HMP Hewell: Coroner warns of deaths unless care improves
Urgent changes are needed in the care given to inmates at a jail to prevent further deaths, a coroner has warned.
Systems at HMP Hewell in Redditch require a "radical overhaul" Geraint Williams said.
The Worcestershire coroner made the recommendations in a letter following the inquest into the death of Kelvin Speakman who hanged himself in 2016.
Mr Williams said the "same failings exist" with "often absent" health care reviews and "inadequate" documentation.
The prison said it had improved staff training for vulnerable offenders.
The coroner said the jail accepted the recommendations by the Prisons & Probation Ombudsman to improve care.
But he said Mr Speakman's death and the deaths of other inmates, due for inquests later this year, show "the same failings exist".
Mr Williams said there were "gaps in information and potentially in the actions being undertaken", which prompted his letter over the jail's Assessment, Care in Custody and Teamwork (ACCT).
The senior coroner for Worcestershire said communication between staff about Mr Speakman was "not consistent or documented", which led him to conclude some staff members were "not aware of the full picture" of his condition.
Mr Speakman, 30, who had a history of mental illness and self-harming, died from pneumonia and a hypoxic brain injury in May 2016.
An inquest jury found his death was accidental due to a "cry for help."
"I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners," Mr Williams wrote.
"Action should be taken to prevent future deaths."
The Prison Service said HMP Hewell improved its training for staff managing vulnerable offenders and a senior member of staff reviews all ACCT cases daily.
"We have also recruited an extra 4,700 officers across the prison estate over the last two and a half years and introduced the key worker scheme which provides every prisoner with a dedicated officer for support," a spokesman said.