25 August 2023

Before Assistant Coroner Ian Arrow
West London Coroner’s Court
14 – 24 August 2023

Luke Clarke was 38 years old when he was found ligatured in his cell in the Covid-19 wing of HMP Wormwood Scrubs on 7 April 2020. He died less than 24 hours after arriving at the prison from St Bernard’s Hospital, Ealing, where he had undergone an assessment under the Mental Health Act 1983 (MHA).

Today, a jury concluded that fear and confusion generated by Covid-19 and inadequate care by prison staff and a lack of liaison between the prison and hospital contributed to his death.  

Luke’s death is one of 12 apparently self-inflicted deaths at the prison in the past five years.

Luke was born in St Neot’s, Cambridgeshire, but later moved to London as a teenager with his mother and siblings. A protective older brother, his family describe him as a “loving, kind, funny and caring” person. Luke previously ran a window cleaning business with his brother around West London.

Luke experienced sexual abuse as a teenager. Subsequently his mental health deteriorated, and he began to rely on drugs and alcohol. In 2004, he was diagnosed with paranoid schizophrenia and was sectioned on a number of occasions. He had a history of serious self-harm and suicide attempts, including trying to jump from a height in September 2019.

Luke was detained by Metropolitan Police Officers on 5 April 2020. One of the police officers who detained Luke said she thought it looked as if Luke was having a psychotic episode. Police officers took Luke to St Bernard’s Hospital, Ealing, where he remained in police detention.

Following his detention, the police found that Luke had been recalled to prison for failing to comply with all of his licence conditions.

At the hospital, Luke was assessed and considered to potentially have Covid-19. The jury, however, heard from various police and prison officers that they understood Luke to be Covid-19 positive.

In the early hours of 6 April 2020, a psychiatrist assessed Luke at the hospital. She considered that he did not have capacity, and recommended that Luke should be detained under the MHA.

A second psychiatrist who saw Luke several hours later found him to be presenting differently. In her opinion, Luke’s earlier behaviour had been due to cannabis intoxication. She decided that Luke did not meet the criteria for detention under the MHA, and that he could be cared for in prison.

Police officers subsequently took Luke to HMP Wormwood Scrubs. The jury heard evidence that a Metropolitan Police Custody Sergeant and a Senior Officer at the prison agreed that Luke should be taken by police directly to the prison rather than into police custody.

Since they believed that Luke had Covid-19, they wanted to reduce contact with other individuals and the need to sterilise spaces where Luke had been.

Prison officers also decided that Luke should not be taken to the reception area of the prison, but should be taken directly to the prison’s designated Covid-19 isolation wing.

Two police officers, together with two prison officers, took Luke to a cell on the Covid-19 wing. Conflicting evidence was heard as to whether the full reception screening process was carried out once Luke was in the cell. A form with questions about suicide and self-harm was not completed.

At 2.50pm the same day, a reception nurse went to see Luke. The nurse gave evidence that she had not been provided with the correct PPE to carry out the assessment. Her managers at the time gave evidence that she had been provided with this.

The nurse conducted the reception screening, which includes questions about an individual’s mental health, through the hatch of the cell door. She stated that Luke refused to engage with her unless he was unlocked and was able to speak to her face to face, as would be the normal procedure.

CCTV footage showed that the nurse spent a maximum of one minute thirty-six seconds conducting the assessment.

Shortly after 5pm, prison healthcare received the second psychiatrist’s assessment of Luke from the hospital. A prison GP and the reception nurse discussed Luke, albeit conflicting evidence was given as to what was discussed, and the GP decided not to go to see Luke.

At around 5pm Luke tried to push past an officer who had opened the door to his cell to deliver food. The officer pushed Luke back into the cell.

Evidence was heard that at no time did prison or healthcare staff consider opening an ACCT, a safety plan for prisoners considered to be at risk of suicide or self-harm.

Just before 9.30pm a night duty officer gave evidence that, having turned the cell light on, he saw Luke standing in the middle of his cell and that Luke gave him the thumbs up sign.

