20 January 2023

Before HM Senior Coroner David Reid
Worcestershire Coroner’s Court
9-20 January 2023

Andrew Paul Shirley, 25, died a self-inflicted death whilst in segregation in HMP Hewell in Worcestershire on 23 March 2021. He was remanded into custody just three weeks prior.

An inquest jury has now concluded that a series of failings by healthcare and prison staff, amounting to neglect, caused Andrew’s death.

The coroner will be making three reports to prevent future deaths to the Governor of HMP Hewell, the chief executive of Practice Plus Group (who provide primary healthcare services at HMP Hewell), and the chief executive of Midlands Partnership NHS Foundation Trust.

The reports will also be shared nationally, reflecting the coroner’s considerable concern that future deaths would occur as a result of failures across the prison estate.

This week, Parliament’s Justice Committee highlighted that the number of people being held in prison on remand is at the highest level it has been for 50 years. Remand prisoners are at higher risk of suicide, and the committee identified a clear lack of support.

Andrew was from Nuneaton, a loving son, brother and soon-to-be father with a passion for fishing and motorbikes. His family describe him as a “very cheeky, mischievous, likeable, caring, loving and thoughtful young man”.

Andrew had ADHD and an established diagnosis of paranoid schizophrenia. He was under the care of adult social services and the community mental health team run by Coventry and Warwickshire Partnership NHS Trust.

On 28 February 2021, Warwickshire police arrested Andrew. Despite expressing suicidal thoughts and intent to harm himself and expressing concerns that his anti-psychotic medication wasn’t working, he was assessed at the Caludon Centre, a mental health hospital in Coventry, and found to be fit to be detained in prison.  

He was placed in 30 minutes observations whilst at police station due to the continued risk he posed himself. A mental health liaison nurse who saw him, had intended to arrange a mental health act assessment, but Andrew was taken to court before this happened and was remanded in HMP Hewell on 1 March 2021.

Despite a wealth of information available about the risk Andrew posed to himself, the nurse assigned to be his care coordinator whilst in prison failed to read key entries in his medical notes, conduct any mental health assessment or put in place any care plan in the three weeks Andrew was in prison.

The inquest heard there were a series of failures to provide the most basic of care to Andrew and that no member of healthcare staff understood or took any steps to mitigate the risk that he might pose to himself.

Despite displaying active symptoms of psychosis, and telling a nurse that voices were telling him to kill himself, Andrew was placed into segregation. No ACCT, or any other suicide or self-harm prevention measures were put in place and Andrew died a self-inflicted death in the evening of 23 March 2021, whilst still in segregation.

Andrew’s parents, on behalf of Andrew’s family, said: Andrew was our son, we loved him and he was unwell. He needed help and support and we thought the prison would keep him safe.

It has been extremely distressing to hear the extent of the failures by those responsible for keeping Andrew safe, to fulfil even their most basic responsibilities towards him. We can’t put into words how much we miss him.

We would like to thank the coroner and the jury for their careful consideration and for their conclusions. We hope that the coroner’s recommendations to prevent further deaths are acted upon and that no more families have to endure the preventable death of their child in prison.”

Tara Mulcair of Birnberg Peirce solicitors, said: “Andrew was a highly vulnerable young man with an established and long-standing diagnosis of paranoid schizophrenia. He arrived at HMP Hewell bristling with risk factors in relation to the risk he posed to himself. Despite this, both healthcare and prison staff failed to understand, assess and mitigate the risk; and he was assessed as fit to be placed in segregation, where he died.

The jury’s damning finding of neglect vindicates Andrew’s family’s concerns and confirms what they have always known – Andrew was badly let down by staff at HMP Hewell. The Ministry of Justice, Midlands Partnership NHS Foundation Trust and Practice Plus Group must reflect on the jury’s conclusions and take urgent action to ensure that lessons are learned so that the failings in Andrew’s case are not repeated in the future.”

Selen Cavcav, Senior Caseworker at INQUEST, said: “Adults with care and support needs should be supported by society, not criminialised. Yet the continued failures across health, social care, policing and prisons are costing lives.

Andrew was arrested and sent to prison whilst in mental health crisis. A decision was made to hold him in prison on remand, rather than seek care in the community. Despite the various risk factors he presented, he was neglected in prison.

This week the Justice Committee challenged the overuse of remand imprisonment, and the inadequate support for people on remand. Urgent change is needed to ensure people in mental health crisis are diverted from prison, and remand is only used as a last resort.”


For further information please contact Lucy McKay on [email protected]  

Andrew’s family are represented by INQUEST Lawyers Group members Tara Mulcair of Birnberg Peirce solicitors and Kirsten Sjøvoll of Matrix Chambers. They are supported by INQUEST caseworker Selen Cavcav.

Other Interested Persons represented include the Ministry of Justice, Midlands Partnership NHS Foundation Trust, Practice Plus Group, Coventry of Warwickshire Partnership NHS Trust, and GeoAmey.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

The Justice Committee report on The role of adult custodial remand in the criminal justice system was published on 17 January. See the committee’s media release and INQUEST’s evidence submission.