7 October 2021

Before HM Senior Coroner Tom Osborne
Milton Keynes Coroners Court
20 – 29 September 2021

Taras Nykolyn died in a brutal and sustained attack in what was supposed to be one of the prison system’s most secure units. He was killed in a planned attack by three other prisoners in the Managing Challenging Behaviour Strategy (“MCBS”) unit at HMP Woodhill on 5 June 2018. An inquest has concluded identifying serious issues.

Evidence was heard that Taras’ attackers were apparently just “bored” (as they put it) and frustrated after a planned move to another prison had been cancelled days earlier. The prisoners – all of whom had recent records relating to serious violence against other prisoners as well as against staff – obtained and smuggled two “shanks” on to a caged exercise yard. These consisted of razor blades and improvised handles. They also obtained a ligature. These were used over the course of 28 minutes while staff looked on. The ferocity of the violence, the number of the perpetrators, and the absence of specialist resources meant that it was impossible for staff to go in earlier.

Several officers were unable to give evidence because they were too traumatised by what they saw over the course of that 28 minutes. The rest spoke of its impact on them. Several spoke of how particularly disturbing it was that the prisoners returned repeatedly to the body, even after Taras was obviously dead, mutilating it further. Some suggested that it appeared they were trying to remove his head.

Following the disclosure of an internal lesson learning review (which senior officers in the prison had not seen until just before the hearing started) the Ministry of Justice accepted that the standard of searching on the unit had been poor, that risk assessments of prisoner association had not been sufficiently quality assured, and that there should have been a more rigorous assessment of exercise on the yard. The latter might have included a review of the use of dogs, PAVA spray, and pyrotechnics. None of that had been available or authorised for use by the team who had to be assembled at speed.

At the conclusion of the hearing the Ministry of Justice also apologised for these failures, expressing its deep regret. The apology was addressed to Taras’s family, but also to the court, and to the prison officers.

The jury went further. In its narrative conclusion it found that the poor quality of the searching, and of the risk assessments, had led to Taras’s death. The jury also expressly recorded findings about:

• Insufficient re-training of staff in search techniques, with staff having to rely on initial training received over many years previously.
• A failure in the control and monitoring of razor blades issued to prisoners.
• Failures of dynamic risk assessment including irregular scheduling; inconsistent attendance at meetings; failures of information sharing; insufficient detail and inaccuracies in minutes; and inadequate review of the relevant decisions both locally and centrally.
• The absence of resources, and contingency planning, for an attack on the yard.

These findings followed evidence about staff shortages at Woodhill, which meant that officers had to be brought into the unit from elsewhere in the prison. This meant that, although those centrally responsible for the MCBS unit believed staff had been specifically selected and trained for working in this particularly dangerous environment, in fact many had not been.

One junior officer told the inquest that not only had he not been selected to work on the unit, but he had asked not to be placed there. His request had been refused, and he had also failed on appeal. He was told he still had to go for reasons of “operational need”. The attack occurred on his first full day on the unit.

The inquest also heard that there had been no change of approach, either to the risk assessment of association, or to the risk assessment of the yard, following a previous incident. In late 2014 a prisoner had attempted to kill another prisoner on an adjoining yard in the same specialist block. In early 2021 the High Court found that the risk assessments in that case had been negligently conducted.

Taras had been 49 years old when he died. He had had no history of violent offending until 2014 when he attacked someone whilst he was experiencing what seemed to be a psychotic episode. When on remand for that offence he killed another prisoner in what appeared was another psychotic episode. He spent time in a secure mental hospital and, at the time of his death, was supposed to be being monitored for a return there. None of this, however, was considered in his risk assessments. As the jury conclusion reflected, no one from the healthcare team was present at the dynamic risk assessment meetings that were supposed to consider association risk

The inquest also heard that Taras was physically unwell. He had required an operation on his jaw that had been delayed. During his months long wait he had not been able properly to eat, and so had lost weight.

The MCBS unit had been designed to provide a framework for the care and case management of prisoners whose behaviour is dangerous, disruptive, and/or particularly challenging to manage whilst in custody, and those considered to present a high risk of harm to others, to try to break the cycle and prevent further harm’.

The unit was supposed to have a high psychological input but the inquest heard that at Woodhill it had been impossible to recruit a full time psychologist to carry out this work. The sessional psychologist told the jury that at the time of Taras’s death none of the three assailants had been engaging with her. Previous engagement had been very intermittent.

The MCBS unit has since been closed. The intention had been to move the prisoners to HMP Long Lartin so that the Woodhill unit could become a separation unit housing extremist prisoners, but that move was cancelled because the staffing at Long Lartin was not ready. The three assailants have since been transferred elsewhere in the prison estate. Mr Brabbs, who was the only one of the three who agreed to be interviewed, said his new regime was “a lot better” and he was now “happy” where he was.

Searching

It was accepted prior to the start of the inquest by the Ministry of Justice that the “searching of prisoners and the razor blade policy: the quality of the searching and control of razor blades were not sufficiently quality assured. The searching therefore was poor, with omissions in checking items and prisoners given scope to distract staff.”

CCTV revealed that physical rub down searching of the prisoners was cursory and the use of a metal detector wand was not thorough. Prison officers also gave evidence stating that they had not had any refresher training in searching since becoming prison officers, in one case 22 years, despite updated prison service instructions on searching.

It was accepted by all that a properly conducted search would have revealed the weapons, and a former governor was clear that had they been found, the exercise would not have been allowed to go ahead until a thorough further search (including of cells where further weapons would have been found) and reassessment of risk had been carried out.

Risk assessments

The inquest heard that a previous violent attack had taken place on the yard of the Close Supervision Unit in 2014. There was no evidence of any internal or external investigation taking place and no changes to procedure or risk assessment of the exercise yard were introduced. The only risk assessment that could be found was dated 2013 and was very unclear. At the time other MCBS units in the country did not have communal exercise. There was no contingency plan in case an incident was to take place on the yard and staff did not have the equipment or numbers of staff to intervene without considerable risk to themselves.

Following the conclusion of his inquest Taras’ wife said: “I have been very shocked and saddened to hear the evidence at the inquest. I have heard how staff were not adequately trained to do their jobs and officers were just brought in to fill gaps, that prisoners did not have sufficient therapeutic input or any initiatives to put them on right path.

I was particularly concerned with the evidence I heard from the former head of security in the prison who took no responsibility for the failings in relation to searching of prisoners and had made no changes to the system as a result. They had also not been provided with the internal investigation designed to learn lessons. No lessons have been learnt. Where is the accountability? These officers are still in their posts or have been promoted. 

I always voiced my concerns about Taras being on that unit as I did not feel that was the right place for him. He came into the prison system but found that the system gave him no hope that one day his life could change when he would be released. In my opinion the prison system utterly failed him and he died in the barbaric and inhumane circumstances.”

Christina Juman of Deighton Pierce Glynn who represents the family said: “Another thing that this inquest has shown is that there is a real issue with secure units like the MCB unit at Woodhill taking prisoners into specialist environments in order to progress them, but in fact brutalising them and making them worse.  There was little or no progression for any of the men on that unit and sadly that resulted in the loss of life Taras Nykolyn in the most brutal way.”

ENDS

NOTES TO EDITORS

For more information contact Lucy McKay on [email protected] or 020 7263 1111

The family was represented by INQUEST Lawyers Group Members Christina Juman of Deighton Pierce Glynn and Nick Armstrong of Matrix Chambers.

The other interested persons represented at the inquest were the Ministry of Justice and Central North West London NHS Trust (CNWL).