Medical staff were unable to inspect him due to his ‘bizarre’ behaviour
HMP Nottingham and nearby housing in Perry Road, Sherwood. (Image: Joseph Raynor/Nottingham Post)
A 59-year-old man who died in the care of HMP Nottingham was not medically inspected once in his six-day stay.
Multiple attempts to give Henry Benoi-Davies, 59, a medical screening were made.
But due to reports that he seemed intoxicated and was seen acting in a ‘bizarre’ manner, nurses left him to his own devices after putting him in the segregation unit.
Benoi-Davies was remanded into prison custody and charged with burglary and assaulting a police officer on March 17, 2022, yet when he arrived, he refused to leave the van or take part in a reception health screen.
He was moved to the segregation unit due to his ‘disruptive’ behaviour and spent most of the six days he was in HMP Nottingham “naked in his cell” while refusing to communicate with staff.
The lack of a health screening ultimately meant Benoi-Davies was not referred to a GP, and his community records were not checked.
Despite attempts to do the checks every day, Benoi-Davies died of heart disease on March 23, 2022.
Nurses checked on Benoi-Davies’ cell several times throughout his short stay at the prison, finding him naked on numerous occasions.
The day before he died, he refused to cooperate, and officers were not able to move him, so his screening was booked for the next day.
One minute after he was given his food on March 23, officers checked his cell to find Benoi-Davies lying on the floor unresponsive.
The Prison & Probation Ombudsman investigated his death and issued an action plan for improvements at the prison for patients who may not want to cooperate with staff.
A clinical review found that heart abnormalities may have been identified if pulse and blood pressure readings had been taken.
In the report, they said: “We are concerned that after repeated attempts to carry out a reception healthscreen, no alternatives were considered to ensure continuity of care.”
The recommendations for the then-head of healthcare at the prison, Nottingham Healthcare NHS Foundation Trust, were as follows:
To ensure that processes are in place to enable reception screening staff to make all reasonable attempts to secure and use past health care records to support reception screenings and ongoing care.Undertaking an immediate review into the actions of nursing staff between March 17 and March 23 in 2022.Review why a GP referral cannot be made until a reception screen has been completed and implement any potential improvements identified.That all healthcare staff receive training and regular updates about the Mental Capacity Act 2005.As well as to ensure that all staff make full and accurate records of any observations they have or have not completed on prisoners, after it was found that a number of Henry’s healthcare records were simply copied and repeated, without a record of how the inmate appeared physically, apart from the fact that he was naked.
Henry Benoi-Davies is the seventh prisoner to die at HMP Nottingham since 2020. Of the previous deaths, five were from natural causes, and one was self-inflicted. Yet the investigation found there were no similarities in the investigation into Henry’s death and the previous deaths.
A spokesperson for Nottingham Healthcare NHS Foundation Trust said: “We once again offer our sincere condolences to Henry’s family and friends, and we apologise for aspects of his care that did not meet the standard he deserved.
“The Trust accepted the Prisons and Probation Ombudsman’s recommendations in 2022 and implemented a programme of changes in response.
“Although healthcare services at HMP Nottingham moved to a new provider in November 2025, we remain committed to supporting them as they continue to build on the improvements already made.”