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Jury finds that failure by HMP Woodhill to learn from previous suicides caused the death by neglect of Daniel Dunkley
HM Coroner Tom Osborne
Milton Keynes Coroner's Office
18 – 28 April 2017
Daniel Dunkley hanged himself at HMP Woodhill on 29 July 2016 and died four days later in hospital. He was the 16th of 18 prisoners who have taken their own life at HMP Woodhill since 2013. The jury at his inquest concluded 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.
The Prison and Probation Ombudsman had previously given damning criticisms to HMP Woodhill over the 16 prior deaths and the failure of the prison to protect inmates from suicide. They made repeated recommendations 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.
The inquest into Daniel’s death heard from multiple witnesses, including senior managers, that the care afforded to Daniel involved significant, serious failings. 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. These included numerous serious flaws and glaring gaps in Daniel’s suicide prevention procedures.
The acting Governor of HMP Woodhill accepted that prior to Daniel arriving at 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.
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. 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. Daniel appeared agitated, worried, anxious and angry. Despite this, no review of his risk was carried out and his observations were left at two per hour.
Daniel’s unit was short staffed and was being run solely by three officers who had all been in the job 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 and Daniel was found hanging 40 minutes later. He had not been checked for almost 2 hours.
Deborah Coles, Director of INQUEST said:
“The unbroken pattern of Woodhill deaths reveals a systemic failure at a local and national level to act in response to critical inquest findings and recommendations for action. This raises serious questions about the accountability at senior management level of those responsible for prison health and safety.
HMP Woodhill and the prison service have repeatedly failed to implement recommendations in the face of a litany of failures. They have clearly ignored warnings about the risks to the health and safety of prisoners, and the necessary sanctions should be enacted against those responsible.
In a week when members of the European Committee on Torture revisited the UK because of their concerns about the state of prisons, all politicians need to address the issues behind this broken and dangerous system and the unacceptable death toll.”
INQUEST have been working with the family of Daniel Dunkley since August 2016. The family is represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Jesse Nicholls from Doughty Street Chambers.
NOTES TO EDITORS
For further information, please contact: Lucy McKay on firstname.lastname@example.org or 020 7263 1111
• HMP Woodhill currently has the highest number and rate of deaths in England and Wales.
• Daniel’s family, along with the family of Ian Brown have brought a judicial review (conclusion imminent) on the high number of deaths in Woodhill prison. The review was heard on 7 April 2017. The conclusion is due to be published early May.
• Ministry of Justice (MOJ) stats show the rate of self-inflicted deaths in prison has more than doubled since 2013.
INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
‘Lobbying that is based on thorough research and casework (such as that done by INQUEST), and focuses on specific issues, such as the deaths of children in custody, needs support.’
– New Philanthropy Capital, 'Trial and error: Children and young people in trouble with the law, a guide for charities'