Mesut Olgun: Prevention of future deaths report
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Date of report: 10/12/2025
Ref: 2025-0618
Deceased name: Mesut Olgun
Coroner name: David Reid
Coroner Area: Worcestershire
Category: Suicide (from 2015)
This report is being sent to: HM Prison and Probation Service
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The Minister of State for Prisons, Probation and Reducing Offending, Ministry of Justice | |
| 1 | CORONER I am David Reid, HM Senior Coroner for the coroner area of Worcestershire |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION AND INQUEST on 20 June 2018 I commenced an investigation and opened an inquest into the death of Mesut Olgun aged 30. The investigation concluded at the end of the inquest on 08 December 2025. The conclusion of the inquest was in two parts: 1) Narrative conclusion – Mesut Olgun died as the result of suicide. 2)Questionnaire: 1. on the night of 7th-8th June 2018, between 2115hrs and 0610hrs, did the operational support grade fail to carry out the majority of the 36 ACCT observations on Mr Olgun which he was required to carry out at the rate for four per hour? YES 2. If YES, did that failure possibly cause or contribute to Mr Olgun’s death? YES 3. When Mr Olgun, was first discovered [REDACTED] in his cell on the morning of 8th June 2018, was a Code Blue emergency called at the earliest opportunity? NO 4. If NO, did that failure possibly cause or contribute to Mr Olgun’s death? YES |
| 4 | CIRCUMSTANCE OF THE DEATH On 6 June 2018, whilst being arrested, Mr Olgun caused himself significant injuries [REDACTED]. While in police custody, he was assessed as being at a high risk of harming himself again, and voiced an intention to kill himself several times. On 8 June 2018, Mr Olgun was seriously injured [REDACTED] in his prison cell at HMP Hewell. On 14 June 2018, Mr Olgun died from these injuries at Alexandra Hospital, Redditch. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstance it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: In his evidence to the inquest, the current Head of Safety at HMP Hewell confirmed that the prison had two “safer cells” (intended to reduce the risk [REDACTED]), but that these were both located within the prison’s segregation unit. He agreed that it would not be appropriate for a new prisoner like Mr Olgun, who had been identified as high risk of self-harm and for whom an ACCT document had been opened, to be located on the segregation unit on his first night in prison. The cost of converting a cell into a “safer cell” is said to be in the region of £70000 for which funding would have to be sought from H.M Prison and Probation Service, but HMP Hewell has not made any bid for such funding since Mr. Olguns death 7.5 years ago/ The Head of Safety at the prison also confirmed in evidence that the two available “safer cells” have been used to house prisoners within the segregation unit who are thought to be at an increased risk of suicide or self-harm. This would suggest that the prison accepts in principle that such cells have a meaningful role to play in reducing such risk. I am concerned that as long as “safer cells” are not made available away from the segregation unit at the HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, (and/or your organisation) have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the February 04, 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested a) [REDACTED] & partners – representing Mr. Olgun’s family b) [REDACTED] Government Legal Department – representing HMPPS c) [REDACTED] Hill Dickinson LLP – representing Practice Plus Group d) [REDACTED] & Co LLP – representing GEOAmey e) [REDACTED] Legal Services, West Mercia Police f) [REDACTED] I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | 10/12/205 David Reid HM Senior Coroner for Worcestershire |