Before HM Senior Coroner for Milton Keynes Tom Osbourne
23 October - 5 November 2019
 
The inquest into the self-inflicted death of 39 year old Darren Williams concluded yesterday. The jury found a series of critical failings that contributed to his death including a ‘consistent failure to follow due processes and relevant protocols’ in Woodhill prison.

On 4 January 2019 at 3.50pm Darren was found suspended from a ligature in his cell and could not be revived. He was the first of four men to die in the prison in 2019. The most recent inspection of HMP Woodhill found the prison is ‘still not safe enough’.
 
The inquest heard that drugs were widely available in HMP Woodhill which simultaneously entailed a culture of debts, threats and violence. On four separate occasions Darren seriously self-harmed as a result of threats of violence. On each occasion suicide and self-harm procedures (known as ACCT) were started and he was moved to another wing within the prison. However, evidence was heard that he was not offered victim support services, which was in breach of the prison’s violence reduction policy, and that no action was taken when Darren named those who were threatening him.
 
The jury found causative 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. In a detailed narrative, the jury found ‘a consistent failure’ to follow applicable processes and protocols.
 
The jury found that:

• prison’s suicide and self-harm prevention measures (ACCTs) were inadequately followed;

• there was a significant failure to complete and allocate actions in Darren’s care maps, an integral part of the ACCT process;

• Darren’s applications to move to the vulnerable prisoner’s unit were either not documented or incorrectly considered and;

• information about Darren’s history of self-harm and suicidal ideation was not suitably shared between relevant prison departments.

The jury further found that the support provided to Darren was ‘inadequate and lacking’ in key areas such as violence reduction, victim support, mental health and family engagement. The jury also made clear that, in light of Darren’s long term history of drug abuse, debt accrual and mental ill health, it was ‘vital [that] these services were offered to him in full’.
 
At the conclusion of the inquest the coroner indicated that he would be making a report to prevent future deaths to the Governor concerning the need for members of healthcare to attend ACCT reviews and for previous ACCTs to be reopened when the same concerns recur rather than starting the process afresh.
 
Carri Williams, Darren’s sister, said: “It’s very important to us as a family that Darren be seen as the person he was and not just a number in the system. He was a son, brother, grandson, uncle and a good friend to many. As a family we believe that his passing was completely preventable, which makes our loss even more unbearable. This has impacted our lives in a terrible way and every day we suffer and question the ‘what ifs’. We now have to visit a cemetery on a regular basis to even feel close to him and stare at mud and ornaments. It’s just awful and unfair. He should have been kept safe.”
 
Selen Cavcav, Senior Caseworker at INQUEST said: “It is chilling that the circumstances and failures of Darren’s death are so familiar. How many more people must lose their life as a result of these deplorable failures in the prison’s duty of care?
 
Darren’s death is one of four self-inflicted deaths in Woodhill prison this year. As deaths in custody spiral and recommendations from inspections, investigations and inquests are ignored, a vicious cycle goes into tailspin. The current system for implementing change is not fit for purpose. A national oversight mechanism is urgently needed, to ensure official recommendations are systematically followed up and to prevent another family from experiencing this loss.” 
 
Jo Eggleton of Deighton Pierce Glynn solicitors said: “We learnt during the inquest that the re-categorisation of Woodhill prison from a local remand prison to a category B training prison which was originally planned for March 2018 has begun at last. No explanation has been provided for the delay, during which eight more men have died there. None the less it will come as a great relief to the still grieving families I have represented over the years that Woodhill will no longer hold remand and short term sentence prisoners.”

ENDS

NOTES TO EDITORS

For further information, interview requests and to note your interest, please contact the INQUEST communications team on 020 7263 1111 or [email protected]; [email protected]

Darren’s family are represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Raj Desai of Matrix Chambers. The family are working with INQUEST caseworker Selen Cavcav.

A total of 18 self-inflicted deaths took place in HMP Woodhill between January 2013 and December 2016 when concerns were first raised at the inquest into the death of Kevin Scarlett (March 2014).
 
Over that period HMP Woodhill had the highest number of self-inflicted deaths of any prison in England and Wales.  
 
Families bereaved by this series of self-inflicted deaths in HMP Woodhill were granted a judicial review aiming to address the high number of self-inflicted deaths in Woodhill. In May 2017 the High Court rejected this claim, however since the hearing highly critical inquests have found:

• The failure by HMP Woodhill to learn from previous suicides caused the death by neglect of Daniel Dunkley (May 2017)
• HMP Woodhill authorities failed to take all reasonable precautions to prevent the death of Tom Morris (July 2017)

Following the public pressure brought by the families involved in these cases, an independent review by Stephen Shaw was commissioned in May 2017 to examine the circumstances of these deaths. Following this, it was announced that Woodhill would convert from a local prison to a category B training establishment. In 2017 there were no self-inflicted deaths at the prison.
 
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).