Surendrakumar Patel

Director General of Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ

11 May 2026

James Puzey 
Assistant Coroner for 
Worcestershire 
Coroner’s Court 
Martins Way 
Stourport-on-Severn 

Dear Mr Puzey, 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR SURENDRAKUMAR 
PATEL 

Thank you for your Regulation 28 report of 10 March 2026 following the inquest into the 
death of Surendrakumar Patel at HMP Hewell on 31 October 2024. I am responding on 
behalf of His Majesty’s Prison and Probation Service (HMPPS). 

I know that you will share a copy of this response with the family of Mr Patel, and I would 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. 

Following evidence heard at the inquest you raised concerns directed to both HMPPS and 
Practice Plus Group (PPG). I understand PPG will respond to those issues relating to the 
delivery of healthcare at HMP Hewell, for which they are responsible. I am therefore 
responding to the issue relating to HMPPS. 

You identified concern regarding the understanding among prison staff of the PPG food 
refusal policy at the time and specifically the requirement for staff to inform the next of kin in 
circumstances where a prisoner has been identified by healthcare as refusing foods and/or 
fluids.  Whilst not fully explored during the inquest hearing, I can assure you that appropriate 
consideration of contact with the next of kin was given, as part of operational consideration of 
Mr Patel’s wellbeing. Mr Patel initially indicated that he did not wish his daughter to be 
contacted but when he later expressed a wish to write to her, this was promptly supported 
and facilitated by staff. 

 
 
 
 
 
 
 
 
 
  
  
  
 HMPPS recognises the importance of family involvement at times of increased vulnerability 
including where a prisoner is refusing food and/or fluid.   A joint review of HMP Hewell’s food 
refusal policy has since been undertaken in partnership with healthcare colleagues. This 
review has strengthened clarity around the consideration of contact with next of kin when a 
healthcare professional identifies a serious risk to an individual’s health. Following the 
completion of the review, awareness sessions will be delivered to prison and healthcare staff 
involved in managing and supporting prisoners who refuse food, including contact with the 
next of kin, to support consistent, compassionate, and informed practice. 

Thank you again for bringing your concerns to my attention. I trust that this response 
provides assurance that action is being taken to address the matters that you have raised. 

Yours sincerely, 

Director General of Operations

FAO Mr James Puzey 
HM Assistant Coroner for Worcestershire  

Trust Headquarters 
Corporation Street 
Stafford 
ST16 3SR 

29 April 2026 

Dear Mr Puzey, 

Thank  you  for  your  Regulation  28  Report  following  the  inquest  into  the  death  of  Mr 
Surendrakumar Patel. I would like to begin by expressing our condolences to Mr Patel’s family 
and acknowledging the seriousness of the concerns you have raised. 

Midlands  Partnership  University  NHS  Foundation  Trust  (MPFT)  has  carefully  reviewed  the 
findings of the inquest and the matters of concern identified within your report. 

MPFT Role and Involvement 

MPFT provides integrated mental health and psychosocial substance use services within HMP 
Hewell.  Primary  responsibility  for  physical  healthcare,  including  nutritional  monitoring, 
implementation  of  food refusal  policies,  and  initial  assessment  of  capacity  in  the  context  of 
food refusal, sits with the primary healthcare provider, Practice Plus Group (PPG). 

Mr Patel was referred to mental health services at reception on 15 October 2024. Following 
multidisciplinary discussion on 24 October 2024, a psychiatric assessment was arranged for 
29 October 2024, which was the earliest available appointment within the service. 

There  is  no  evidence  in  the  medical  records  to  suggest  that  a  request  for  a  more  urgent 
psychiatric assessment was made or that the referral was escalated to reflect an immediate 
or acute mental health crisis. 

In line with the primary healthcare provider’s food refusal policy, mental health involvement 
was sought, and Mr Patel was assessed by a mental health practitioner on 24 October 2024 
following identification of concerns. 

Clinical Context 

Our review indicates that Mr Patel’s presentation was clinically complex and evolved over a 
short period of time. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In particular: 

•  His oral intake fluctuated, with evidence of intermittent consumption of food and fluids 

during the period in question 

•  There was no clear diagnosis of a depressive disorder or other acute mental illness 

identified by clinicians 

•  His  presentation  was  at  times  understood  as  distress  related  to  imprisonment, 

alongside possible volitional elements in his reduced intake 

•  He had significant pre-existing physical health difficulties affecting his ability to eat 

It is also important to note that Mr Patel’s oral intake was not consistently absent in the days 
preceding  his  hospital  admission.  Records  indicate  intermittent  consumption  of  food  and 
fluids, including in the period 24 – 26 October 2024. His clinical presentation was therefore 
one of reduced and inconsistent intake rather than sustained total refusal. 