No further checks were made on Luke throughout the night, despite the prison’s policy that all first night prisoners should have hourly checks. The night duty officer did not conduct the required 6am roll call check.

At around 9.30am on 7 April 2020, a prison GP went to see prisoners on the isolation wing. She gave evidence she did not know Luke was there as he did not have a name plate on his cell door.

Prison officers and healthcare staff went to see Luke at around 11am. He was found ligatured in his cell.

The jury concluded that Luke died as a result of asphyxia. They found that a number of  failures contributed to his self-inflicted death, including:

  • Inadequate care by a prison officer overnight on 6-7 April 2020;
  • Inadequate steps to ensure that it was known that he was in cell 80 (throughout the period of his detention);
  • The fact that Luke had been isolated in his cell, with very minimal human interaction;
  • The brevity of the prison nurse’s interactions with Luke (in a purported reception health screen) and inadequacies in the response of more senior healthcare staff
  • Inadequate reception screening by prison officers;
  • The failure to open an ‘ACCT’ document (which gives rise to implementation of observations and other specific measures of support);
  • Inadequate liaison between hospital and prison;
  • Inadequate planning by the prison for Covid-19.

They also found that the fear and confusion generated by the Covid-19 pandemic among staff and prisoners at HMP Wormwood Scrubs, as well as other institutions, contributed to his death.

They noted that due to Covid-19, usual procedures at the prison were not followed, and alternative procedures were at the time not fully developed, nor was there clear accountability for the regime’ on the wing where prisoners with Covid-19 were isolated. 

The family await the coroner’s decision on whether he will make a report to prevent future deaths.

Luke’s family said: “Our family welcome the jury’s findings. The lack of care, and failure of staff to follow protocols, as well as the failure to put in place appropriate procedures, at HMP Wormwood Scrubs during Covid-19, contributed towards Luke taking his own life.

We hope Luke’s death is not in vain, and that changes within the prison following Luke’s passing, and the way healthcare information is communicated from hospital to the prison, will prevent future loss of life.”

Helen Stone of Hickman and Rose Solicitors, said:  

“The jury’s conclusions indicate that the staff working at HMP Wormwood Scrubs fundamentally failed in their duty of care towards Luke and that, as at the beginning of April 2020, the provisions put in place to respond to the impact of covid were inadequate and dangerous when applied to already vulnerable prisoners.

An INQUEST spokesperson said: “Luke was sent to prison and within 24 hours he was dead. He needed care and support for his mental ill health, not criminalisation.

Luke was neglected by a prison which has a long record of failing to protect the health and wellbeing of those who are owed a duty of care. We must urgently dismantle prisons and redirect resources to holistic, community-centred mental health services.”



For further information, please contact Leila Hagmann on [email protected].

The family are represented by INQUEST Lawyers Group members Helen Stone of Hickman and Rose Solicitors and Paul Clark of Garden Court Chambers; and were previously represented by Tom Stoate of Doughty Street Chambers. They are supported by INQUEST Caseworker Caroline Finney.

Other Interested Persons represented at the inquest were HMP Wormwood Scrubs, Practice Plus Group; Barnet Enfield and Haringey Mental Health NHS Trust; West London NHS Trust; The Commissioner of Police for the Metropolis; and London North West University NHS Trust.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Since 2013, there have been 18 self-inflicted deaths at HMP Wormwood Scrubs, 12 of which took place since 2018. The most recent death was in July 2023.

Relevant cases:

  • Winston Augustine, 43, died on 30 August 2018 at HMP Wormwood Scrubs. He had been transferred to the segregation unit only 48 hours before he was found ligatured in his cell. An inquest found that at the time of his death. Winston was in a state of severe pain and starvation. Media release.
  • Ketheeswaren ‘Kumar’ Kunarathnam, a 45 year old Sri Lankan immigration detainee, died on 23 February 2018 at HMP Wormwood Scrubs. An inquest found that Kumar died by suicide, and identified failings from all organisations involved in his care and detention. Media release.