29 April 2024

Before Coroner Dr Séan Cummings
Milton Keynes Coroners Court
15-26 April 2024

Robert Fenlon, 36, died a self-inflicted death whilst on remand at Woodhill prison on 5 March 2016. Now an inquest jury has concluded that the reprehensible failures by two senior prison officers involved amounted to unlawful killing by gross negligence manslaughter. 

This is the first time an inquest has found that a self-inflicted death in detention amounted to unlawful killing, according to INQUEST’s data. 

The jury found that Senior Officer (SO) Dyson and SO Cushion’s conduct was so exceptionally bad as to amount to a criminal failure. The jury also concluded that Robert’s death was contributed to by neglect (meaning a gross failure to provide Robert with basic care and attention). 

The jury also concluded that there was a serious failure by the prison to implement previous recommendations made after the earlier deaths at Woodhill, and that this serious failure contributed to Robert’s death. 

In the 48 hours prior to his death, Robert had attempted to hang himself and separately had been found with a ligature tied up.

At the time of Robert’s death, Woodhill prison had the highest number of self-inflicted deaths of any prison in the country. Robert was the second of seven people to take their own lives in the prison in 2016, and one of 28 since 2013.*

Robert was from Northampton. His family describe him as big hearted, someone who would help anyone. His daughter remembers his love of books and history. Robert had a long history of substance misuse and mental ill-health. On 15 October 2015, he was remanded to HMP Woodhill.

In February 2016, Robert passed a note under his cell door saying he was in total despair and contemplating suicide. Subsequently, a safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place.

Over the following week, Robert’s mental health deteriorated. He became distressed, extremely paranoid, delusional, and afraid that other prisoners might harm him. No referral was made to the mental health team, a failing that was described as serious by multiple witnesses at the inquest.

On 3 March 2016, officers found Robert ligatured in his cell. There was a conflict in the evidence heard at the inquest about whether a required review of the ACCT took place. SO Dyson insisted that a review took place in the cell soon after Robert was found, and that two members of healthcare attended and participated. 

The healthcare staff flatly denied that any review took place, and the healthcare assistant told the jury that SO Dyson had sought to blame her for his own serious failings. The jury found that SO Dyson had lied: no ACCT review took place and the review document had been fabricated. 

Witnesses at the inquest accepted that Robert should have been put under constant supervision. Instead, his risk was marked as ‘raised’ and his observations set to two per hour. SO Dyson accepted he did not even read the ACCT and that his approach was fundamentally flawed and woefully inadequate.

The next day, an officer again found Robert with a ligature tied up in his cell. The Senior Officer on duty – SO Cushion – finished his lunch before returning to the wing to see Robert. He told the inquest he did not conduct the necessary case review but had “a chat” with Robert instead. 

SO Cushion did not read the ACCT but was aware of the attempted hanging the previous day. SO Cushion took none of the steps required by the ACCT, he recorded no change to Robert’s risk, and he took no further action to keep Robert safe. He accepted in evidence that these were very serious failures.

In the morning of 5 March 2016, officers found Robert unresponsive and ligatured in his cell. He was taken to hospital where he later died.

The jury concluded that Robert died by unlawful killing contributed to by neglect. They found that the following failures and inadequacies contributed to Robert’s death:

  • Failures to follows ACCT procedures, including at two earlier ACCT reviews;
  • An inadequate system to assign ACCT case managers;
  • Staff were inadequately trained in ACCT and conducting risk assessment;
  • None of the 43 recommendations made following previous deaths at Woodhill had been implemented by the time of Robert’s death in March 2016.

Robert’s family said: “We are very grateful to the Coroner and the jury for their care and attention, and to our legal team for their dedication and support over the last 8 years. We have waited a very long time to get justice for Robert. 

We knew from the outset that he was badly failed but we weren’t prepared for just how badly and how many people failed in their duty. Nor did we expect officers to lie, to cover up their wrongdoing and blame others. 

We are disappointed that the prison service tried to prevent the jury from expressing their view about unlawful killing despite the compelling evidence. It demonstrates the same closed thinking that prevented them from learning from those who died before Robert. 