The  inquest  concluded  that  Mr  Patel  died  from  a  lower  respiratory  tract  infection,  with 
malnutrition contributing in the context of self-neglect. The inquest did not make a finding that 
Mr Patel lacked mental capacity in relation to his decision-making during this period and the 
Trust agree with that finding. This reflects the clinical complexity of his presentation and the 
challenges  in  distinguishing  between  physical  illness,  psychological  distress,  and  volitional 
behaviour. 

Psychiatric Assessment and Escalation 

We note the concern raised regarding the timeliness of psychiatric assessment. 

Mr Patel was discussed at the multidisciplinary team meeting on 24 October 2024, at which 
point referral for psychiatric assessment was agreed and an appointment was arranged for 29 
October 2024, the earliest available appointment within the service. 

Prior to this, Mr Patel had been assessed by a mental health practitioner on 24 October 2024. 
Mental  health  assessment  therefore  occurred  within  an  appropriate  timeframe  following 
identification of concerns. 

At the time of assessment, his presentation was not indicative of a clear acute mental illness 
requiring  urgent  psychiatric  intervention.  In  addition,  records  indicate  that  from  24  October 
onwards he was taking fluids and intermittently consuming food. 

Taken together, the clinical picture during this period did not demonstrate features that would 
ordinarily warrant a more urgent psychiatric assessment. 

It is also relevant that the period between the reported onset of food refusal (21 October 2024) 
and  multidisciplinary  review  (24  October  2024)  was  brief,  and  during  this  time  Mr  Patel 
remained  under  active clinical  observation,  including  management through ACCT and food 
refusal processes. 

In this context, the scheduling of psychiatric assessment within the earliest available timeframe 
following multidisciplinary discussion was consistent with the clinical information available at 
the time. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Food Refusal Policy and Capacity Assessment 

We acknowledge the concerns raised regarding awareness and implementation of the food 
refusal policy. 

It is important to clarify that: 

•  The food refusal policy referenced is held and operationalised by PPG. 
• 

Initial  identification  of  food  refusal,  implementation  of  the  policy,  and  assessment  of 
capacity at the point of refusal sit within PPG. 

MPFT  recognises  that  where  policies  held  by  partner  organisations  have  implications  for 
mental health services, there must be clear engagement to ensure shared understanding and 
effective implementation across providers. 

Learning and Actions 

MPFT will take the following actions in response to the concerns identified: 

1.  Policy Engagement with Practice Plus Group 

MPFT will ensure that arrangements are in place for policies developed or updated by 
the primary healthcare provider that have implications for mental health services to be 
shared in advance for clinical input and alignment. 

2.  Targeted Dissemination and Awareness 

MPFT  will  ensure  that  relevant  policies  impacting mental  health practice are  clearly 
disseminated  within  its  teams,  with  explicit  guidance  on  roles,  responsibilities,  and 
expected interfaces with primary care services. 

These actions will be implemented within three months and overseen through existing clinical 
governance structures. 

Conclusion 

MPFT is committed to learning from this case and to working with system partners to ensure 
clarity of roles, responsibilities, and communication in the management of patients presenting 
with complex combinations of physical and mental health needs. 

We hope this response provides assurance that appropriate and proportionate steps are being 
taken to address the concerns identified. 

Yours sincerely 

Chief Executive

Practice Plus Group 
Building 1330 
Arlington Business Park 
Theale  
Reading 
RG7 4SA 

HM Assistant Coroner Mr James Puzey 
Coroners Court  
The Civic, Martins Way,  
New St 
Stourport-on-Severn,  
DY13 8UN 

28 April 2026 

Dear Sir, 

Regulation 28: Prevention of Future Deaths report, Mr Surendra Patel (Dec’d) 

Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus 
Group following the Inquest into the death of Mr Surendra Patel (Dec’d). Practice Plus Group 
would like to express its condolences to Mr Patel’s family and friends. 

Practice  Plus  Group  is  the  lead  provider  of  healthcare  services  at  HMP  Hewell.  There  is  a  sub-
contracting arrangement in place with Midlands Partnership NHS Trust (“MPFT”) in respect of the 
provision of mental health services, whom have provided a separate response to the issues raised 
in the Prevention of Future death report as have the Ministry of Justice on behalf HMP Hewell.  

