Mesut Olgun

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Independent investigation into
the death of Mr Mesut Olgun,
a prisoner at HMP Hewell,
on 14 June 2018
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
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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.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Mesut Olgun died after he was found hanged in his cell on 14 June 2018 at HMP
Hewell. He was 30 years old. I offer my condolences to Mr Olgun’s family and friends.
Mr Olgun was recognised as being at high risk of suicide and self-harm when he arrived at
Hewell on 7 June. He met the criteria for constant supervision but staff put him on four
checks an hour. I do not know if this would have been sufficient to keep Mr Olgun safe
because the night patrol officer did not make the required checks. He was convicted of
misconduct in a public office in November 2023. This criminal investigation led to the delay
in issuing this report.
I recommend that if a prisoner meets the criteria for constant supervision but staff decide
against it, there is a documented multi-disciplinary discussion to justify this. I also consider
that using interpreting services would have helped staff to properly assess Mr Olgun’s risk.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman May 2026
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 11
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Summary
Events
1. At 3.30am on 6 June 2018, police were called to an incident where Mr Mesut Olgun
was breaking shop windows. Mr Olgun was armed with a meat cleaver and cut his
throat when police arrived. He injured a police dog and resisted arrest. The police
took him to hospital for treatment to his injuries and put him under constant
supervision in their custody.
2. On 7 June, Mr Olgun appeared at court and was remanded to prison. Court custody
staff checked him six times an hour and completed a suicide and self-harm warning
form. They also contacted HMP Hewell to warn them that Mr Olgun was on his way
to them and was at high risk of suicide and self-harm.
3. Staff started Prison Service suicide and self-harm monitoring procedures (known as
ACCT) in reception and a nurse assessed Mr Olgun. Staff decided that he would be
subject to four checks every hour. Mr Olgun was assessed as unsuitable to share a
cell due to his risk to potential cellmates.
4. At about 6.47am the following morning, prisoners from the adjacent open prison
noticed Mr Olgun hanging in his cell when they were picking up litter from the
exercise yard. Their civilian supervisor alerted prison staff. Staff cut Mr Olgun down
and started CPR assisted by prison nurses. Paramedics took Mr Olgun to hospital
but he died six days later.
5. Subsequent investigations by the prison and police discovered that the night patrol
officer had not made the required checks on Mr Olgun and falsified the ACCT
record. He has since been found guilty of misconduct in a public.
Findings
6. Mr Olgun met the criteria for constant supervision when he arrived at the prison. He
had recently seriously self-harmed and said he had thoughts of suicide. The
circumstances of his alleged offences also gave cause for concern in terms of his
mental health. It is not clear who initially decided that four observations per hour
would be sufficient for Mr Olgun. A missing part of the ACCT document
compounded this issue. There is no evidence that a conversation took place
between staff to decide on the appropriate level of observations for Mr Olgun. In
addition, the night patrol officer did not complete the necessary observations
overnight and falsified records to say that he had done so.
7. Police records indicated Mr Olgun needed an interpreter. Staff at Hewell did not use
an interpreter which would have helped them to more accurately assess Mr Olgun’s
risk to himself and others.
Recommendations
• The Governor should ensure that when prisoners meet the criteria for constant
supervision, a documented multi-disciplinary conversation takes place to determine
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the appropriate level of ACCT observations if they are not subject to constant
supervision.
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The Investigation Process
8. HMPPS notified us of Mr Olgun’s death on 14 June 2018.
9. The investigator issued notices to staff and prisoners at HMP Hewell informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
10. The investigator obtained copies of relevant extracts from Mr Olgun’s prison and
medical records and CCTV from 8 June 2018. She also obtained further information
from West Midlands Ambulance Service and West Mercia police. She interviewed
six members of staff between June and August 2018.
11. NHS England commissioned a clinical reviewer to review Mr Olgun’s clinical care at
the prison.
12. Our investigation was suspended at the request of West Mercia police in
September 2018, pending an investigation into the actions of the night patrol officer
on the night of 7/8 June. The night patrol officer was subsequently convicted of
misconduct in a public office. At the conclusion of his criminal trial in November
2023, we unsuspended our investigation.
