training and address shortcomings in mental health assessments at HMP Cardiff. The prison has seen a series of self-inflicted deaths in recent years, prompting a review of procedures and training to prevent such incidents in the future. Mr. Davies’ case underscores the importance of prioritising mental health care and responding effectively to inmates in crisis within the prison system.
If you have any concerns about prison conditions or inmate welfare in Wales, you can reach out to WalesOnline at [email protected]. The tragic loss of Shane Davies serves as a reminder of the critical need for improved mental health support and emergency response protocols in correctional facilities to prevent further tragedies like this from occurring.