This is an opportunity for the Prison Service to carry out some serious reflection and change their approach. We hope, for us and for other bereaved families, that they take that chance.” 

Selen Cavcav, caseworker at INQUEST, said: “We have been saying for years that state neglect and failure to learn lessons kills. This jury conclusion finally recognises this in the strongest possible terms. It was nothing short of criminal that so many vulnerable people in Woodhill were allowed to die preventable deaths. 

Today we think of all 28 of the people who have died in this prison since 2013, and their families who have fought for justice and change. 

We know that the problems are not confined to HMP Woodhill. Our overcrowded, understaffed and squalid prisons are not working in cutting down crime and reducing re-offending. Instead of going ahead and building more prison spaces, the focus needs to be on diverting people away from custody and investing in community alternatives.”

Jo Eggleton, of Deighton Pierce Glynn, who represents Robert’s family, said: “Robert's daughter alongside her mother has fought tirelessly for 8 years to uncover the truth about her dad's death. This conclusion shows why she was right to do so. 

The jury's findings could not be more serious: it reflects the appalling way Robert was repeatedly failed by senior prison officers at a time when staff were well aware of the high number of self-inflicted deaths at Woodhill. 

Those running the prison were on notice of the repeated failings and should have taken urgent steps to stop this from happening. Although Robert died 8 years ago, HMIP's Urgent Notification issued last year after finding Woodhill unsafe, suggests that many of the issues raised during this inquest are still ongoing today.”



For further information, please contact Leila Hagmann on [email protected] or 020 7263 1111.

The family are represented by INQUEST Lawyers Group members Jo Eggleton & Rachel Tribble of Deighton Pierce Glynn and Jesse Nicholls of Matrix Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.

Other Interested Persons at the inquest are HMP Woodhill, CNWL NHS Trust, Via (previously WDP) and Carole Mead who was a healthcare assistant. 

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

*Deaths in HMP Woodhill:

INQUEST data and monitoring shows that there have been 28 self-inflicted deaths in HMP Woodhill in the 11 year period from 29 April 2013 – 29 April 2024. The most recent death was in November 2023.

The 11 people who took their own lives in the prison before Robert were:

  • Kevin Scarlett on 22 May 2013
  • David Hunter on 26 May 2013
  • Sean Brock on 10 November 2013
  • Stephen Farrar on 12 December 2013
  • Dwane Harper on 4 April 2014
  • Jonathan White on 14 October 2014
  • Daniel Byrne on 27 February 2015
  • Ryan Harvey on 8 May 2015
  • Ian Brown on 19 July 2015
  • Joanne Latham on 27 November 2015
  • Simon Turvey on 29 December 2015

Scrutiny of HMP Woodhill since 2013

Families bereaved by this series of self-inflicted deaths in HMP Woodhill were granted a judicial review aiming to address the high number of self-inflicted deaths in Woodhill. In May 2017 the High Court rejected this claim. Since the hearing there have been a series of highly critical inquests examining the deaths at Woodhill. 

Following the public pressure brought by the families involved in these cases, an independent review by Stephen Shaw was commissioned in May 2017 to examine the circumstances of these deaths. Recommendations were made and some were implemented, while others were not.

After significant scrutiny, in the year of 2017 there were no self-inflicted deaths at the prison. Sadly this change did not last and self-inflicted deaths continued from 2018 and returned to exceptionally high levels in the years which followed. 

Since 2013, HM Inspectorate of Prisons inspected the prisons five times and made significant numbers of recommendations, many of which were not enacted.

In September 2023, HM Inspectorate of Prisons issued an Urgent Notification calling on the Ministry of Justice to take immediate action on continued concerns at HMP Woodhill. The Chief Inspector of Prisons said, “It was especially troubling to find at this most recent visit that none of the recommendations from our 2021 inspection had been achieved. Indeed, many poor outcomes we had previously identified had worsened in some important areas, particularly with regard to safety.”

INQUEST is calling for a National Oversight Mechanism to challenge the failures of institutions like Woodhill to enact potentially lifesaving recommendations arising from inquests and other inquiries and investigations. This would be a new independent public body responsible for collating, analysing and following-up on recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths.