3rd March 2014

Milton Keynes Coroner’s Court, Civic Offices, Milton Keynes
Before Senior Coroner Tom Osborne

Following a three day inquest, a jury has today returned highly critical findings concerning the death of Kevin Scarlett at HMP Woodhill.  

The jury found that on the 22 May 2013 Kevin Scarlett was found in his cell at 1.01, hanging from a bunk using a sheet as a ligature and died as a result of an accident.  

Recording serious failings in the care provided by HMP Woodhill, the jury recorded that Kevin’s risk of self harm or suicide had not been properly assessed, that he should not have been left alone in a double cell, that he should have been allocated to a safer cell (a special cell with no ligature points) and that he should have been subject to enhanced case management (a risk assessment track specifically designed for complex individuals who regularly self harm).

Concluding the inquest, Senior Coroner Tom Osborne stated that he would be writing to NHS England and the National Offender Management Service to raise his particular concerns that HMP Woodhill did not have a tool to assess Kevin’s level of risk of self harm and suicide. 

Kevin Scarlett was 30 years old at the time of his death on 22 May 2013. He had a long history of mental health problems, having been diagnosed with schizophrenia and bipolar disorder, although doctors were later working to a diagnosis of emotionally unstable personality disorder. He was a regular self harmer, and had made a number of serious attempts to kill himself.

In a particularly tragic twist to the case, Kevin's father Chris had also killed himself, not half a mile from the prison where Kevin took his own life. Kevin had been 12 years old when his father died.

Kevin had entered HMP Woodhill on 14 January 2013 as a remand prisoner. There his self harming and suicide attempts continued. Despite his presentation and profile, however, the prison repeatedly assessed his risk of suicide as low.  Evidence at the inquest also revealed:

- Kevin was subjected to a basic regime, where he was confined to a cell for 22 hours a day with no TV, no radio, and nothing else to do.
- A note was placed on Kevin's cell door that warned other prisoners that if they spoke with Kevin they would themselves be at risk of having privileges removed. This was a particularly damaging to Kevin because he was subject to bail conditions that also prevented him from having contact with members of his family.
- Kevin was left on his own in a double cell, with a bunk bed to which he could attach the bed sheets from which he ultimately hung himself.
- Prison staff did not consider allocating him to a safer cell, which the jury heard were available on his wing.

Patricia Scarlett, Mr Scarlett’s mother said:

“At points in this process, it has felt that Kevin has become a faceless individual, represented as just another difficult person who could not be helped.  Kevin was a very kind hearted person. To us he was a loving and loyal son, brother, uncle and friend.  For years he battled with mental illness and had complex mental health needs which were consistently underestimated.  Knowing how vulnerable Kevin was, it has been painful for us to hear evidence that he was treated in such a harsh way by those who should have been ensuring his care and protection.  He will be deeply missed and remains always in our hearts and thoughts.

“I sincerely hope that if nothing else, lessons will be learned. I am grateful to the coroner and to the jury who have clearly given a lot of careful thought to the conclusions they have reached."

Victoria McNally, INQUEST caseworker for the family said:

“There has been an alarming rise in self inflicted deaths in prison over the last year. Similar to Kevin Scarlett, many of these cases involve the death of mentally vulnerable men in circumstances where the systems of care and protection have broken down. What is particularly disturbing in this case is the punishment meted out to a man in a highly vulnerable state, without any consideration of the devastating impact that this could have. It begs the question how a prison could have exercised such poor levels of judgement in its duty of care.”

Jo Eggleton, Deighton Pierce Glynn, solicitor for the family, said:

“It is sadly all too common that inquests looking into self inflicted deaths in prison concern the management of those with complex mental health issues.  There were 4 self inflicted deaths in HMP Woodhill in 2013, second only to HMP Wormwood Scrubs which has many more prisoners.  The Prison and Probation Ombudsman has previously made recommendations to HMP Woodhill about assessing a prisoner’s risk of self- harm. It is a tragedy for Kevin and his family that despite previous recommendations mistakes are still being made. Added to this is the worry expressed by the prison’s “Independent Monitoring Board in their latest report that the year on year increases in cuts and services may lead to a further decline in prisoner safety”. I hope that HMP Woodhill and the Ministry of Justice now do right by Kevin’s family and ensure that lessons are learned not just locally but across the whole prison estate.

INQUEST has been working with the family of Kevin Scarlett since his death. The family is represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn solicitors and barrister Nick Armstrong of Matrix chambers.

Notes for editors

For further details contact Jo Eggleton of Deighton Pierce Glynn on 020 7407 0007