4 May 2021

Before HM Senior Coroner for Milton Keynes Tom Osborne
H.M. Coroner’s Court, 1 Saxon Gate East, Milton Keynes (remote hearing)
Opened 4 May 2021
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 opened on 4 May and is scheduled over three weeks.

Woodhill has faced many years of scrutiny following high numbers of deaths at the prison since 2013. In 2019 there were four self-inflicted deaths at HMP Woodhill, including Mark’s. There was a further self-inflicted death at the prison in January 2021.  

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 therefore due to be released from custody on 24 April, shortly before his death.

Mark had arrived at the prison in a state of distress. The inquest will hear that he was arrested following a lengthy standoff with police on 17 April, during which he self-harmed and repeatedly threatened to jump from height with a ligature. Medical staff at the police station later said he was fit to detain.

Mark was taken to Court on 18 April but taken to hospital before appearing, after he self-harmed by hitting his head and was unconscious. While at hospital his licence was recalled and upon being discharged he was taken to HMP Woodhill.

Whilst at HMP Woodhill, Mark was subject to suicide and self-harm monitoring (ACCT), mostly on constant watch.

At about 13:40 on 23 April, Mark had an altercation with another prisoner. Staff intervened and Mark was restrained, during which he was injured. He was taken to the segregation unit. Less than an hour later staff entered his cell and found Mark had ligatured.

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, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]  

Mark’s family are represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Maya Sikand QC & Cian Murphy from Doughty Street 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).

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.