02 May HMP Woodhill’s negligence caused Daniel Dunkley’s death
Jury finds that failure by HMP Woodhill to learn from previous suicides caused the death by neglect of Daniel Dunkley.
Daniel Dunkley hanged himself at HMP Woodhill on 29 July 2016 and died on 2 August 2016. The jury at his inquest concluded on Friday that Daniel took his own life with neglect contributing to his death. They also found that the failure by HMP Woodhill to implement recommendations made after previous deaths caused Daniel’s death.
Daniel was the 16th prisoner to take his own life at Woodhill between May 2013 and August 2016. These previous deaths resulted in damning criticisms from the PPO over the failure of the prison to protect inmates from suicide, and made repeated recommendations to the prison on changes required to keep inmates safe.
The jury’s narrative conclusion at Daniel’s inquest made a number of severe criticisms of his care:
- The prison failed to carry out their suicide prevention procedures appropriately;
- There was an inadequate understanding of the importance of the prison’s suicide prevention procedures across the board;
- Staff failed to follow up Daniel’s non-attendance at an urgent mental health assessment on the day he hanged himself;
- There were failures of communication between members of prison staff and between prison and healthcare staff;
- There was a failure to respond adequately to Daniel’s threats to kill himself on the day he hanged himself;
- Mandatory observations were not carried out;
- The system for ensuring that staff carried out mandatory suicide-prevention observations was inadequate
- The staffing level on Daniel’s wing was inadequate and it was an error for inexperienced officers to be working on the wing alone;
- The failure by the prison to implement previous recommendations caused Daniel’s death.
HM Senior Coroner for Milton Keynes observed that the evidence had shown that at the time of Daniel’s death HMP Woodhill was an organisation at breaking point, compromising prisoner safety. He urged the Prison Service and the Government to support the current Governor to protect prisoners’ lives.
Richard Vince, the Deputy Director of the High Security Estate, and Ms Marfleet, the acting Governor of HMP Woodhill, accepted a litany of serious failings in Daniel’s case that were completely unacceptable.
In the days leading up to his death Daniel had frequently been tearful, low in mood, suicidal, and fixated on finding out the location of his girlfriend, who he believed was in hospital. This issue had caused him extreme emotional reactions, and he was referred for a mental health assessment three times in the two days before he hanged himself. Two days before his death he had been found with a noose around his neck, and the next day he had again threatened to kill himself.
On the day he was found hanging Daniel had been assessed by a Senior Officer as low risk. All witnesses at the inquest agreed that Daniel’s risk was clearly high at this point and his situation had significantly deteriorated over the past few days. Daniel threatened to kill himself twice in the next 1½ hours, and appeared agitated, worried, anxious and angry. Despite this, no review of Daniel’s risk was carried out and his observations were left at two per hour.
Daniel’s unit was short staffed for the afternoon shift and was being run solely by three officers who had all been employed for only 3 months. No system was in place to ensure that staff carried out the mandatory suicide prevention checks and no senior officer briefed staff on Daniel’s high risk state and threats to kill himself. In the early afternoon Daniel told an officer that he could not see a way out and was going to hang himself. The officer issued Daniel with disciplinary paperwork, left and told two of the three wing officers that Daniel had threatened to kill himself and that they should keep an eye on him and make sure his observations were up to date. The wing staff did nothing in response and Daniel was found hanging 40 minutes later. He had not been checked for almost 2 hours.
The acting Governor of HMP Woodhill accepted that prior to Daniel arriving at HMP Woodhill the prison had repeatedly assured the PPO that changes had been made. She accepted that if the prison had implemented these previous recommendations Daniel would probably not have died.