13. We informed HM Coroner for Worcestershire of the investigation. The Coroner 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 one of Mr Olgun’s uncles to
explain the investigation and to ask if he had any matters he wanted us to consider.
Mr Olgun’s uncle asked for detail about Mr Olgun’s time in Hewell and how often he
had been monitored. The investigator subsequently met two of Mr Olgun’s uncles
and their solicitor when our investigation was suspended to inform them of our
findings so far.
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Background Information
HMP Hewell
15. HMP Hewell holds up to 900 adult male prisoners on remand or serving short
sentences. Physical healthcare is provided by Practice Plus Group (formerly Care
UK). Midlands Partnership Foundation Trust provide mental health services and
substance misuse services are provided by Inclusion.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Hewell was in December 2022. Inspectors
reported that the prison had made excellent progress since the previous inspection
in 2019 and was cleaner, more decent and safer. Disappointingly, failings in the
care of prisoners in their early days in custody remained a priority concern.
Inspectors found that not enough was being done to support prisoners most at risk
of suicide and self-harm. There was no strategy or action plan, limited data analysis
and investigation of serious self-harm incidents, and poor oversight of
implementation of PPO recommendations.
17. HMIP conducted an independent review of progress at Hewell in November 2023.
Inspectors found that early days in custody arrangements still needed improving
and too little was being done to reduce self-harm. The recorded rate of self-harm
had not reduced and was on an upward trend. The quality of ACCT case
management remained too variable.
Independent Monitoring Board
18. 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 30 September 2023, the IMB
reported that overcrowding at the prison had got worse and prisoners were often
locked up for 22 hours a day. Despite these challenges, the IMB found that staff
tried to deliver a safe, fair and humane regime. However, self-harm incidents had
risen again and the key work scheme had not functioned as intended due to short
staffing.
Previous deaths at HMP Hewell
19. There was one self-inflicted death at HMP Hewell in the three years before Mr
Olgun died. In that we identified some issues with ACCT management. Up to the
end of 2023, there had been nine self-inflicted deaths since Mr Olgun’s, with the
most recent in July 2023. Of these, four have identified issues in the assessment
and management of the prisoner’s risk to themselves. Two are still currently under
investigation but early findings involve issues with management of the risk of
suicide and self-harm.
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Assessment, Care in Custody and Teamwork
20. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
21. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
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Key Events
22. Details about Mr Mesut Olgun’s background are scarce. He was a Turkish national
whose last visa to stay in the UK expired in 2009. Mr Olgun previously served a
sentence in HMP Bristol in 2012 and was considered for removal from the UK under
immigration powers. However, after release from prison, he failed to keep in touch
with the immigration authorities and was listed as ‘out of contact’.
Police and court custody, 6 – 7 June 2018
23. At 3.30am on 6 June 2018, a member of the public witnessed Mr Olgun breaking
shop windows and called the police. Police told the investigator that Mr Olgun was
under the influence of alcohol and drugs, might have been having a psychotic
episode and had a meat cleaver in his possession. The first officer on scene was a
dog handler. Mr Olgun started cutting his own throat, so the handler released his
dog to try to stop him. Mr Olgun then attacked the dog and the handler and other
officers had to intervene.
24. The police took Mr Olgun to hospital where he received treatment for his injuries.
Cuts to his arms and legs were steri-stripped, a cut to his head was stapled and the
self-inflicted wounds to his neck were stapled and stitched. He was given a tetanus
injection and antibiotics for a dog bite. Police records do not indicate that Mr Olgun
had a mental health assessment.
25. After treatment in hospital, Mr Olgun was taken to a police station. The police
assessed him as at high risk of harm to himself and others and placed him under
constant supervision. At 11.00am, a police medical officer examined him and
decided he needed further treatment in hospital due to a high heart rate and
possible atrial fibrillation (irregular heartbeat). He was discharged back to police
custody after receiving further treatment and medication for his injuries. He did not
receive a mental health assessment.
26. During the afternoon of 6 June, a police medical officer determined that Mr Olgun
was fit for interview but that he needed a Turkish interpreter. Police waited four
hours for one to arrive. Mr Olgun said he had mental health issues and described
visual and auditory hallucinations. He said he was not receiving treatment for his
mental health. Mr Olgun told police that he had tried to harm himself before, most
recently by cutting his throat just before he was arrested.
