15th May 2017


HM Assistant Coroner for Milton Keynes Elizabeth Grey
8 – 12 May 2017

A jury has found that further failures in the management of a vulnerable prisoner in HMP Woodhill.

The Milton Keynes jury had been hearing evidence in the inquest into the death of Michael Cameron, who was 45 at the time of his death. On 26 April 2016 Michael was found hanging in his cell. He had been in the prison for just seven days. Despite being recognised as a risk of suicide and self harm, and as someone who should not be left in a cell on his own, Michael had not seen a GP throughout his time in the prison; had not had a full mental health assessment; had not been observed in accordance with his monitoring requirements, and on the day it was found had been left on his own because an officer decided his cell mate had had to be moved out.

The jury found that the procedures and adherence to them were inadequate to provide the level of care required to address all the contributory factors to Michael’s death.

The jury found: 
• a failure to carry out appropriately the suicide and self harm procedures and reviews;
• a failure to carry out the observations put in place to keep Michael safe;
• a failure to respond appropriately to Michael’s risk of self harm and suicide by not making an urgent referral for him to be seen by the mental health team for a full mental health assessment;
• that it was not appropriate to move Michael’s cell mate leaving Michael alone in his cell.

Michael was the 14th out of 18 self-inflicted deaths in HMP Woodhill between May 2013 and December 2016. The inquest heard that six of those deaths had occurred within the first 14 days of entering custody. At least 14 of them had been prisoners on their own in their cell. All 18 had been deaths by hanging.  During the first part of 2016 there was a death in the prison, on average, every 45 days. Michael’s was the third death that year.

Maureen Cameron, the mother of Michael said:
“I am pleased that the jury have confirmed what I have suspected from the outset about failures in Michael’s care. I have heard that changes have now been implemented. I hope this might help others in future but it was too late for Michael.  If those changes had been made sooner it might have made a diference for Michael and those that died after him.”

Jo Eggleton, the solicitor for Mrs Cameron, and who has acted in many of the Woodhill cases, said:
“Yet again a jury has found failures in the care of an obviously vulnerable man. Whilst it is encouraging to hear that procedures are changing the inquest also heard from a senior officer that as recently last week one officer was tasked with looking after 180 prisoners overnight including 19 who were subject to monitoring under the suicide and self harm  procedures. That’s an impossible task. Clearly more still needs to be done. “

INQUEST have worked with the family of Michael Cameron since 2016. Maureen Cameron was represented by Jo Eggleton of Deighton Pierce Glynn solicitors, and Nick Armstrong of Matrix Chambers.




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

  1. Daniel Dunkley’s inquest concluded on 28 April 2017 with a neglect verdict, and also found lack of action on previous deaths had contributed to Daniel’s death. Deborah Coles, director of INQUEST has called for corporate manslaughter charges to be brought in this case.
  2. HMP Woodhill currently has the highest number and rate of deaths in England and Wales.
  3. Two of the 18 families bereaved since 2013 by deaths at HMP Woodhill have brought a judicial review (conclusion imminent) on the high number of deaths in the prison. The review was heard on 7 April 2017. The conclusion is due to be published in May.
  4. Ministry of Justice (MOJ) stats show the rate of self-inflicted deaths in prison has more than doubled since 2013.

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.