27 January 2020

Before H.M. Assistant Coroner, Mr Darren Stewart OBE
Surrey Coroner’s Court

14 -24 January 2020

The inquest into the death of David Dunnings, 35, has concluded with the jury finding he died from suicide whilst at HMP Coldingley on 8 July 2017. He was serving an Indeterminate Sentence for Public Protection (IPP) and was significantly over tariff when he was moved to HMP Coldingley in September 2016.

The jury identified numerous serious failures which contributed to his death, including:

  • There was a complete failure to follow process and to communicate within the prison, and, more importantly, to Mr Dunnings himself;
  • The ACCT system, designed to safeguard prisoners, was not sufficiently informed or quality checked and was lacking in consistency of delivery and auditable actions;
  • A multidisciplinary approach was not possible due to the inadequate mental health care provisions resulting in a serious failure in the ACCT process;
  • The risk posed to Mr Dunnings of being on the segregation wing was underestimated, given that he was an IPP prisoner over tariff; a fact that was inadequately acknowledged; and
  • There was a serious failure in communication between multiple agencies working in siloed and multiple systems and policies within HMP Coldingley.

David’s family described him as loving, caring man with a huge heart. He had a history of self-harm which manifested during times of emotional distress and anxiety, and a diagnosis of personality disorder.

The inquest heard that on 14 June 2017, David was moved to HMP Coldingley’s segregation unit following his alleged involvement in barricading a cell – a charge which was later quashed. That evening David self-harmed  and was placed on suicide and self-harm monitoring procedures, known as Assessment, Care in Custody and Teamwork (ACCT). David then spent a further three and a half weeks in segregation (where prisoners are allowed around half an hour out of their cell per day) – despite the fact that prison rules state segregation should only be used in exceptional circumstances when a prisoner is subject to ACCT procedures.

Evidence was heard at the inquest that David was told the prison were considering recategorising him from a Category C to a Category B prisoner. This would have been a significant setback in David’s IPP sentence and should have been recognised as a well-known stressor and trigger for suicide.

During his time in segregation, David repeatedly expressed suicidal ideation, and by late June he was telling prison and healthcare staff that he was thinking of hanging himself, and that he would kill himself after he had said goodbye to his family after their next visit as his sentence had ‘done him in’.

On the afternoon of 7 July 2017, David was erroneously told by a prison custodial manager that he had been recategorised. The coroner noted that this decision had been “lingering” for weeks, in spite of a recommendation by the prison psychiatrist, Dr Darren Bull, that David be informed as soon as possible so that he could properly prepare himself. Despite this, David’s level of observation under ACCT processes on 7 July was not increased.

At around 1.05am on 8 July 2017, a prison officer found David in his cell, suspended from a ligature. Despite attempts at resuscitation and the attendance of paramedics, David’s death was confirmed at 2.12am.

Giving evidence to the inquest, then Deputy Governor of HMP Coldingley, Niall Bryant, accepted that there were “indefensible failures” in the way in which David recategorisation had been handled. No review board was convened, there was no input from David himself or any probation officer, and he was not provided with any formal paperwork or told he could appeal.

The Prison and Probation Ombudsman (PPO) investigation found that “Mr Dunnings was not sufficiently protected by the ACCT procedures which became formulaic and not focussed on his risk”. The PPO also found that there were also failures in the procedures and safeguards designed to provide additional protection for prisoners in the segregation unit. In relation to David’s IPP sentence, the PPO found: “It is clear that his indeterminate sentence and the uncertainty about how long he might have to remain in prison were significant sources of anxiety to him and it is hard not to conclude that they played a key role in his decision to kill himself”.

The clinical reviewer who examined David’s death, Dr Andrew Foulkes, was critical of various aspects of the mental health care he received at HMP Coldingley, provided by Central and North West London NHS Foundation Trust (CNWL). In particular, Dr Foulkes found that there was “no evidence that a structured assessment of [Mr Dunnings’] suicide risk had taken place” during his time on segregation and when he was supposed to have been monitored, although this was denied by CNWL at the inquest.

HMP Coldingley accepted the findings of the PPO report in full and staff told the coroner that there have been wide-ranging changes to the systems in place to consider and communicate with prisoners about recategorisation. Prisoners subject to ACCT monitoring at Coldingley are no longer placed in the segregation unit. More mental health staff are now in place, and a funding bid has been made for mental health cover in the prison at weekends – although this has not yet been secured.

