Prisoner lay naked in cell dying and asking for help
A PRISONER starved to death after lying naked on the floor of his cell for hours while trying to ask for help. The prisons watchdog said it was “very concerned about the actions of staff” at HMP Cardiff on the night Alan Davies, 53, died.
Mr Davies was sentenced to 19 years in prison in 2017. In December that year, while at HMP Parc, Mr Davies began to refuse food and two months later he was admitted to a psychiatric hospital. In 2021 hospital staff decided he no longer needed detention under the Mental Health Act. On September 2 that year – 10 days before his death – Mr Davies was transferred to HMP Cardiff.
On arrival, hospital staff told the prison that Mr Davies had not eaten for 16 days but had drunk fluids. The prisoner did not say why he was not eating, though he said he did not want to take his own life.
Prison staff started suicide and selfharm prevention procedures. Mr Davies was allocated a cell in the healthcare inpatient unit. He did not appear to eat any food during his time at HMP Cardiff.
Prisons ombudsman Adrian Usher wrote in his report: “He had a drink on September 3 but there is no evidence that he had anything to drink after this. He refused all clinical observations and engaged little with prison and healthcare staff, sometimes turning his back on them when they tried to speak to him.”
On September 10 a prison doctor and an operational manager discussed whether Mr Davies should be admitted to a general hospital. The prison doctor said she decided not to admit Mr Davies “because she was told that Mr Davies had been eating shop-bought snacks in the psychiatric hospital” and this meant “he had been refusing food for eight days rather than 24 days as she had initially thought”, the report went on.
On the night of September 11 Mr Davies spent more than two and a half hours lying naked on the floor of his cell, seemingly unable to get up. “In-cell camera footage shows that he tried to call for help many times,” said Mr Usher.
“Although the staff on duty looked in his cell several times and could see him on a monitor in the staff office, no-one went into the cell to provide assistance.
“At 2.54am, a healthcare assistant identified that Mr Davies was not breathing. Two minutes later, the healthcare assistant and an officer opened the cell, began CPR and radioed for emergency assistance. Paramedics took Mr Davies to hospital, where he died later that morning.”
The ombudsman said the circumstances of Mr Davies’ death are “troubling and shocking”. Mr Usher noted that the staff on duty did not give assistance until they realised he had stopped breathing.
“We are very concerned about the actions of staff on the night of Mr Davies’ death,” Mr Usher added. “It should have been clear that he was in distress and required assistance. It is unacceptable that he was left lying naked on the floor of his cell, unable to get up and trying to ask for help for so long.”
The cause of death was recorded as cardiac arrest in a setting of dehydration and starvation. An inquest jury found he died from an equal combination of neglect, misadventure and self-neglect. Mr Usher said the HMP Cardiff governor should conduct a disciplinary investigation into one particular prison officer’s actions on the night Mr Davies was found unresponsive. He also said senior managers should have been involved in care planning and that an opportunity to admit Mr Davies to hospital earlier was missed.
And staff “took too long” to open Mr Davies’ cell and get emergency help after realising he was not breathing, the ombudsman said.
In his recommendations Mr Usher said the prison governor should ensure that prisoners at risk of selfharm or refusing food be managed “in line with national instructions”.
These include the need for “comprehensive care plans” and case reviews that consider “all relevant information”.