27. On 7 June, Mr Olgun was charged with criminal damage, causing unnecessary
suffering to an animal, possessing an offensive weapon in a public place, affray and
assault occasioning actual bodily harm.
28. At 8.14am, Mr Olgun was taken to court. His person escort record (PER) showed
that he had cut his throat on 6 June, had mental health issues and was a risk to
himself. The front page and risk indicator page were marked “*HIGH RISK*” in
several places and the front page included reference to the interpreting services
which had been used. Mr Olgun arrived at court at 9.25am and court custody staff
observed him six times an hour.
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29. Court custody staff completed a suicide and self-harm warning form and attached it
to Mr Olgun’s PER. They ticked boxes to indicate that Mr Olgun had made
statements of intent to self-harm or kill himself, had harmed himself within the
previous month and noted Mr Olgun “seems very depressed.” Staff recorded that
Mr Olgun had cut his own throat the previous day and was at high risk of hurting
himself. They noted that Mr Olgun had hardly spoken during the day. Mr Olgun was
remanded to custody and taken to HMP Hewell.
HMP Hewell, 7 – 8 June 2018
30. Mr Olgun arrived at Hewell at about 5.00pm. A supervising officer (SO) was in
charge of reception. He said he received a telephone call from GEO Amey (who
were transporting Mr Olgun to prison) alerting him that Mr Olgun was on the way to
the prison and was a high risk of suicide and self-harm. The SO was told that Mr
Olgun’s offence was high profile and that he had cut his throat the day before. The
SO spoke to Mr Olgun at the reception desk and said he did not appear distressed
or unwell.
31. At 5.15pm, an officer completed Mr Olgun’s cell sharing risk assessment (CSRA)
and started Prison Service suicide and self-harm monitoring (known as ACCT). She
noted on his CSRA that Mr Olgun’s case was high profile and had been in the news
the previous day. She also noted Mr Olgun had mental health issues and had said
he wanted to kill himself. She concluded that Mr Olgun was a high risk to others if
he shared a cell. This meant that Mr Olgun would not share a cell on his first night
as was the usual practice at Hewell. The Duty Governor approved the officer’s
decision.
32. The SO said that he anticipated that Mr Olgun would be put under constant
supervision in the prison’s inpatient unit so, while Mr Olgun had his initial health
assessment with a nurse, he rang a custodial manager (CM) so she could start
arranging extra night staff.
33. The nurse said he looked briefly at Mr Olgun’s injuries without completely removing
the dressings because he did not have the necessary medical supplies to redo the
dressings. (These would have been changed the next day.) From his brief
examination, the nurse noted that the self-inflicted cut to Mr Olgun’s throat was
superficial and not close to an artery. This was in contradiction to police records
which noted that the wound had been stapled and stitched.
34. The nurse said Mr Olgun could speak and understand English well. He told him that
he had broken a shop window and then waited for the police because he felt under
threat from an individual in the community. The nurse said he explored this issue
with Mr Olgun but could find no evidence of paranoid, psychotic or delusional
beliefs. Mr Olgun was clear that the person he was under threat from was not in
prison and said he felt safe and relieved now he was in Hewell.
35. The nurse said he explored Mr Olgun’s risk of suicide and self-harm and asked him
why he had cut his throat. Mr Olgun said he was angry with the police but was not
clear about his arrest and why he had cut himself. The nurse said he felt like he
could not get to what was at the root of Mr Olgun’s actions. Mr Olgun told him that
he had no current thoughts of suicide or self-harm.
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36. The nurse said an ACCT had already been opened by reception officers and Mr
Olgun had been put on four observations an hour. He considered constant
supervision but said in his opinion there was no clinical reason Mr Olgun needed
that level. He appeared quite calm, and the nurse was satisfied that observations
every 15 minutes would pick up any changes in his mental state that might require
increased observations. He said he discussed the level of observations with the SO.
The nurse sent referrals to the GP and the mental health team for Mr Olgun to have
follow-up appointments. He also gave him some co-amoxiclav (an antibiotic) for the
dog bites and referred him to nurses to have his dressings checked the next day.
