PFD report

Surendrakumar Patel · Prevention of Future Deaths report

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Issued 10 Mar 2026•Worcestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report

Concerns: 8
Recipients: 4
Responses found: 3
Stated actions: 7

Recipients and published responses

Government Legal DepartmentNo response found Midlands Partnership University NHS Foundation TrustResponse found Practice Plus GroupResponse found Recipient name withheldNo response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 11 November 2024 I commenced an investigation and opened an inquest into the death of Surendrakumar Patel, aged 78.
The investigation concluded at the end of the inquest on 10 March 2026.
The conclusion of the inquest was a Narrative Conclusion.
QUESTIONNAIRE FINDINGS
1. Mental Health Assessment
(a) During SP’s time at HMP Hewell, were sufficient steps taken to ensure a proper and timely assessment and potential diagnosis of his mental condition by a psychiatrist and for a treatment plan to be formulated?
Answer: NO
(c) If NO, did that failure possibly cause or contribute to SP’s death on 31.10.24?
Answer: CANNOT SAY

2. Weight Monitoring
(a) Was SP’s weight monitored with sufficient frequency and was sufficient action taken in response to weight loss?
Answer: YES

3. Healthcare Plan
(a) Were sufficient steps taken to ensure that a properly detailed healthcare plan was prepared after SP’s food refusal and intention to end his life on 22 October 2024?
Answer: YES

4. Food Refusal Policy – Mental Capacity
Food Refusal Policy required capacity assessment as soon as practicable.
(a) Should SP’s capacity to refuse food have been assessed urgently after 22 October 2024?
Answer: YES
(c) Did that failure possibly contribute to death?
Answer: CANNOT SAY

5. Self-Neglect
If SP understood the consequences of not eating:
(a) Taking into account malnutrition, weight loss (9kg between 15–26 October 2024), stopping eating entirely (21–26 October 2024), and his statements about not wanting to live—was his death contributed to by self-neglect through malnutrition?
Answer: YES
Conclusion:
Surendra Patel died from natural causes contributed to by self-neglect through malnutrition.

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised8

Failure to consider and advocate for family contact
Part of recurring concern: Failure to involve families and carers in safety-critical care decisions
Delays in full medical assessment by a senior healthcare professional
Part of recurring concern: Failure to escalate significant clinical concerns to appropriately senior clinicians Part of recurring concern: Failure to provide effective senior clinical oversight of patient care
Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids
Part of recurring concern: Unreliable management of food and fluid refusal in prisons Part of recurring concern: Unreliable recording and involvement of prisoners’ next of kin

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 6

Action
Deliver awareness sessions to prison and healthcare staff on supporting prisoners who refuse food, including contact with next of kin.
Stated by HM Prison and Probation ServiceStated planned
Action
Complete a joint review of HMP Hewell’s food refusal policy to clarify consideration of next-of-kin contact where serious health risks are identified.
Stated by HM Prison and Probation ServiceStated completed
Action
Ensure partner healthcare policies affecting mental health services are shared in advance for clinical input and alignment.
Stated by Midlands Partnership University NHS Foundation TrustStated planned

Respondent positions 8

Position
Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.
Stated by HM Prison and Probation ServiceRedirects responsibility

Position
Active clinical observation through ACCT and food refusal processes was sufficient before psychiatric assessment.
Stated by Midlands Partnership University NHS Foundation TrustExisting arrangements considered sufficient
Position
PPG, not MPFT, holds responsibility for physical healthcare, food refusal policy implementation, and initial capacity assessment.
Stated by Midlands Partnership University NHS Foundation TrustRedirects responsibility
Position
The clinical presentation did not indicate a need for more urgent psychiatric assessment.
Stated by Midlands Partnership University NHS Foundation TrustDisputes the concern
Position
The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.
Stated by Practice Plus GroupExisting arrangements considered sufficient
Position
Family advocacy was not considered necessary because the patient did not request family support and no benefit from contact was identified.
Stated by Practice Plus GroupNo action considered necessary
Position
There was no clinical reason to believe the patient lacked capacity to refuse food, fluids or other offered care.
Stated by Practice Plus GroupDisputes the concern
Position
A formal capacity assessment would not necessarily have changed the care provided, according to the clinical reviewer.
Stated by Practice Plus GroupDisputes the concern

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 1

1
Implement lessons learned from the case across Practice Plus Group services.
Stated by Practice Plus GroupStated planned

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised8

Failure to consider and advocate for family contact

Delays in full medical assessment by a senior healthcare professional

Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids

Lack of prison staff awareness of the HMP Hewell food refusal policy

Lack of healthcare staff awareness of the food refusal policy

Failure to recognise when mental capacity assessment is required after food refusal begins

Failure to ask the prisoner whether food refusal information should be shared

Failure to consider hospital transfer for prisoners severely weakened by weight loss

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

Actions described in response 6

Respondent positions 8

Recipient-stated actions 1