Henry Benoi-Davies

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Independent investigation into
the death of Mr Henry Benoi-
Davies (aka Jimmy Assani),
a prisoner at HMP Nottingham,
on 23 March 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Henry Benoi-Davies died from ischaemic heart disease on 23 March 2022 at HMP
Nottingham. He was 59 years old. I offer my condolences to Mr Benoi-Davies’ family and
friends.
When Mr Benoi-Davies arrived at Nottingham on 17 March 2022, he refused to cooperate
with staff, and they thought he was under the influence of alcohol or drugs. The reception
nurse was unable to carry out his reception health screen due to his behaviour and he was
taken straight to the prison’s segregation unit. Mr Benoi-Davies’ bizarre behaviour
continued, and nurses were unable to carry out a health screen over the next six days. On
23 March, he was found unresponsive on his cell floor.
Mr Benoi-Davies’ physical health was not assessed at any time during his six days at
Nottingham. The lack of reception health screen meant that Mr Benoi-Davies was not
referred to a GP nor were his community records checked. I am concerned that after
repeated attempts at a reception screen, no one considered alternatives to ensuring that
Mr Benoi-Davies received continuity of care. I am also concerned that nurses did not
complete a mental capacity assessment on Mr Benoi-Davies to establish whether he had
capacity to make decisions about his healthcare.
The clinical reviewer concluded that the care that Mr Benoi-Davies received was only
partly equivalent to that which he could have expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman October 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 17 March 2022, Mr Henry Benoi-Davies (also known as Jimmy Assani) was
remanded in prison custody, charged with burglary and assaulting a police officer.
He was sent to HMP Nottingham.
2. When he arrived at Nottingham, Mr Benoi-Davies refused to leave the van. Officers
asked the reception nurse to assess him on the van, but she was unable to carry
out the reception health screen due to his disruptive behaviour. Officers moved him
to the segregation unit.
3. Each day, nurses tried to complete a reception screen with Mr Benoi-Davies.
However, they were unable to because of his bizarre behaviour. He spent most of
his time naked in his cell and did not communicate with staff.
4. At around 11.25am on 23 March, while delivering meals to prisoners in the
segregation unit, staff saw Mr Benoi-Davies unresponsive on his cell floor. Staff
called a medical emergency code, entered the cell and started CPR. Healthcare
staff attended quickly and assisted.
5. At 11.46am, paramedics arrived and continued with resuscitation attempts.
However, these were unsuccessful and at 12.06pm, the paramedics pronounced
that Mr Benoi-Davies was dead.
6. The post-mortem report concluded that Mr Benoi-Davies died of heart disease.
Findings
7. The clinical reviewer found that the care that Mr Benoi-Davies received at
Nottingham was only partly equivalent to that which he could have expected to
receive in the community.
8. Mr Benoi-Davies’ physical health was not assessed by a medical practitioner at any
time during his six days at Nottingham. The lack of reception health screen meant
that he was not referred to a GP, his community records were not checked and he
did not have pulse and blood pressure readings taken. Nurses also failed to carry
out a mental capacity assessment.
9. The clinical reviewer also found that the standard of record keeping was poor.
Recommendations
• The Head of Healthcare should ensure that processes are in place to enable
reception screening staff to make all reasonable attempts to secure and use past
healthcare records to support reception screenings and ongoing care.
• The Head of Healthcare should undertake an immediate review into the actions of
nursing staff between 17 and 23 March 2022 in relation to Mr Benoi-Davies’
reception screening, assessment and care.
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• The Head of Healthcare should review why a GP referral cannot be made until a
reception screen has been completed, and implement any potential improvements
identified.
• The Head of Healthcare should ensure all healthcare staff receive training and
regular updates about the Mental Capacity Act 2005.
• The Head of Healthcare should ensure that all staff make full and accurate
SystmOne records of any observations they have, or have not, completed on
prisoners, including their rationale for clinical decision-making.
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The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Nottingham informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. NHS England commissioned an independent clinical reviewer to review Mr Benoi-
Davies’ clinical care at the prison.
12. The investigator and clinical reviewer interviewed seven members of staff at HMP
Nottingham on 10 May and three members of staff by video on 30 May.
13. We informed HM Coroner for Nottingham of the investigation who gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
14. The Ombudsman’s family liaison officer contacted Mr Benoi-Davies’ next of kin, his
son, to explain the investigation and to ask if he had any matters he wanted us to
consider. His solicitor responded to our letter. They had no questions but asked for
a copy of the report.