37. The SO said Mr Olgun was with the nurse for about 45 minutes, which is a long
time for a reception interview. He said the nurse came to see him in his office
afterwards and told him that he thought Mr Olgun did not need constant supervision
and four checks an hour was sufficient. The SO said he deferred to the nurse’s
opinion because he knew he was an experienced mental health nurse and had
spent a long time talking to Mr Olgun.
38. An officer completed Mr Olgun’s first night in prison interview in the first-night centre
on Houseblock Three. She said Mr Olgun appeared distant and upset and gave
one-word answers. The officer asked him if he felt suicidal or like harming himself
and Mr Olgun answered yes to both. The officer explained about the Listeners
(prisoners trained by The Samaritans to offer confidential peer support), the
Samaritans phone (a mobile telephone with a direct line to The Samaritans), the
mental health team and the Chaplaincy. She said Mr Olgun looked blank and upset
as if he was not taking in the information she was giving him. The officer spent
about 15 minutes with him, trying to get him to talk more openly, but he remained
the same.
39. At the end of the interview the officer briefed the wing SO and the other staff on
duty. She said she and the other staff on duty checked Mr Olgun more often than
four times an hour because they were so concerned about him. The officer asked
Mr Olgun how he was every time she checked him, and he put his thumbs up.
When an operational support grade (OSG), the night patrol officer, came on duty,
she briefed him before stopping work around 8.45pm.
40. A nurse said he remembered giving Mr Olgun his medication at about 9.00pm. He
said Mr Olgun had a lot of bandages but was mentally well and did not appear
distressed.
41. The OSG was suspended from duty pending an internal investigation when
interviews took place and we have not spoken to him. The OSG completed the
ACCT record to indicate that he had checked Mr Olgun four times an hour between
9.00pm and 10.00pm, once between 10.00pm and 11.00pm and then four times an
hour until 6.10am on 8 June. The investigator was provided with CCTV from
5.00am to 7.22am on 8 June. During this period, the OSG completed the ACCT
record to show he checked Mr Olgun at 5.10am, 5.25am, 5.40am, 5.55am and
6.10am. CCTV showed the OSG only checked Mr Olgun once at 5.36am by the
CCTV clock (which we calculated was about 12 minutes behind the correct time).
We understand from the police that the OSG made very few checks on Mr Olgun
during the night.
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Emergency response
42. At about 6.45am on 8 June, a civilian employed by the Prison Service to supervise
waste management was supervising a small group of prisoners from a nearby open
prison cleaning rubbish from the Houseblock Three exercise yard. He said that that
a prisoner told him that he thought he could see a prisoner hanging in one of the
ground floor cells. He said that he immediately used his keys to enter the
houseblock as he knew the night orderly officer (officer in charge of the prison at
night) had an office there. He alerted a CM and the OSG that a prisoner might be
hanging in one of the cells.
43. The clock on the CCTV was wrong so we have used the times from the incident
logs and ambulance records. The OSG got to Mr Olgun’s cell first, looked through
the observation panel, banged on the door and used his radio. Within a minute, the
CM joined him. He too looked through the observation panel and used his radio
before opening Mr Olgun’s cell door. At 6.47am, staff noted in the incident log that
staff had called for a “response” and nurse to Houseblock Three. No one radioed a
code blue emergency.
44. Mr Olgun was hanging from the locker on his wall by a ligature made from his
sheet. The CM supported Mr Olgun’s weight while the OSG cut the ligature. They
laid Mr Olgun on the floor and the CM started cardio-pulmonary resuscitation
(CPR).
45. Four minutes later, at 6.51am, a nurse arrived with emergency equipment and
began assembling it outside the cell. He radioed a code blue. (An emergency code
used when a prisoner is not responding or having difficulty breathing). Staff in the
control room immediately requested an ambulance which was dispatched with the
highest priority within a minute.
46. The nurse attached a defibrillator to Mr Olgun. It advised no shock but to continue
CPR. Another nurse got to the cell and gave Mr Olgun oxygen via an ambu-bag.
47. At 7.01am, paramedics arrived and took over resuscitation. They gave Mr Olgun
adrenaline and his heart restarted but he was unable to breathe unaided. At
7.42am, they took Mr Olgun to hospital. Mr Olgun remained unresponsive in
intensive care until he died on 14 June.
