Oxfordshire coroner says HMP Bullingdon must make changes after death of Daniel Davey

Paedophile Daniel Davey died in jail after taking his medication back to his room, stashing it away, and taking a toxic dose in one night.

Now, Darren Salter – Oxfordshire's lead coroner – will send a letter to the prison and care providers asking them to put things in place to ensure it does not happen again.

He will issue a 'regulation 28' which is a letter written to an organisation or person by a coroner to say that action is needed after a death.

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Mr Salter told the Oxfordshire Coroners Court yesterday, at the final day of the inquest, that he will raise the issue of medication allowed in the rooms of prisoners – especially those with mental health issues who are under the special prison watch scheme.

He will also tell the prison that officers should be able to search the room for medication, and take it away if they need to.

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Instead, at the moment, officers can take away weapon-like sharp objects – but not medication.

He explained that taking it away will bring its own risks, but said: "It needs to be that if there is an issue, they can liaise quickly with healthcare and put a plan in place – like the search of a cell."

The advice will be sent to the prison as well as healthcare providers like Care UK.

It comes after the jury concluded that Davey 'took the pills on purpose', but that health care teams failed to share important information and review the risk he was to himself.

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In the statement read to the rest of the court, the jury explained that they had come to a 'narrative conclusion' about the death of the sex offender – who was one month in to his 10-year and six-month sentence for sexually abusing a 5-year-old boy.

It went on: "HMP Bullingdon failed to preform a search of Mr Davey's cell.

"Health care failed to share information of Mr Davey."

During the inquest, the court has heard how Davey self-harmed days before overdosing in his cell.

He had also been taken off the monitoring scheme, which made sure staff at the prison asked him if he was okay every half an hour.

The court also heard from a mental health nurse in charge of 21-year-old Davey, who explained that he had 'laughed' about a 'secret plan' but showed no other signs of being depressed or 'feeling suicidal'.

The former McDonald's worker had also talked to staff about moving to another prison, HMP Grendon, a category D prison which is closer to his family.

Last week, the jury were told how he had changed his medication in the run up to his application to move from the Bicester prison.

Concluding the inquest, the jury said: "He had been taken off medication based on 'misleading information' but he had not been checked by a medical professional."

The family said: "‘We are grateful to the jury for seeing Daniel as the vulnerable young man that he was. They have been damning in their conclusion about the care provided to Daniel from both prison and healthcare staff at HMP Bullingdon. We hope that his unnecessary death improves the care for those in HMP Bullingdon and prevents another family having to go through what we have".