15. Mr Benoi-Davies’ family received a copy of the draft report. They did not make any
comments.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
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Background Information
HMP Nottingham
17. HMP Nottingham is a Category B prison, operated by Her Majesty’s Prison Service.
The prison holds approximately 1000 adult males. Nottinghamshire Healthcare NHS
Foundation Trust provides 24-hour healthcare services at the prison.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Nottingham was in January 2020. Inspectors
raised that safety of prisoners continued to be an ongoing issue for Nottingham,
although noted they were making efforts to address this. They reported that from
their previous inspection, healthcare services had improved and noted that staff-
prisoner relationships in the segregation unit were positive.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to February 2021, the IMB reported
that they had concerns that mental health facilities were not meeting prisoners’
needs, resulting in some prisoners remaining in the segregation unit longer than
necessary. They also noted reduction in violence levels at the prison, suggesting
some improvements in safety at Nottingham.
Previous deaths at HMP Nottingham
20. Mr Benoi-Davies was the seventh prisoner to die at Nottingham since March 2020.
Of the previous deaths, five were from natural causes and one was self-inflicted.
There are no similarities between our findings in the investigation into Mr Benoi-
Davies’ death and our investigation findings for the previous deaths.
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Key Events
21. On 17 March 2022, Mr Henry Benoi-Davies (also known as Jimmy Assani) was
remanded in prison custody, charged with burglary and assaulting a police officer.
He was sent to HMP Nottingham.
22. When Mr Benoi-Davies arrived at Nottingham, he refused to leave the van. He
seemed confused, had been refusing to wear clothes and had urinated in the
holding cell. Staff asked the reception nurse to assess him on the van. The nurse
said that Mr Benoi-Davies was only half-dressed, was banging on the window of the
holding cell and could not communicate properly. She thought he might be under
the influence of drugs or alcohol. She asked if a member of substance misuse staff
could see him but was told that she would need to make a referral in the usual way.
She had just returned from maternity leave and was unsure what to do.
23. Officers moved Mr Benoi-Davies to a cell in the segregation unit due to his
behaviour. The reception nurse scheduled a reception health screen for the
following day. She also referred him to the mental health team and substance
misuse service (SMS).
24. That afternoon, a nurse recorded that Mr Benoi-Davies had failed the segregation
algorithm due to ‘no communication and bizarre presentation’. (The segregation
algorithm assesses whether a prisoner is fit to remain in segregation.) She noted
that he was lying naked on his cell floor, was staring with his eyes wide open and
had an odd smile when spoken to. She thought he might be under the influence of
drugs. She spoke to SMS and they accepted him onto their stabilisation unit (which
means that SMS staff carry out regular checks). SMS staff checked on Mr Benoi-
Davies regularly over the next three days. He remained in the segregation unit. (A
prison manager authorised that he should remain in segregation as he could not be
managed safely elsewhere in the prison.)
25. On 18 March, a nurse recorded that Mr Benoi-Davies was naked in his cell and
talking to unseen person/stimuli. She noted that he might be under the influence of
an illicit substance or psychotic and that she would continue to monitor him.
26. That day, a nurse recorded that he was unable to see Mr Benoi-Davies for a mental
health triage due to time constraints.
27. On 19 March, Mr Benoi-Davies flooded his cell. An officer recorded that he was in a
state of confusion and anger. The officer noted that he had been seen every day on
the healthcare rounds. However, the only notes in his medical record that day were
the ones made by SMS staff.
28. On 20 March, a nurse recorded that she had been to see Mr Benoi-Davies but he
was naked, confused and had flooded his cell. She did not carry out a health
screen. Staff moved Mr Benoi-Davies to another cell.
29. On the morning of 21 March, two nurses went to assess Mr Benoi-Davies. An
officer opened the cell door observation panel and saw Mr Benoi-Davies sitting on
his bed naked. The officer asked Mr Benoi-Davies to put some clothes on but he
refused. The nurses did not assess him.
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30. That afternoon, a nurse went to see Mr Benoi-Davies. She noted that he was sitting
on his bed naked and that he turned to look at her when she spoke to him but when
he replied, no sound came out. She noted that she would discuss him with the
doctor at the complex cases meeting on 24 March.
31. On 22 March, an officer noted that Mr Benoi-Davies had poured his dinner over
himself. He also recorded that he continued to misuse his cell bell.
32. That day, a nurse recorded that she had contacted the segregation unit and had
been told that Mr Benoi-Davies was in no fit state to be assessed as he was lying
on his bed naked. She recorded that she would rebook his health screen for the
next day. At interview, she said that it was standard for prisoners to be brought to
the healthcare unit for their reception screen (because they had the healthcare
computers there) and as Mr Benoi-Davies was naked and uncooperative, officers
would not move him.
Events of 23 March
33. At 10.50am on 23 March, a nurse checked on Mr Benoi-Davies in his cell. She saw
him conscious, lying on the floor. She did not consider his presentation to be out of
the ordinary from her recent interactions with him.
34. At 11.11am, a nurse recorded that she had contacted the segregation unit about
doing Mr Benoi-Davies’ reception screen but had been told he was disorientated
and still naked, as he had been for the past six days. She noted that she had
rebooked the health screen for the next day.
35. At 11.24am, two officers and a custodial manager (CM) arrived on the wing and
started giving meals to prisoners in their cells. Approximately one minute later, they
arrived at Mr Benoi-Davies’ cell. The CM opened the cell hatch and saw Mr Benoi-
Davies on the floor but could not see him breathing. The CM opened the cell and
called a medical emergency code. An officer began CPR. Another officer arrived
shortly afterwards and took over.
36. At 11.27, nurses arrived at the cell. An officer continued to give CPR and alternated
these duties with a prison nurse.
37. At 11.46am, paramedics arrived and continued to provide emergency first aid. An
officer continued to provide CPR despite there being several healthcare colleagues
present. Mr Benoi-Davies was pronounced dead at 12.06pm.
Contact with Mr Benoi-Davies’ family
38. The prison appointed an officer as the family liaison officer (FLO). Nottingham did
not have a listed next of kin for Mr Benoi-Davies. The FLO located Mr Benoi-Davies’
brother’s details as a previously listed next of kin by reviewing prison records. Mr
Benoi-Davies’ brother was in another prison. The Deputy Governor rang the prison
to arrange for them to notify Mr Benoi-Davies’ brother of his death in person. This
was done at approximately 1.40pm on 23 March.
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39. The following day, Mr Benoi-Davies’ son attended court for a hearing due to take
place for Mr Benoi-Davies. The court passed this information to Nottingham and at
approximately 4:30pm, the FLO rang Mr Benoi-Davies’ son to notify him of his
death. The court had already made him aware.
40. The prison contributed financially to Mr Benoi-Davies’ funeral in line with national
instructions.
Support for prisoners and staff
41. After Mr Benoi-Davies’ death, the Head of Safety debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
42. The prison posted notices informing other prisoners of Mr Benoi-Davies’ death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Benoi-Davies’ death.
Prison staff offered support to a prisoner who witnessed the incident.
Post-mortem report
43. The post-mortem report concluded that Mr Benoi-Davies died from ischaemic heart
disease.
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Findings
Clinical care
44. The clinical reviewer found that the care that Mr Benoi-Davies received at
Nottingham was only partly equivalent to that which he could have expected to
receive in the community.
45. Mr Benoi-Davies’ physical health was not assessed by a medical practitioner at any
time during his six days at Nottingham. The lack of reception health screen meant
that he was not referred to a prison GP, he did not have pulse and blood pressure
readings taken, there was no medications reconciliation (where community
medications are checked and continued if appropriate) and there was no urine
testing. The clinical reviewer said it was possible that heart abnormalities may have
been identified if pulse and blood pressure readings had been taken.
46. The clinical reviewer noted that healthcare staff were recording notes on Mr Benoi-
Davies’ prison SystmOne record (electronic medical record) from the day he arrived
at Nottingham so would have had access to his past medical history. These records
showed that Mr Benoi-Davies displayed similar behaviour at Nottingham in 2010
and he was diagnosed with bipolar affective disorder. There is no evidence that the
healthcare staff caring for Mr Benoi-Davies between 17 and 23 March accessed this
information. They might have been able to make more informed decisions about Mr
Benoi-Davies’ care had they done so.
47. We are concerned that after repeated attempts to carry out a reception health
screen, no alternatives were considered to ensure continuity of care. We
recommend:
The Head of Healthcare should ensure that processes are in place to enable
reception screening staff to make all reasonable attempts to secure and use
past healthcare records to support reception screenings and ongoing care.
The Head of Healthcare should undertake an immediate review into the
actions of nursing staff between 17 and 23 March 2022 in relation to Mr Benoi-
Davies’ reception screening, assessment and care.
The Head of Healthcare should review why a GP referral cannot be made until
a reception screen has been completed, and implement any potential
improvements identified.
48. The clinical reviewer was concerned that nurses did not complete a mental capacity
assessment on Mr Benoi-Davies. We recommend:
The Head of Healthcare should ensure all healthcare staff receive training and
regular updates about the Mental Capacity Act 2005.
49. The clinical reviewer found that record keeping was of poor quality and not in line
with nursing standards. Records about observations made on Mr Benoi-Davies
through his observation panel appeared to be copied and repeated. There was no
record of how Mr Benoi-Davies appeared physically, only that he was naked. We
recommend:
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The Head of Healthcare should ensure that all staff make full and accurate
SystmOne records of any observations they have, or have not, completed on
prisoners, including their rationale for clinical decision-making.
Inquest
50. At the inquest, held from 1 to 9 June 2026, the jury concluded that although
evidence suggested there had been multiple failings in the care of Mr Davies,
ultimately he had died from natural causes.
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