Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of follow-up on mental health history and drug overdose
The earlier warning
Gary McDonald · 20 Sept 2022 · David Reid, Worcestshire
“During his initial healthcare screening appointment on the evening he arrived at HMP Hewell ( 25.3.21 ) and his secondary healthcare screening appointment the following day, Mr [name redacted] denied any mental health issues, and denied any current thoughts of suicide or self-harm.”
judiciary.uk/…/gary-mcdonald-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Gary McDonald (20 Sept 2022) · stated timescale: Day 5 - Initial Management Review and key word search undertaken by a Seniorurse
“the Head of Healthcare has consulted with other stakeholders within the team about the concern raised and have considered ways this concern can be alleviated. The healthcare team have introduced an updated version (V4) of the EDiC pathway and passport. This”
What recurred
- 27 Jul 2026 · Adam Clark - Prevention of future deaths report (2) · David Reid · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Gary McDonald · 20 Sept 2022
“During his initial healthcare screening appointment on the evening he arrived at HMP Hewell ( 25.3.21 ) and his secondary healthcare screening appointment the following day, Mr [name redacted] denied any mental health issues, and denied any current thoughts of suicide or self-harm.”
Later · Adam Clark - Prevention of future deaths report (2) · 27 Jul 2026
“the agency nurse who conducted the deceased's initial healthcare screening appointment on his arrival at HMP Hewell may not have looked at his PER, either because he did not have access to a copy of it, or because he had not been trained to ensure that he looked at it.”
What happened next
No web check of the stated actions has been published for this chain.