Inquest jury finds self-inflicted death at Woodhill prison was unlawful killing

Robert Fenlon, 36, died a self-inflicted death whilst on remand at Woodhill prison on 5 March 2016. Now an inquest jury has concluded that the reprehensible failures by two senior prison officers involved amounted to unlawful killing by gross negligence manslaughter. This is the first time an inquest has found that a self-inflicted death in detention amounted to unlawful killing, according to INQUEST’s data.

The jury found that Senior Officer (SO) Dyson and SO Cushion’s conduct was so exceptionally bad as to amount to a criminal failure. The jury also concluded that Robert’s death was contributed to by neglect (meaning a gross failure to provide Robert with basic care and attention), and that there was a serious failure by the prison to implement previous recommendations made after earlier deaths at Woodhill, and that this serious failure contributed to Robert’s death.

In the 48 hours prior to his death, Robert had attempted to hang himself and separately had been found with a ligature tied up in his cell.

At the time of Robert’s death, Woodhill prison had the highest number of self-inflicted deaths of any prison in the country. Robert was the second of seven men to take their own lives in the prison in 2016, and one of 28 since 2013 (see notes).

Robert was from Northampton. His family describe him as big hearted, someone who would help anyone. His daughter remembers his love of books and history. Robert had a long history of substance misuse and mental ill-health. On 15 October 2015, he was remanded to HMP Woodhill.

In February 2016, Robert passed a note under his cell door saying he was in total despair and contemplating suicide. Subsequently, a safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place.

Over the following week, Robert’s mental health deteriorated. He became distressed, extremely paranoid, delusional, and afraid that other prisoners might harm him. No referral was made to the mental health team, a failing that was described as serious by multiple witnesses at the inquest.

On 3 March 2016, officers found Robert ligatured in his cell. There was a conflict in the evidence heard at the inquest about whether a required review of the ACCT took place. SO Dyson insisted that a review took place in the cell soon after Robert was found, and that two members of healthcare attended and participated.

The healthcare staff flatly denied that any review took place, and the healthcare assistant told the jury that SO Dyson had sought to blame her for his own serious failings. The jury found that SO Dyson had lied: no ACCT review took place and the review document had been fabricated.

Witnesses at the inquest accepted that Robert should have been put under constant supervision. Instead, his risk was marked as ‘raised’ and his observations set to two per hour. SO Dyson accepted he did not even read the ACCT and that his approach was fundamentally flawed and woefully inadequate.

The next day, an officer again found Robert with a ligature tied up in his cell. The Senior Officer on duty – SO Cushion – finished his lunch before returning to the wing to see Robert. He told the inquest he did not conduct the necessary case review but had “a chat” with Robert instead.

SO Cushion did not read the ACCT but was aware of the attempted hanging the previous day. SO Cushion took none of the steps required by the ACCT, he recorded no change to Robert’s risk, and he took no further action to keep Robert safe. He accepted in evidence that these were very serious failures.

In the morning of 5 March 2016, officers found Robert unresponsive and ligatured in his cell. He was taken to hospital where he later died.

The jury concluded that Robert died by unlawful killing contributed to by neglect. They found that the following failures and inadequacies contributed to Robert’s death:

  • Failures to follows ACCT procedures, including at two earlier ACCT reviews;
  • An inadequate system to assign ACCT case managers;
  • Staff were inadequately trained in ACCT and conducting risk assessment;
  • None of the 43 recommendations made following previous deaths at Woodhill had been implemented by the time of Robert’s death in March 2016.

Robert’s family said: “We are very grateful to the Coroner and the jury for their care and attention, and to our legal team for their dedication and support over the last 8 years. We have waited a very long time to get justice for Robert. We knew from the outset that he was badly failed but we weren’t prepared for just how badly and how many people failed in their duty. Nor did we expect officers to lie, to cover up their wrongdoing and blame others. We are disappointed that the prison service tried to prevent the jury from expressing their view about unlawful killing despite the compelling evidence. It demonstrates the same closed thinking that prevented them from learning from those who died before Robert. This is an opportunity for the Prison Service to carry out some serious reflection and change their approach. We hope, for us and for other bereaved families, that they take that chance.”

Selen Cavcav, caseworker at INQUEST, said:We have been saying for years that state neglect and failure to learn lessons kills. This jury conclusion finally recognises this in the strongest possible terms. It was nothing short of criminal that so many vulnerable men in Woodhill were allowed to die preventable deaths.

Today we think of all 28 of the people who have died in this prison since 2013, and their families who have fought for justice and change.

Our failing systems of inspection and scrutiny are leading to repeated failures like this, which are costing countless lives. Bereaved people’s calls for change are being ignored. INQUEST is calling for a new way of responding to deaths in detention which would ensure recommendations arising are enacted: a national oversight mechanism to protect lives.”

Jo Eggleton, who represents Robert’s family, said:Robert’s daughter alongside her mother has fought tirelessly for 8 years to uncover the truth about her dad’s death. This conclusion shows why she was right to do so. The jury’s findings could not be more serious: it reflects the appalling way Robert was repeatedly failed by senior prison officers at a time when staff were well aware of the high number of self-inflicted deaths at Woodhill. Those running the prison were on notice of the repeated failings and should have taken urgent steps to stop this from happening. Although Robert died 8 years ago, HMIP’s Urgent Notification issued last year after finding Woodhill unsafe, suggests that many of the issues raised during this inquest are still ongoing today.”

Robert’s family were represented by DPG’s Jo Eggleton & Rachel Tribble and Jesse Nicholls from Matrix Chambers.

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