Inquest finds inadequate care contributed to death of Frazer Williams who took his life at HMP Guys Marsh

Thursday 23 May 2024

Paul Clark, of the Garden Court Chambers Inquests & Inquiries Team, represented Frazer’s Family, instructed by Maya Grantham of Leigh Day.

Share This Page

Email This Page

Inadequate diagnosis and treatment of Frazer Williams’ mental health condition was among the probable causes of the 28-year-old’s death at HMP Guy’s Marsh, a jury unanimously found. 

The management of Frazer’s risk at HMP Guys Marsh; and inadequate safeguarding measures taken after he was informed that he would be transferred to a psychiatric hospital for inpatient treatment were also cited as contributing factors in Frazer’s death on 7 March 2022.

In their conclusions given on Friday 17 May, the jury identified missed opportunities to improve Frazer’s mental health including inadequacies in the prison system’s suicide and self-harm safeguarding process, known as Assessment, Care in Custody, and Teamwork (ACCT) and a multidisciplinary forum for discussing complex prisoners, known as Safety Intervention Meetings (SIM), which the jury described as inadequate in detail and lacking in documentation.

Over the course of a three-and-a-half-week inquest, a jury heard evidence about Frazer’s presentation throughout his time at HMP Guys Marsh including continued refusals to engage with staff, self-neglect and mood incongruent delusions about flushing his toilet. 


Frazer was initially imprisoned at HMP Lewes from ​4 June 2021 until 4 October 2021. During that time, his mental health deteriorated, and he was monitored under an ACCT, which resulted in Frazer spending periods under constant supervision. 

In September 2021, while at HMP Lewes, Frazer was also diagnosed with bulimia and a personality disorder. The coroner’s expert psychiatry witness believed that, based upon the records available to practitioners at that time, this was a misdiagnosis, and that Frazer’s presentation was more consistent with a severe depressive episode with psychotic features. 

Frazer was released from HMP Lewes into the community on 4 October. However, he was remanded back into custody at HMP Winchester just three days later, on 7 October 2021. 

While at HMP Winchester, Frazer was not monitored under an ACCT, and he did not undergo a psychiatric assessment until 22 December 2021. At this time the psychiatrist identified a possible diagnosis of a more enduring psychotic disorder.

On 14 January 2022 Frazer was transferred under restraint to HMP Guys Marsh, a Category C men’s prison. The jury heard that mental health staff at HMP Guys Marsh raised concerns that Frazer’s transfer from HMP Winchester had been unsafe. The following day, because of concerns about Frazer’s behaviour, including lying in the dark in his cell and refusing to engage with staff, he was placed on an ACCT, and this remained open until his death.

Frazer was also under the care of the mental health team at HMP Guys Marsh. On 21 January 2022, a psychiatrist at the prison changed Frazer’s anti-psychotic medication, however the coroner’s expert witness believed this was prescribed at a sub-therapeutic dose. 

On 8 February 2022 a mental health nurse requested an urgent psychiatry review of Frazer. In her referral she described that Frazer had dramatically declined and was refusing to engage with others. She noted that he was spending long periods in the dark with covers over his head, that he was not leaving his cell and was refusing meals. She noted his delusions and described the cell as being in an unhealthy state.

The following day Frazer was reviewed by a psychiatrist. It was recommended that Frazer’s anti-psychotic medication dosage be increased and that he should be transferred to a psychiatric hospital for inpatient mental health treatment. A GP at the prison reviewed Frazer the next day and endorsed the psychiatrist’s recommendation to transfer him to hospital. Both the Psychiatrist and GP found that Frazer lacked capacity to make decisions on his health and wellbeing. 

He was assessed and accepted by a clinician from the psychiatric secure hospital on 25 February 2022 and his transfer was scheduled for 7 March.

On 3 March, Frazer was told by a mental health nurse that he would be admitted to a psychiatric hospital. He responded by telling the nurse that the transfer would not be happening and then left the room. No ACCT review took place following the delivery of this news. 

Frazer was found dead in his cell in the early hours of 7 March 2022, before his transfer to the psychiatric hospital could be affected. 

Prevention of future deaths

At the conclusion of the inquest hearing, the coroner confirmed that she would be sending a Prevention of Future Deaths report to the following recipients: Minister of State for Prisons; the Secretary of State for Health and Social Care; the Director General of HM Prison and Probation Service; the Chief Executive Officer of NHS England; the Governor of HMP Guys Marsh; and the Chief Executive Officer of Unilink Software Limited – the company which provides the prisoner email service to English and Welsh prisons. 

The report, which will be sent within two weeks of the inquest concluding, will address a combination of national matters and issues specific to HMP Guys Marsh. These include:

  •          The systemic inequity between patients in the community and patients in prison when hospital admission is required for mental health treatment; 
  •          The lack of joint national policy between NHS England and HMPPS on self-neglect in the prison system;
  •          The lack of a national directory for use by prisons detailing healthcare provision available at each establishment; and 
  •          The lack of national guidelines on prison-to-prison handover.

Frazer’s mum, Tracey Fitter, said:

“I am thankful to the coroner and the jury for thoroughly considering all the evidence that has been presented over the course of the last three and a half weeks. For our family, the conclusion is bittersweet. While we are glad that the coroner will be writing a Prevention of Future Deaths report that could save other families the heartache we have experienced, sadly it has come too late for Frazer. 

“Frazer was an incredibly loyal, protective, and loving member of our family. He was selfless and put others ahead of himself regardless of consequences or impact to himself. He was a unique and one-of-a-kind person that touched many hearts with his warmth.

“Frazer always made us laugh with his funny jokes, impersonations, his love for singing rap music and his fun sense of humour. He never complained, was strong willed and had a sense of determination, and a cheeky infectious smile that was well-known to those that were able to truly get to know him. 

“Frazer had so much to give, and it goes without saying our family are still devastated by his death. We are trying to come to terms with the circumstances surrounding his death and what he endured in the months leading up to it. There is a huge hole in our lives that can’t be filled, and we miss him every single day.”

Maya Grantham, the solicitor representing Frazer’s Family, said:

“Frazer’s inquest has shone a light on just how unsafe prison is for someone as unwell as Frazer. The inquest heard evidence from healthcare witnesses who confirmed that, when they saw Frazer at HMP Guys Marsh, their view was that prison was unsafe for him, and that he needed to be in a hospital. Despite that recognition, Frazer remained in prison until his death. Not only did he remain in prison, his risk was not managed appropriately whist he awaited transfer to a Psychiatric hospital.

“The current “good practice” guidance requires that patients in prison be transferred to psychiatric hospital within 28-days of referral. Not only is that considerably longer than patients in the community usually wait, the 28-day timeframe is rarely achieved when the patient is in prison. 

“The current process of referral and transfer from prison to psychiatric hospital urgently requires reform. We are glad that the coroner has identified this systemic inequity in her Prevention of Future Deaths report and hope that this will bring about some change.” 

Related Areas of Law

We are top ranked by independent legal directories and consistently win awards.

+ View more awards