Pauline Whitfield, David’s mother-in-law, said:David was trying to focus on the future and was rebuilding his family relationships. We were shocked to hear how badly he was let down in prison. The IPP sentence David was subject to was unfair and unjust, and made him vulnerable – which should have been properly recognised. The way in which David was wrongly told he had been recategorised should never have happened, and the mental health care was woefully inadequate at the time David was in Coldingley. We heard a lot about how the systems have changed since David died and we can only hope that is really the case, so that other families don’t have to go through what we have suffered”.

Shelley Peynado-Clarke of Tuckers Solicitors, who represents David’s family said:As an IPP prisoner well over tariff, and as someone who should have been recognised as being at high risk of suicide, it is shocking that David was deprived of the proper safeguards which should have been aimed at reducing his risk. Prison staff were unaware of the proper procedures for ensuring that the stress and uncertainty of David’s sentence were mitigated, which had tragic consequences in this case.

Remy Mohamed, caseworker at INQUEST said: “Prisons, by their very nature, are dehumanising places which create and intensify vulnerability. This is further heightened for the 2,223 people who remain on indeterminate sentences, not knowing when they will be released.

David’s death follows a number of deaths in prison which have been linked to the detrimental harms of IPP sentences. The deterioration in David’s mental health was clear, which makes the basic failings identified at the inquest all the more unfathomable.”


For further information please contact the INQUEST communications team on 020 7263 1111 or [email protected][email protected]

The family is represented by INQUEST Lawyers Group members Shelley Peynado-Clarke of Tuckers Solicitors and Tom Stoate of Garden Court Chambers.

The other Interested Persons were the Ministry of Justice (for HMP Coldingley), and Central and North West London NHS Foundation Trust who provided primary and mental health care at the prison.

Earlier this month INQUEST published a new report exposing the national scandal of deaths in prison, many caused by neglect and repeated failures. The evidence is gathered from our casework with bereaved families and our monitoring of inquests - illustrating the repeated failings and providing a unique insight into the harms and dangers of imprisonment. Read more.

Other deaths of people on IPP sentences include:

  • Shane Stroughton, 29, died a self-inflicted death on 13 September 2017, whilst a prisoner at HMP Nottingham. Aged 19 he was given an IPP sentence for a minimum two and a half years but had remained in prison for nearly ten before being released in June 2017. He was recalled to prison shortly after release. The jury found serious failures in the suicide and self-harm monitoring procedures and in communication with Shane’s family. Media Release.
  • Charlotte ‘Charlie’ Nokes, 38, died at HMP Peterborough on 23 July 2016. Despite being sentenced to a minimum term of 15 months, Charlotte had been in prison for over eight years. The inquest into her death is due to open on 24 February 2020. Charlotte’s family spoke to the BBC about her life.
  • Kelvin Speakman, 30, died of self-inflicted injuries at HMP Hewell on 9 May 2016. He had a history of mental ill health and drug and alcohol dependence. Kelvin had been sentenced in 2007 for a minimum of two years but had been in prison for nine when he died. His family spoke to the Guardian about his experiences. 
  • Tommy Nicol, 37, was found with a ligature in his cell at HMP The Mount and died four days later in hospital on 25 September 2015. Tommy made a complaint to the prison six months prior, in which he described his inability to progress in his IPP sentence towards release as “psychological torture”. Media Release.
  • Steven Trudghill, 23, died at HMP Highpoint on 9 January 2014. The coroner wrote a Prevention of Future Deaths report (2016) which raised concerns about other prisoners on IPP sentences who were at continued risk. He said, it is the “case that there are complex mental health needs which might actually be the reason for the continuing risk that keeps them in custody, as with Steven, yet the specific treatments are not available within the prison system”. Media release.

IPP sentences

  • IPP sentences came into use on 4 April 2005, as part of section 225 of the Criminal Justice Act 2003, introduced by then Home Secretary, David Blunkett.
  • In 2007 the Queen's Bench Division of the High Court ruled that the continued incarceration of prisoners serving IPPs after tariff expiry where the prisons lack the facilities and courses required to assess their suitability for release was unlawful.
  • In 2010 a joint report by the chief inspectors of prisons and probation concluded that IPP sentences were unsustainable for prisons in the UK.
  • On 3 December 2012 the IPP sentence for new cases was abolished by the Legal Aid, Sentencing and Punishment of Offenders Act.
  • In November 2019 it was reported that there are still 2,223 people serving IPP sentences who have yet to be released (93% over the original tariff) and a further 1,206 serving an IPP sentence who are back in prison having been recalled while on licence.