13 March 2020

Note: This inquest was delayed and relisted in May 2021.

Before HM Senior Coroner for Milton Keynes Tom Osborne
HM Coroner’s Court, 1 Saxon Gate East, Milton Keynes, MK9 3EJ
Starts 16 March 2020, 10am, expected to last 15 days
Mark Culverhouse, 29, was found unresponsive with a ligature in the segregation unit of HMP Woodhill at around 2.49pm on 23 April 2019. He was resuscitated and taken to Milton Keynes Hospital but died the following day. The inquest into his death opens on Monday 13 March.
Mark arrived at Woodhill prison on Thursday 17 April 2019 after his licence was recalled. He should have been released on 18 April because he had no time left to serve on his licence. However, 18 April was Good Friday, a bank holiday, and staff who calculate sentences were not at work until 23 April.
Mark was taken to court on 18 April, but before appearing he self-harmed by hitting his head. He became unconscious and was taken to hospital. While at hospital his licence was recalled and upon being discharged he was taken to HMP Woodhill. Whilst at Woodhill prison Mark was subject to suicide and self-harm monitoring processes (known as ACCT) and was under constant supervision for most of this time.
At about 1.40pm on 23 April Mark had an altercation with another prisoner. Staff intervened and Mark was restrained, during which he was injured, and he was taken to the segregation unit. Less than an hour later staff entered his cell and found him unresponsive.
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’.
The inquest will consider:

  • Mark’s arrest and recall to prison.
  • Suicide and self-harm prevention measures (ACCT).
  • The actions of mental health professionals and healthcare.
  • Events of the 23 April 2019, when he was found ligatured.



For further information, to request a photo of Mark and to note your interest, please contact Lucy McKay or Sarah Uncles on 020 7263 1111 or [email protected] [email protected]

Mark’s family are represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Maya Sikand from Garden Court Chambers.

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).

Recent inquest conclusions following 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.