07 Aug Rajwinder Singh: Jury Finds Neglect Contributed to the Death of Father of Three at HMP Wandsworth

Before HM Assistant Coroner Bernard Richmond KC
Inner West London Coroners Court
23 July – 6 August 2025

CONTENT WARNING: This press release contains themes of self-harm and suicide

Rajwinder entered HMP Wandsworth on 9 June 2023, at a time when it was governed by Katie Price, and before Charlie Taylor issued an urgent notification. Rajwinder arrived with a Self-Harm and Suicide Warning Form (SASH) in his Personal Escort Record (PER), alerting the prison to his risk and recommending constant observation.  This was not read by either prison or healthcare staff and no ACCT was opened.

An ACCT was opened a few days later by healthcare on 12 June 2023 following extremely concerning behaviour and Rajwinder was placed on hourly observations.  Further acts of self-harm followed, steadily escalating, to tying a ligature, setting fire a mop in his cell and then to his own hair: this last act of self-harm led to his ACCT observations being increased to two an hour.  An examination of his ACCT revealed that observations were frequently missed, including entire days and nights without checks being recorded.  There were no required quality conversations levels set in his ACCT on any ACCT review. Throughout the life of his ACCT, the supervisor quality assurance checks were not done and it was accepted by the then Head of Safer Custody that there had been a failure of the ACCT system within HMP Wandsworth at both the individual and systemic level. Oxleas Healthcare made a series of admissions following a damning Root Cause Analysis, including that there was no equivalence of care. Rajwinder was on numerous medications, including pregabalin to manage the chronic pain he suffered from due to fibromyalgia. His medication was missed on a number of occasions due to prison resources, and his pregabalin was reduced without consultation with him or telling him, which caused him real distress. Oxleas had no choice but to admit that the one and only mental health assessment he had, carried out by an agency nurse on 20 June, who did not read his medical records, was poor.

Rajwinder complained about his cell conditions describing them as squalid and the Head of Safer Custody at the time, described the constant observation cell that Rajwinder was found hanging in as indecent; whilst another cell was said to be not fit for anyone, had no sink or access to water and should have been taken out of service.  Rajwinder was placed, alone, in a constant observation cell, with no TV or telephone, despite not being on constant observation.  An officer seconded from HMP Wakefield to HMP Wandsworth described how she almost left in the first week and found boxes filled with dead rats on the D wing landing where Rajwinder was housed.

The jury heard how on the evening of the 20 June 2023 Rajwinder was to be observed twice every hour. The inquest heard that there was no record of any handover from the prison officers to the OSG and the prison officers both left their shift before it officially ended, whilst cell bells were going off.  Two officers falsely recorded that checks had been completed on three different occasions. This was only revealed after the Prison and Probation Ombudsman (PPO) sought the CCTV.

That same night, Rajwinder pressed his emergency cell bell four times. Only one bell was answered within the required five-minute window. The final call went unanswered for 30 minutes.  When staff eventually came to Rajwinder’s cell he was unresponsive, he was taken to St George’s Hospital but tragically died five days later.

After hearing evidence for two weeks the jury concluded that Raj did not intend to take his life and died by misadventure contributed to by neglect. The jury also found that the following probably contributed in more than a minimal way to Raj’s death:

1. The reduction of his medication pregabalin and the failure to communicate this to Rajwinder;
2. The inconsistent provision of Rajwinder’s medication and the consequential effect that this had on his physical and mental health;
3. The failure to provide Rajwinder with adequate mental health support and;
4. The failure to answer Rajwinder’s cell bell within the required 5 mins on the night.

The jury also found that the failure to conduct the required ACCT observations on the night possibly contributed to his death.

Rajwinder’s wife Remi Masih expressed her devastation “There have been so many shocking failings. To hear an officer describe Raj’s cry for help when he first ligatured as ‘manipulative’ and the only mental health nurse who assessed call him a ‘faker’—is heartbreaking, on top of all their other failures. If they had just listened and treated him with dignity, he would still be here with me and our children.”

The family’s solicitor Christina Juman, of Deighton Pierce Glynn said: “Raj was let down time and time again in the 12 days he was at HMP Wandsworth, the failings are so stark that the Prison and Probation Ombudsman went so far as to state:

The failures in this case were voluminous and diverse. There were multiple opportunities for meaningful interventions within Mr Singh’s care that would have led to a different outcome, that were repeatedly missed. I do not make the following statement lightly, but I consider that had Mr Singh been sent to a different prison in 2023, not in such a state of crisis, he would almost certainly still be alive today.

The coroner will be making a PFD Report at the end of October.

HMP Wandsworth

Last year the HMP Chief Inspector of Prisons took the rare step of issuing HMP Wandsworth with an Urgent Notification in May 2024 after they found that “failings were evident in almost all aspects of the prison’s operation.”

However the most recent HMPI report in 2025 found that whilst there had been changes that: “improvements remained limited and fragile, and it was clear that outcomes across many areas were still concerning.”

ENDS

If you are affected by the issues in this release, Samaritans are available 24/7. Call 116 123 free, email jo@samaritans.org, or visit www.samaritans.org.

Notes for the media

Please refer to the Samaritans’ guidelines on reporting inquests:

https://www.samaritans.org/about-samaritans/media-guidelines/guidance-reporting-inquests/

1. Raj’s family are represented by INQUEST Lawyers Group members Christina Juman of Deighton Pierce Glynn solicitors, and by Maya Sikand KC of Doughty Street Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.
2. Other Interested Persons represented include, the Ministry of Justice, Oxleas NHS Foundation Trust, and three former officers from HMP Wandsworth and one current officer, each separately represented.
3. Request for photographs and further information should be directed to londonadmin@dpglaw.co.uk.

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