10 December 2019

Before HM Senior Coroner for Milton Keynes Tom Osbourne
2 to 9 December 2019

The inquest into the death of Chris Carpenter, 34, concluded yesterday with the jury identifying a series of failures by prison and healthcare staff at HMP Woodhill. The jury also concluded that the risk management of Chris, ‘a very vulnerable prisoner’ was ‘inadequate’. On 18 August 2018 Chris was found unresponsive in his cell. His death was drug related. Chris was the last of four men to die in the prison in 2018. The most recent inspection of HMP Woodhill found the prison is ‘still not safe enough’, despite extensive scrutiny following extremely high levels of deaths in recent years.

The inquest heard that Chris was recalled to HMP Bullingdon on 18 July, one month after his release on licence. He had a documented history of mental ill health and debts stemming from problems related to drug misuse. He was transferred to HMP Woodhill on 20 July. Concerns were raised with the safer custody team that Chris was vulnerable due to the recent death of his father and may self-harm or take his own life if his mental health deteriorated. The jury heard that there was no evidence that any meaningful safeguards were put in place.

The inquest heard from Governor Spellman that at the time Woodhill prison was experiencing unprecedented use of ‘Spice’, a novel psychoactive substance (NPS), and unprecedented levels of violence. The availability of drugs brought with it a culture of debts, threats and violence.

Chris made numerous attempts to alert prison staff to the threats he was facing, including handing them two written notes with his concerns. On 15 August 2018 Chris reported that he had been threatened with a bladed weapon, and even went so far as to name the prisoner who threatened him. A day later he handed prison staff a note stating that he feared for his life, requesting to move to the vulnerable prisoner’s unit. No meaningful action was taken despite Chris’s clear distress.

Chris was found unresponsive in his cell just two days later as a result of synthetic cannabinoid toxicity. High doses of prescription drugs that were not prescribed to Chris were also found in his system.

The jury found failures in:

  • Co-ordinating concerns regarding Chris’s welfare
  • Documenting and sharing information vital to safeguarding Chris
  • Carrying out necessary searches after reports of threats involving bladed weapons, drug use and drug selling
  • Reassuring Chris’s that appropriate actions to keep him safe were being taken

Linda Carpenter, Chris’s mother, said: “It’s utterly disgraceful to know my son was threatened with a blade and no searches or procedure was followed to ensure a basic level of care was given to him.”

Carole Carpenter, Chris’s sister, said: “How many times did my brother have to ask for help before anyone listened, it’s heart-breaking to know that in his final days he was suffering so much and in distress and no one listened. As a family we believe Chris was attempting to take his own life through all the suffering and distress he was in.”

Jo Eggleton of Deighton Pierce Glynn solicitors said: “Chris’s story is tragically all too familiar and he won’t have been the only one under threat at this time. Another who was, Darren Williams, took his own life on 4 January 2019. The jury at his inquest found very similar failings. Evidence at Chris’s inquest suggested that everyone was well aware of the problems at the time yet nothing was done to resolve them.”  



For more information contact INQUEST Communications Team on 020 7263 1111 [email protected][email protected].

Chris’s family are represented by INQUEST Lawyers Group members Jo Eggleton of Deighton Pierce Glynn and Maya Sikand of Garden Court Chambers.

Following a series of 18 self-inflicted deaths in HMP Woodhill between 2013 and 2016, bereaved families were granted a judicial review aiming to address the high number of self-inflicted deaths in HMP Woodhill. In May 2017 the High Court rejected this claim, however since the hearing an independent review by Stephen Shaw was commissioned to examine the circumstances of these deaths.

In 2017 there were no self-inflicted deaths at HMP Woodhill, three unclassified and one ‘natural cause’ death. In 2018 there were four deaths in Woodhill prison, a homicide, a drugs related death, a non self-inflicted death and a self-inflicted death. In 2019 there have been four deaths, all of which were self-inflicted.

The recent inspection of HMP Woodhill found the prison has ‘deteriorated significantly’ since the previous inspection in 2015 and is ‘still not safe enough’. See INQUEST response (June 2018).

Darren Williams, 39, died a self-inflicted death in HMP Woodhill on 4 January 2019.  The jury found failures relating to information sharing, ACCT processes and the handling of reports made by Darren explaining the threats he was facing due to being in debt. Media Release.