Surendrakumar Patel
10 Mar 2026 · Coroner James Puzey · Worcestershire
The coroner's concerns
1. lack of mental capacity assessment for food refusal
“Failure to recognise that a mental capacity assessment was required as soon as food refusal began”
2. lack of hospital transfer for severely weakened prisoners
“Failure to consider hospital transfer for prisoners severely weakened by weight loss”
3. delayed full medical assessment for prisoners with severe weight loss
“Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival”
4. lack of family contact advocacy
“Failure to consider and advocate for family contact”
5. lack of next of kin notification about food refusal
“Not informing Next of Kin of the prisoner's decision to refuse food/fluids”
6. lack of prisoner consultation on sharing information
“Not asking the prisoner whether such information should be shared”