24 May 2021

Before HM Senior Coroner Tom Osborne
Milton Keynes Coroner’s Court
4 - 21 May 2021

The inquest into the death of 29-year-old Mark Culverhouse concluded on Friday 21 May 2021, with the jury finding critical failures contributed to his death. These included putting Mark in segregation and unlawfully detaining him past his license expiry date. He had spent four days in custody. On 23 April 2019, shortly before 15.00, Mark was found unresponsive under a sheet on the floor of a cell in the segregation unit at HMP Woodhill. He had used a ligature and later died.

The senior coroner, Tom Osborne, indicated that he will be writing a report to prevent future deaths highlighting Mark’s recall to prison when his licence had in fact expired, as well as the delay in releasing him once in prison. The coroner said he was “outraged” by Mark’s unlawful detention which, he said, had led Mark further into crisis, and eventually death. He said that it was contrary to the Magna Carta of 1215.

The inquest had heard that on 17 April 2019, Mark was in serious crisis in the community. He climbed up scaffolding and threatened to jump from the third storey of a building. He was brought down by skilled negotiators but then arrested for offences directly related to the incident.

Mark was then taken to Northampton Police Station, where two doctors deemed him fit to be detained despite the negotiator wanting him to have a formal Mental Health Act assessment. Mark was subsequently interviewed and charged. The next day he was taken to Northampton Magistrates’ Court but, before he taken up to the court, he had to be taken to hospital after deliberately hitting his head very hard in the cell area. Mark repeatedly indicated that he would kill himself if returned to prison.

While he was in hospital, the probation service decided to recall Mark to prison in relation to a previous short sentence of driving while disqualified, despite the fact he was suicidal. The inquest heard that the probation services do not calculate sentences before deciding to recall someone. He was still in deep crisis upon arrival and was captured on CCTV saying he had been recalled for trying to take his own life and asking to be taken to hospital. It transpired that he had no time left to serve on his licence and should in fact have been immediately released. However, no administrative staff were present to calculate his release date over the Easter bank holiday weekend, so he remained incarcerated, and in four days was twice removed to segregation.

Mark was subject to suicide and self-harm monitoring throughout his time in the prison (he was on an ACCT). On 19 April he was forcibly removed to segregation where he repeatedly hit his head very hard and expressed the wish to die. He was later found unresponsive and taken to hospital. He spent a number of days on constant observation.

On 23 April 2019, after an altercation with another prisoner, Mark was restrained and again taken to segregation, although still on an ACCT. There were only two documented observations and both times he was said to be under a sheet. Earlier that same day, administrative staff had been alerted to the fact that Mark might be due for immediate release. This was not communicated to him. By the time they confirmed the calculation he had ligatured.

The inquest jury concluded that the decision to transfer Mark to the Segregation Unit on 23 April contributed to his death. They found that the manner of observations, with his body obscured during the purported observations, were insufficient. The jury also concluded that a defect in the system of recall and release from prison that led to Mark’s unlawful detention, and contributed to his death.

Mark was the second 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’.

Wendy Culverhouse, mother of Mark said: “Mark is the light in my life. He just wanted some help. He should have been taken care of, not sent to prison. The coroner and the jury know Mark should not have been in prison. I hope that changes will be made so no family ever has this terrible experience.”

Jo Eggleton of Deighton Pierce Glynn solicitors said: “The fact that a man in suicidal crisis was recalled to prison by probation officers in relation to a 16-week sentence is bad enough, but in this case it transpired that Mark had 81 unused days due to him. Had probation known that they could not have recalled him. The defect in the system meant that he spent four nights in custody, where he repeatedly expressed that he was in crisis.

The ACCT system did not protect him – despite the exceptionality requirement, he was twice placed in segregation by officers concerned with discipline and not his obvious vulnerability. He was then able to ligature in segregation because prison officers ignored that fact he was under a sheet on the two occasions they purported to observe him through the panel.”

Deborah Coles, Director of INQUEST, said: “Woodhill has had one of the highest numbers of self-inflicted deaths in prison in recent years, with numerous critical inquests identifying failures in their care. Despite promises that lessons will be learned after every death, they maintain unsafe practices and continue to put people at risk. 

Mark’s imprisonment and subsequent death at Woodhill should never have been allowed to happen. Not only because this prison has had ample opportunity to change, but because there was no lawful basis for his detention. For these failures Mark paid with his life.

What would it take for this prison to prevent deaths, and for the Ministry of Justice to take effective action to prevent the imprisonment of people with serious mental ill health, and protect lives in prisons?”


For further information please contact Lucy McKay on 020 7263 1111 or [email protected].

Mark’s family are represented by INQUEST Lawyers Group members Jo Eggleton and Rajiv Nair from Deighton Pierce Glynn and Maya Sikand QC and Cian Murphy of Doughty Street Chambers. The family are supported by INQUEST caseworker Natasha Thompson.

Other Interested persons represented were HMP Woodhill, Northamptonshire Police, Northamptonshire Healthcare NHS Foundation Trust, GEOAmey, and Central and Northwest London NHS Foundation Trust.

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

ACCT is the suicide and self-harm monitoring procedure in prisons. It stands for Assessment, Care in Custody and Teamwork.


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 were four deaths, all of which were self-inflicted.

The most 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).

Other inquests following recent deaths at HMP Woodhill:

- Chris Carpenter,
34, was found unresponsive in his cell in August 2018. The inquest found that his death was drug related. The jury identified a series of failures by prison and healthcare staff and concluded that the risk management of Chris, ‘a very vulnerable prisoner’ was ‘inadequate’. Media release, December 2019.
- 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, November 2019.
- Ryan Harvey, 23, died on 8 May 2015, after he was found hanging in his cell in HMP Woodhill five days prior. The jury found a series of systemic failures caused his death, including a failure by healthcare staff to undertake an adequate assessment of his learning disability and conduct an assessment of his mental health. Media release, January 2019.