Contact with Mr Olgun’s family
48. Mr Olgun did not list any next of kin when he first arrived at Hewell. The police and
prison contacted Mr Olgun’s next of kin on 8 June to inform them he was in hospital
and an uncle visited him there the same day. On 9 June, the prison appointed a
family liaison officer who maintained contact with the family. On 14 June, the prison
Imam completed the Islamic rites at the request of the family, who were present
when Mr Olgun died. The prison made a financial contribution to Mr Olgun’s funeral
in line with national guidance.
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Support for prisoners and staff
49. After Mr Olgun’s death, the CM 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.
50. The prison posted notices informing other prisoners of Mr Olgun’s 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 Olgun’s death.
Post-mortem report
51. The pathologist gave the cause of death as hypoxic brain injury (lack of oxygen to
the brain) due to hanging. Toxicology tests showed Mr Olgun had no alcohol or
drugs in his system.
Investigations after Mr Olgun’s death
52. On 21 June, the Deputy Governor asked the Head of Security to investigate the
checks made by the OSG on Mr Olgun during the night of 7/8 June. In light of the
Head of Security’s investigation, the Governor at the time held a disciplinary
investigation. The investigator requested a copy of the Head of Security’s
investigation, but the prison declined to provide it. She was provided with a copy of
the terms of reference and a copy of the outcome which was sufficient in the
circumstances. The then Governor found that the OSG had not made the required
checks and had falsified the ACCT record. He re-graded the OSG to a non-
operational administrator role and issued him with a final written warning to remain
in force for two years.
53. West Mercia police also investigated the OSG’s conduct that night. In November
2023, he was found guilty of misconduct in a public office. At the time of writing he
was awaiting sentence.
Coroner’s Inquest
54. A Coroner’s inquest concluded on 8 December 2025. The medical cause of death
was given as hypoxic brain injury (lack of oxygen to the brain) as a result of
hanging. The jury concluded that the failure of the OSG to carry out all required
observations and a delay in calling a code blue emergency caused or contributed to
Mr Olgun’s death.
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Findings
Assessment and management of risk
55. Mr Olgun had a number of risk factors that indicated he was at high risk of suicide
on 6 and 7 June. He had suicidal thoughts, had expressed a desire to kill himself,
gave a history of poor mental health and appeared very depressed. Most seriously,
on 6 June, he made cuts to his throat that required stapling and stitching at hospital.
The police treated this as a suicide attempt, recognised he was high risk and put
him under constant supervision. Court custody officers also deemed him at high risk
of suicide and self-harm. They monitored him six times every hour and, unusually,
telephoned Hewell prior to his arrival in addition to completing a suicide and self-
harm warning form.
56. Reception staff at Hewell began ACCT monitoring as soon as Mr Olgun arrived and
set the level of observation at four checks an hour. The SO and initial health
assessment nurse gave contradictory accounts of how this level was arrived at. The
SO said he assumed Mr Olgun would be under constant supervision and had begun
the process of calling in extra staff to facilitate this. He said that when the nurse
decided four observations an hour were sufficient, he deferred to him as an
experienced mental health nurse. The nurse said that the level of four observations
an hour had already been set by reception staff before he assessed Mr Olgun. He
said he began the assessment thinking constant supervision was likely but
concluded that four observations an hour was enough once he had spoken to Mr
Olgun. The ACCT document showed the SO recorded four observations an hour on
the cover, but the entry has no time. In addition, the immediate action plan, which
should have been completed by a prison manager within an hour of the ACCT
being opened, was not provided to the investigator. This would have included the
level of observations for Mr Olgun. The prison have not been able to determine
whether this is because the action plan was lost, or one was not completed at the
time.
57. However the decision was arrived at, both the nurse and SO were aware of the
level of observation and neither tried to persuade the other that constant
supervision was necessary.
58. Guidance on constant supervision is contained in Prison Service Instruction (PSI)
64/2011, Safer Custody. This has been revised and expanded since Mr Olgun died.
At the time, the PSI gave three reasons for the use of constant supervision:
• Serious attempts and/or compelling preparations for suicide e.g. making a
ligature, hoarding medication and/or writing a suicide note.
• Credible expression of a wish to die.
• A recent and credible attempt to take own life e.g. both in prison and recently
prior to imprisonment.
