14th June 2011

before HM Coroner for Thurrock and Essex, Caroline Beasley-Murray
sitting at The County Hall, Chelmsford, Essex CM1 1LX

The inquest into the death of Simon Gregory concluded yesterday, with a jury returning a unanimously critical verdict. The jury found that Mr Gregory killed himself, in part because:

[The]state failed to protect and recognise [the] risk of the prisoner through inappropriate care and support, inadequate staffing levels during patrol state and lack of essential equipment to deal with medical emergency.

Mr Gregory died in HMP Chelmsford on 27 November 2007, only days after cutting his wrists, repeatedly asking to speak to the Samaritans and telling cellmates and staff that he was suicidal.

Although the prison placed Mr Gregory on regular observations having assessed him as being a suicide risk, the family raised serious concerns about whether appropriate steps were taken to secure his safety and wellbeing.

On the night of Mr Gregory’s death a staff shortage meant that a prison officer on day shift was pulled straight onto the night shift, and was responsible for the entire population of 126 prisoners of E Wing. There was no handover and in his evidence the officer explained he had no time to read the observations written down in Mr Gregory’s record. The Senior Officer who assessed Mr Gregory referred to him as “desperate and in need of support,” but his comments were never read by the officer on the wing.

Kat Craig, solicitor for the family, said:

Mr Gregory’s death is a tragic example of a failure on behalf of the prison to adequately intervene and respond to an acute need for support and care. The jury’s findings on this point are firm indication that more should have been done, and that the prison was ill-equipped and under-resourced to deal with vulnerable prisoners.


The family hopes that the failings identified will improve conditions for vulnerable prisoners in future.

Katrina White, Mr Gregory’s youngest sister, said:

Simon was a kind and loving father, son and brother. Simon’s death, which we firmly believe could have been avoided, has left a big hole in our lives. We have however found some solace in the verdict that the prison failed to protect and recognise the risk he posed to himself through inappropriate care and support, inadequate staffing levels during patrol state and lack of essential equipment to deal with medical emergency. I hope this will encourage HMP Chelmsford, and others caring for vulnerable people in custody, to improve the care provided to prisoners like Simon.

The jury also found that there was “lack of essential equipment to deal with medical emergency” following the evidence of a prison nurse that no defibrillator was taken to Mr Gregory’s cell when he was found hanging, in part because it was “cumbersome” and that it was very old, and did not work very well.

Mr Gregory’s death is one of a number of deaths in HMP Chelmsford in the last ten years [see full list below]. A Senior Officer accepted on cross-examination by the family’s barrister that there had been “a lot of self-inflicted deaths by hanging in [the] prison.” Sadly, another death has occurred in HMP Chelmsford in similar circumstances only last month.

The government initially refused funding for the family to be legally represented in this case, stating that they were “not satisfied” that it was necessary for the family to be legally represented. The family’s solicitor challenged the refusal of funding and threatened to bring judicial review proceedings, but the government only conceded the matter at 15:45 on the Friday before the inquest was due to start.

Ms White, a 25 year old mother of two, stated:

I was appalled and deeply distressed to learn that I, as a bereaved family member, would not be able to draw on the support and expertise of my legal team during the inquest, whilst the prison was able to rely on public funds to be represented throughout. I am grateful to my legal team for working throughout the weekend and preparing so thoroughly for my brother’s inquest. I believe I could never have achieved the result without them, and that it is in the public interest that lessons are learnt by the prison so no other family is made to endure the loss of a loved one.


Helen Shaw, Co-Director of INQUEST, said:

The issues raised by the jury in its verdict on Simon Gregory’s death demonstrate that there are fundamental and systemic problems at HMP Chelmsford which undermine its ability to keep vulnerable prisoners safe. His death is one of a number of self-inflicted deaths in the prison, the latest of which occurred just last month. Serious questions need to be asked about what has been learned and done in response to previous inquest findings.

Not only have the family had to bear the stress of such traumatic bereavement but also they have been additionally distressed by the appalling delays in obtaining funding for their legal representation – when by contrast the Prison Service is automatically legally represented at public expense. The extensive and thoughtful verdict from the jury demonstrates how important family legal representation is in assisting the coroner to hold a full and fearless inquest.

Simon Gregory’s family was represented by INQUEST Lawyers Group members counsel Colin Hutchinson of Garden Court Chambers, instructed by Kat Craig of Christian Khan Solicitors.

Notes to editors:

Self-inflicted deaths HMP Chelmsford 2001-date




Date of death



Simon King


UK White


Billy Coulson


UK White


Lee Rawlinson


UK White


Vinith Kannathasan




James Sullivan


UK White


Joker Idris


Black African


Simon Gregory


UK White


Stewart Kight


UK White


Peter Kirkwood


Black African


Stuart Hampson


UK White


Marcus Downie


UK Black


Derek Ive




Source: INQUEST Casework and monitoring