Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0618, written 10 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Dec 2025 |
|---|---|
| Reference | 2025-0618 |
| Deceased | Mesut Olgun |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 26 January 2026 David Reid HM Senior Coroner for Worcestershire HM Coroner’s Court Martins Way Stourport-on-Severn DY13 8UN Dear Mr Reid REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR MESUT OLGUN Thank you for your Regulation 28 report of 10 December 2025 following the inquest into the death of Mesut Olgun at HMP Hewell on 14 June 2018. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS). I know that you will share a copy of this response with Mr Olgun’s family, and I would firstly like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have raised concerns regarding the availability of ligature resistant (LR) cells, formerly known as safer cells, at HMP Hewell. HMPPS is committed to reducing the risks of self-harm and self-inflicted deaths as far as possible, both through the design of the built environment and the processes by which staff support prisoners. LR cells are an important measure in reducing these risks, and we aim to build new prisons and wings to this standard. However, much of the existing prison estate predates the introduction of the LR standard which means that some prisons currently have very few such cells, or none at all. At present, HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments, which were selected on the assessed levels of risk at the time. We are hopeful that further installations will be possible in 2026/27, again prioritising locations with the highest assessed level of risk. It is important to emphasise that an LR cell on its own cannot eliminate risk. The term “ligature-resistant” replaced “safer cell” to reflect the reality that prisoners may still find other means to self-harm. Staff guidance makes clear that LR cells are a valuable measure, but they must be used alongside other forms of support. Where LR cells are unavailable, or where moving a prisoner could increase risk, these alternative measures remain essential. Nonetheless, HMPPS’ ongoing ambition is to strengthen this approach further by expanding LR cell provision wherever resources permit. To support individuals at risk of self-harm or suicide, HMPPS uses the Assessment, Care in Custody, and Teamwork (ACCT) case management approach, with the purpose of an ACCT being to identify an individual’s risks, triggers and protective factors, and to put in place a care plan to provide individual, person-centred support to address issues and reduce risk. As part of any ACCT case review, those involved will consider a range of measures to mitigate risk, including the prisoner’s location and, where appropriate, considering a move to a cell better suited to managing their level of risk. As noted in your report, HMP Hewell has two LR cells within the segregation unit which will be suitable to use for many prisoners. In addition, as described above the prison will use other important measures to help keep people safe, including constant supervision for those at the highest level of risk. At present, HMP Hewell has three constant supervision cells available across the main residential areas, ensuring that at-risk individuals can receive close and continuous support when needed. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter. Yours sincerely, Interim Director General of Operations
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