4 October 2023

PLEASE NOTE: This inquest has been adjourned unexpectedly, pending relisting.

Before Coroner Dr Séan Cummings
Milton Keynes Coroners Court
Civic, 1 Saxon Gate East, Milton Keynes, MK9 3EJ

Robert Fenlon, 36, died by ligature whilst on remand in Woodhill prison on 5 March 2016. In the 48 hours prior to his death, he had ligatured twice. Now an inquest will look at the circumstances of his death and the care he received in prison.

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 men to take their own lives in the prison in 2016, and one of 27 since 2013. 

Robert was from Northampton. His family describe him as a big-hearted person who would help anyone. His daughter remembers his love of books and history. 

Robert had a long history of substance use 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 would self-harm. 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, paranoid and afraid that other prisoners might harm him.

On 3 March, two prison officers found Robert ligatured in his cell. The next day, another officer again found Robert with a ligature in his cell. 

In the morning of 5 March, officers found Robert unresponsive and ligatured in his cell. He was pronounced dead soon after.

Following Robert’s death there was a prolonged police investigation at the conclusion of which the Crown Prosecution Service decided not to bring charges against the prison service, two senior prison officers or a healthcare assistant. Robert’s family unsuccessfully challenged that decision in the High Court. 

It is expected that the inquest will now consider the adequacy of management of risks to Robert in the lead up to his death.

The family hope the inquest will address their concerns about the care that Robert received prior to his death, and whether his death could have been prevented both at the time and had recommendations following previous deaths been acted on sooner. 

They also hope it will look at any ongoing risks in Woodhill as highlighted in HM Inspectorate of Prisons’ Urgent Notification issued on 1 September 2023. 



For further information, please contact Lucy McKay on [email protected] 

A photo of Robert is available here.

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

Other Interested Persons represented at the inquest are HMP Woodhill, CNWL NHS Trust, The Prison Officers Association, 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.