This  response  addresses  the  matters  of  concern  insofar  as  they  relate  to  Practice  Plus  Group 
only.  

Practice Plus Group welcomes the opportunity to respond to the concerns raised by HM Assistant 
Coroner.  The  circumstances  of  this  case  were  complex.  Mr  Patel  arrived  in  prison  in  a 
malnourished  state  which  the  Inquest  learnt  had  been  an  ongoing  chronic  issue  for  him  dating 
back at least one year. Further, and whilst Mr Patel was remanded at HMP Hewell, at no time was 
he  found to  lack  capacity to refuse food  and  fluids  and  /or proposed medical  assessments.  This 
meant that, when assessments and food and fluid was offered and declined, the healthcare staff 
were required, pursuant to the Mental Capacity Act 2009, to respect the wishes of Mr Patel. This 
was reflected in the conclusion reached by the Jury that Surendra Patel died from natural causes 
contributed to by self-neglect by malnutrition.  

The  Inquest  revealed  that  both  the  primary  healthcare  staff  (Practice  Plus  Group)  and  mental 
health  staff  (MPFT)  responded  to  Mr  Patel  with  sensitivity,  care  and  compassion  following  Mr 
Patel’s decision to refuse food and fluid. It is also of note that the clinical reviewer commissioned 
by  NHSE  to  assist  with  the  investigation  undertaken  by  the  Prison  &  Probation  Ombudsman’s 

[Company number] 

    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 investigations  confirmed  at  the  Inquest  that  the  standard  of  care  provided  to  Mr  Patel  whilst  he 
was in prison was good.     

The clinical reviewer did however identify areas where improvements could be made and some of 
these recommendations chime with the concerns listed below.  

Matter of Concern 1 

Amongst Healthcare  staff,  both  MPFT  and  PPG, there  was  a  general  lack  of awareness  of 
the terms of the then current PPG food refusal policies. This took the form of: 

a.  A  failure  to  appreciate  that  once  food  refusal  had  begun.  A  mental  capacity 

assessment should be undertaken as soon as practical: 

Response  

Following  notification  of  Mr  Patel’s  refusal  to  eat  and  drink  from  22  October  2024,  a  plan  was 
already in place for Mr Patel to be reviewed by a GP on 23 October 2024. This had been arranged 
following  a  Multi  Professionals  Clinical  Case  Clinic  (“MPCCC”)  It  was  not  possible  for  the  GP 
consultation to take place on that date and so 
 GP, was tasked with reviewing Mr Patel 
on 24 October 2024. He did this and would have gone on to complete a formal Mental Capacity 
Act  Assessment,  but  Mr  Patel  refused  to  allow 
  to  examine  his  neck  wound  and 
terminated the consultation before 

 could complete the planned assessment.   

 explained when giving evidence at the Inquest that he had no reason to doubt that Mr 
Patel  had  capacity  to  refuse  food  and  fluids. 
  was  concerned  however  as  he  found  it 
difficult to reconcile the reason Mr Patel was remanded into custody with the presentation of the 
man he met on 24 October 2024.  

spoke with the attending consultant 
The following day, and at the next weekly MPCC, 
psychiatrist  employed  by  MPFT  about  Mr  Patel. 
  asked  the  attending  consultant 
psychiatrist to assess Mr Patel urgently. Arrangements were made for the psychiatrist to assess 
Mr Patel on 29 October 2024 which was the very next day the consultant psychiatrist was due to 
attend  HMP  Hewell.  The  standard  expected  time  for  a  patient  to  be  seen  following  an  urgent 
referral to a consultant psychiatrist at HMP Hewell was 14 days at that time.  

The  arrangements  made  were  for  the  psychiatric  assessment to  be  undertaken  within  7 days  of 
the primary healthcare team being notified of Mr Patel’s Unfortunately, Mr Patel was admitted to 
the local Acute Hospital on 27 October 2024. Therefore, the assessment never took place.  