The PSI made clear that these examples were for guidance only and that each case
should be considered individually and not in isolation by any one person.
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59. According to this guidance, Mr Olgun fitted the criteria for constant supervision as
he had recently seriously self-harmed and said he had current thoughts of suicide.
The police had treated him cutting his throat as a suicide attempt. The nurse asked
him about this but said that he was unsure what Mr Olgun’s intentions were. Staff
judgement is fundamental to the ACCT system. The system relies on staff using
their experience and skills to make a considered, objective evaluation of all risk
factors when assessing the risk of suicide and self-harm. We do not consider that it
would be helpful or appropriate for us to criticise the nurse’s judgement call with the
benefit of hindsight. The nurse spent 45 minutes with Mr Olgun and came to a
considered conclusion that four observations an hour were sufficient. What is less
clear is whether there was any effective discussion as both the SO and the nurse
credited each other with setting the frequency of observations.
60. We do not know whether four checks an hour would have been enough to keep Mr
Olgun safe because the OSG did not check him at the required frequency.
However, he last checked Mr Olgun just under an hour before he was found
hanged, so we consider that Mr Olgun should have been checked three or four
times between then and being found hanging. Given that nearly six years has
passed since Mr Olgun’s death, it is difficult to make meaningful recommendations.
However, following a death at the prison in 2022 for which the investigation remains
ongoing, we have preliminary concerns that staff in reception did not adequately
assess the risk information available to them (including that the prisoner had been
constantly supervised when in police or court custody) and open an ACCT. We
therefore make the following recommendation:
The Governor should ensure that when prisoners meet the criteria for
constant supervision, a documented multi-disciplinary conversation takes
place to determine the appropriate level of ACCT observations if they are not
to be subject to constant supervision.
ACCT checks by the OSG
61. The OSG did not complete the ACCT checks as he should have on the night that
Mr Olgun died and falsified the record. He was convicted of misconduct in a public
office. We make no further recommendation.
Use of interpretation services
62. Mr Olgun was a Turkish national and his first language was not English. The police
had waited four hours for the arrival of an interpreter before they interviewed him.
After Mr Olgun’s arrival at Hewell, staff do not appear to have considered the use of
interpretation services.
63. The nurse said that Mr Olgun could speak and understand English well. However,
he also reflected that Mr Olgun was not clear about his arrest or why he had cut
himself. The nurse felt he could not understand the cause of Mr Olgun’s actions. An
officer said that Mr Olgun gave one-word answers which may have been due to his
limited command of English. These interactions were the best opportunity to
properly gauge Mr Olgun’s risk to himself and given his high number of risk factors,
best practice would have been to have used The Big Word translation service.
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64. The lack of use of interpreting services has not been an issue which we have raised
in any of our investigations at Hewell since the death of Mr Olgun. We have recently
made a national recommendation that the Prison Service introduce a standardised
policy to help staff assess a prisoner’s English language ability and inform the use
of interpreting services. HMPPS have yet to respond to this. We make no further
recommendation in this case.
Clinical care
65. The clinical reviewer concluded that the clinical care Mr Olgun received was
equivalent to that he would have received in the community.
Emergency response
66. PSI 03/2013, Medical Emergency Response Codes, requires prisons to have a
medical emergency response code protocol, which should ensure that staff call an
appropriate code to summon help immediately and to ensure an ambulance is also
requested at once. HMP Hewell uses two emergency codes, code red (which
indicates heavy loss of blood) and code blue.
67. Neither the OSG nor the CM who first got to Mr Olgun’s cell radioed a code blue.
The nurse who arrived at the cell four minutes later radioed the code blue which led
to the control room requesting an ambulance. Therefore the lack of calling a code
blue led to a delay in calling the ambulance, as well as the attending nurse not
being aware that there was an emergency.
68. Due to the long suspension of this investigation, we do not know why the initial staff
at the cell did not call a code blue. However, we last made a recommendation about
this issue following a death in 2021 after which staff received additional reminders
and training. The lack of calling an emergency code has not come up in any of the
six investigations we have completed following deaths at the prison since then. We
therefore do not regard it as a systemic issue and make no recommendation.
Prisons and Probation Ombudsman 13
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