Melvin Grant

This is a media release by Bhatt Murphy, reshared by INQUEST

On 20 October 2025 a jury in the Bedfordshire and Luton Coroner’s Court returned a narrative conclusion that Melvin Grant intended to end his life in his prison cell at HMP Bedford on 14 November 2023, and that the decision to downgrade his observation levels from constant to intermittent probably contributed to his death.

Melvin was a remand prisoner at HMP Bedford, having been transferred from HMP Thameside at the end of September 2023.

Evidence heard at the inquest suggested that he experienced a rapid deterioration in his mental health during the six and a half weeks he spent at HMP Bedford. By early November 2023 he had stopped taking his prescribed medications, including methadone.

He had also been struggling to contact family members via the prison telephone system, and his family had been unable to see him in person due to a problem with the prison visits booking line.

The jury found that at the relevant time Melvin was presenting with symptoms of acute psychosis including auditory hallucinations, paranoia, low mood and depression.

During the healthcare reception screening on his arrival at the prison, and during a later mental health assessment, Melvin stated that he had no history of self-harm. In fact he had seriously self-harmed in prison in 2014, but this inconsistency between his self reporting and the medical records was not picked up by staff.

The nurse who carried out Melvin’s mental health assessment on 13 October 2023 concluded that there was “no role for the mental health team” despite Melvin reporting that he was suffering from fluctuating mood, struggling to sleep and feeling suicidal, and that he wanted to engage with the mental health team.

Melvin seriously self-harmed on two occasions prior to the incident which caused his death. After the first incident on 9 November 2023, an ACCT (Assessment, Care in Custody and Teamwork; a process intended to protect prisoners at risk of self-harm or suicide) was opened.

On 13 November 2023 after a second serious self-harm incident, Melvin was placed on a constant watch. A prison officer who attended hospital with Melvin after this second incident recorded in his ACCT (Assessment, Care in Custody and Teamwork; a process intended to support prisoners at risk of self-harm or suicide) document that he had made clear to hospital staff that he did not wish to be alive as he was hearing voices in his head which were too much to bear.

During a further mental health assessment on 13 November 2023, Melvin disclosed that he was hearing voices in his head which had “become such a nuisance that the only way to stop them was by ending his life”, and that he had no plan to end his life but would wait for instructions from the voices.

This information was recorded in Melvin’s notes but not reviewed by the members of staff who attended the meetings where Melvin’s level of observations were decided. Neither this information, nor the notes made by the prison officer earlier in the day, was reviewed by the prison and healthcare staff who later decided to reduce Melvin’s level of observations.

Less than 24 hours after being placed on constant watch, at a meeting which lasted only 9 minutes, an ACCT review team of prison and healthcare staff decided to reduce his observation levels to four checks per hour.

At 21:38 on 14 November 2023 Melvin was discovered in his cell; the jury found that the self-harm injury he had suffered and the resultant brain injury caused his death seven days later. Whilst not found to be causative of Melvin’s death, the jury identified a “significant delay” by prison control room staff to call an ambulance after staff had called the emergency ‘code blue’ over the radio, and described the emergency response by healthcare staff as “extremely inadequate”.

NHFT have admitted a number of ‘shortcomings’ in the medical response from healthcare staff, including that there was a failure to follow Trust policy to take an ABCDE (airway, breathing, circulation, disability, exposure) approach to assessing Melvin, that the senior nurse was out of date for Immediate Life Support Training and failed to take charge of the resuscitation efforts.

Melvin’s brother Morris Grant said: “Melvin was failed by the systems that were supposed to keep him safe. It was deeply frustrating to hear at the inquest how many of those responsible for looking after Melvin took no initiative to gather or share relevant information, and appeared to 'pass the buck' or rely on others rather than taking responsibility themselves. The length of time that it took for Melvin's inquest to be heard was also not only very distressing for us as a family, but allowed many witnesses to respond to questions by saying that they did not remember. No family should have to endure such a lengthy wait for answers about what happened to their loved one.”

Selen Cavcav, Senior Caseworker at INQUEST, said: “Melvin needed care and support. Instead, his death is a stark reminder that prisons cause severe distress. In just six and a half weeks on remand at HMP Bedford, where inspectors flagged rampant racism, Melvin’s mental health rapidly declined. His distress was dismissed and his needs ignored. Too many Black people remain locked up in prison where they face racism and neglect on a daily basis. Without urgent intervention, the risk of further deaths remains. The government must invest in community-based alternatives that address the root causes of harm, not more prisons.”

Melvin’s family are represented by Joanna Khan of Bhatt Murphy and Abimbola Johnson of Doughty Street Chambers. For further information or request for comment please contact Joanna Khan at Bhatt Murphy on 020 7729 1115 or j.khan@bhattmurphy.co.uk