It is of note that the clinical reviewer commented when giving evidence at the Inquest that she did 
consider the referral had been made as soon as was practically possible and, in any event, even if 
a formal Mental Capacity Act assessment had taken place, she was not convinced it would have 
made any difference to the care provided.  

b.  A failure to consider hospital transfer for patients in a physically weak state due 

to weight loss  

Response  

Practice  Plus Group  accept  with the  benefit  of  hindsight that transfer to  hospital  may  have  been 
considered a couple of days earlier following the first time Mr Patel consented to having his weight 
checked on 25 October 2024. The case was complex in that, at no time during the period that Mr 
Patel refused food and fluid did his vital observations give any cause for concern.  The jury heard 

[Company number] 

    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 during the Inquest that, whilst Mr Patel was eating and drinking very little, Mr Patel was drinking 
small amounts of fluid during the period of food and fluid refusal and that by 25 October 2024 he 
had  reversed  his  decision  to  refuse  food  and  fluids  such  that  Mr  Patel  had  started  to  eat  small 
amounts of food.  

c.  A  failure  to  expedite  full  medical  assessment  by  a  senior  registered  Healthcare 
professional:  in  particular  assessment  by  psychiatrist  of  the  reasons  for  food 
refusal in circumstances where a wear a prisoners physical health puts his long-
term health or survival at risk. 

Response  

This concern is in part addressed in response 1a above. However, MPFT did confirm during the 
Inquest that, since the death of Mr Patel, the number of consultant forensic psychiatrics available 
to  attend  HMP  Hewell has  increased. It  is  now anticipated that  in  urgent  circumstances  such  as 
the scenario described above, it would now be possible for a psychiatric review to take place in 3 
days. HM Assistant Coroner also heard during the Inquest about the current business case which 
has been sent to NHSE seeking to increase staffing levels across both primary care and mental 
health  care  which  will  also  assist  in  ensuring  the  timeframe  in  referral  to  assessment  may  be 
expedited even further.  

d.  A failure to consider an advocate for family contact 

Response 

Healthcare  staff  do  consider  whether  it  is  appropriate  to  contact  family  members  to  support  the 
patient through a period of food and fluid refusal. In this case, the evidence heard at the Inquest 
was that whilst the family raised concerns that they were seeking to contact the prison, the prison 
was  unable  to  find  any  evidence  to  confirm  such  contact  was  being  sought.  This  was  not 
something  Practice  Plus  group  had  any  knowledge  about  or  was  able  to  assist  the  Assistant 
Coroner with.  

So far as Practice Plus Group is concerned, Mr Patel did not request any family support.  Mr Patel 
told  the  nursing  staff  that  his  only  external  support  had  been  his  wife  and  that  he  was  not  in 
contact  with  his  daughter  at  the  time  he  entered  HMP  Hewell.  Therefore,  the  need  to  act  as  an 
advocate for family contact did not arise in this specific case.  

Had  family  contact  been  sought either by Mr  Patel,  or considered  to  be of  benefit to Mr  Patel,  it 
would  have  been  necessary  to  consult  with  the  prison  before  any  final  decision  was  made  to 
contact the family owing to the nature of the index offence which Mr Patel had been charged and 
remanded into prison for.     

Action:  

The factual matrix leading to Mr Patel’s transfer to hospital on 27 October 2024 was complex. Mr 
Patel was not a typical prisoner who refuses food and fluid in that he was not refusing food and 
fluid to influence a decision or outcome to improve his incarceration at HMP Hewell. He arrived at 
HMP in a malnourished state owing to other physical health co-morbidities. At no time was there 
any clinical reason to believe that Mr Patel may lack capacity to refuse food and fluids and/or any 
other aspects of the care provided to him which, in the main, he consented to.  

This does not mean that Practice Plus Group has not reflected on this case. The outcome of the 
Inquest follows a period whereupon the food and fluid refusal pathway has robustly been tested 
and, as a result, Practice Plus Group considers it to be robust and fit for purpose regardless of the 

[Company number] 

    
 
 
 
 
 
 
 
 
 
 
 
 
 reason for the food and fluid refusal. In addition to local feedback to the primary healthcare staff at 
HMP Hewell following the outcome of the Inquest, Practice Plus Group has planned to roll out a 
series of talks nationally across the Group in July 2026 to feedback on the recent high profile food 
and fluid cases they have been involved in, and to reinforce the need to follow the food and fluid 
pathway in full.    

In  summary,  Practice  Plus  Group  is  committed  to  providing  a  high-quality  healthcare  service  at 
HMP  Hewell  and  are  doing  everything  we  can  to  ensure  those  detained  there  are  as  safe  as 
possible and receive the best quality care. We are deeply sorry that Mr Patel died following care 
from  our  service,  and  we  will  ensure  that  the  lessons  learnt  are  not  just  implemented  at  HMP 
Hewell but across Practice Plus Group’s services. 

We trust that the above responses provide the information that you require but please do not 
hesitate to contact us if Practice Plus Group can be of any further assistance.  

Yours faithfully 

Medical Director  
Health in Justice 
Practice Plus Group 

On behalf of Practice Plus Group 

[Company number]