Mesut Olgun · Prevention of Future Deaths report

On 20 June 2018 I commenced an investigation and opened an inquest into the death of Mesut OLgun aged 30. The investigation concluded at the end of the inquest on 08 December 2025. The conclusion of the inquest was in two parts:
1) Narrative Conclusion - Mesut Olgun died as the result of suicide.
2) Questionnaire:

1. On the night of 7th-8th June 2018, between 2115hrs and 0610hrs, did the Operational Support Grade fail to carry out the majority of the 36 ACCT observations on Mr. Olgun which was required to carry out at the rate of four per hour?

YES

2. If YES, did that failure possibly cause or contribute to Mr. Olgun’s death?

YES

3. When Mr. Olgun was first discovered ████████ in his cell on the morning of 8th June 2018, was a Code Blue emergency called at the earliest opportunity?

NO

4. If NO, did that failure possibly cause or contribute to Mr. Olgun’s death?

YES

On 6 June 2018, whilst being arrested, Mr. Olgun caused himself significant injuries ████████
████████ While in police custody, he was assessed as being at a high risk of harming himself again, and voiced an intention to kill himself several times. On 8 June 2018, Mr. Olgun was seriously injured ████████ in his prison cell at HMP Hewell. On 14 June 2018, Mr. Olgun died from these injuries at Alexandra Hospital, Redditch.

In his evidence to the inquest, the current Head of Safety at HMP Hewell confirmed that the prison had two “Safer Cells” ( intended to reduce the risk ████████ ), but that these were both located within the prison’s Segregation Unit. He agreed that it would not be appropriate for a new prisoner like Mr. Olgun, who had been identified as a high risk of self-harm and for whom an ACCT document had been opened, to be located on the Segregation Unit on his first night in prison. There are therefore no “Safer Cells” located within the main body of the prison. The cost of converting a cell into a “Safer Cell” is said to be in the region of £70,000, for which funding would have to be sought from H.M. Prison and Probation Service, but HMP Hewell has not made any bid for such funding since Mr. Olgun’s death 7½ years ago.

The Head of Safety at the prison also confirmed in evidence that the two available “Safer Cells” have been used to house prisoners within the Segregation Unit who are thought to be at an increased risk of suicide or self-harm. This would suggest that the prison accepts in principle that such cells have a meaningful role to play in reducing such risk.

I am concerned that as long as “Safer Cells” are not made available away from the Segregation Unit at HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison.