“Inadequate” diagnosis and treatment of an inmate’s mental health condition was among the probable causes of his suicide in prison, an inquest has found.

Frazer Williams, described as “loyal, protective, and loving” by his family, was a prisoner at HMP Lewes for four months.

In that time, his mental health deteriorated and he was monitored under Assessment, Care in Custody and Teamwork (ACCT) plan, which is part of the prison system’s suicide and self-harm safeguarding process.

The 28-year-old, who was an inmate in the prison in Brighton Road, Lewes, spent periods of his incarceration from June 4, 2021, to October 4 that year under constant supervision.

Frazer, from Andover, ended up taking his own life on March 7, 2022.

The Argus: Frazer Williams was 'loyal, protective and loving', his family saidFrazer Williams was 'loyal, protective and loving', his family said (Image: Family handout)

In a three-and-a-half week inquest at Dorset Coroner’s Court in Bournemouth, which concluded on May 17 this year, the court heard from a psychiatry witness.

In September 2021, while at HMP Lewes, Frazer was also diagnosed with bulimia and a personality disorder.

The psychiatry witness believed that, based on 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 October 4. However, he was remanded back into custody at HMP Winchester just three days later, on October 7. 

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

On January 14, 2022, Frazer was transferred under restraint to HMP Guys Marsh, a Category C men’s prison in Dorset.

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 January 21, 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 February 8, 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 Argus: 'Inadequate' care contributed to Frazer Williams' death, an inquest found'Inadequate' care contributed to Frazer Williams' death, an inquest found (Image: Family handout)

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 the capacity to make decisions on his health and wellbeing. 

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

On March 3, 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 March 7, 2022, before his transfer to the psychiatric hospital could be effected. 

In their conclusions given on Friday, May 17, the jury identified missed opportunities to improve Frazer’s mental health including inadequacies in the prison system’s suicide and self-harm safeguarding process ACCT.

At the conclusion of the inquest hearing, senior coroner for Dorset Rachael Griffin confirmed she would be sending a Prevention of Future Deaths (PFD) report to the Minister of State for Prisons and the Secretary of State for Health and Social Care, among others.

The report will address several issues covered in the inquest, including the systemic inequity between patients in the community and patients in prison when hospital admission is required for mental health treatment.

Frazer’s mum, Tracey Fitter, said: “While we are glad that the coroner will be writing a PFD 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.

“Frazer had so much to give, and it goes without saying our family are still devastated by his death. There is a huge hole in our lives that can’t be filled, and we miss him every single day.”

Maya Grantham, the solicitor for the family, said: “Frazer’s inquest has shone a light on just how unsafe prison is for someone as unwell as Frazer.

“We are glad that the coroner has identified this systemic inequity in her PFD report and hope that this will bring about some change.”

The solicitor's office declined to provide the reason for Frazer's jail sentence.