8 July 2016

HM Senior Coroner Peter Dean heard the inquest into the death of Steven Trudgill, a 23 year old who died at HMP Highpoint. The inquest concluded on 24 May 2016, after two and a half weeks of evidence. Steven was found hanging in his cell by a prison officer on 9 January 2014 and died shortly after. The jury conclusion was suicide. HMC Peter Dean has now issued a Prevention of Future Death report to the Prisons Minister expressing his concerns about the mental health needs of prisoners serving IPP sentences.

Steven was a vulnerable young person, with longstanding mental health problems. He was remanded into custody when he was 18 and subsequently transferred 4 times to different prisons. He began to self harm whilst in custody and had been subject to prison suicide and self-harm preventions procedures on numerous occasions throughout his detention, including at HMP Highpoint where he was transferred in December 2013, shortly before his death.

The inquest heard that Steven was ‘stuck’ in the system. He was serving an IPP, and was several years past the minimum term which had been set by the sentencing judge. As with all indeterminate sentenced prisoners, Steven could only be released by the Parole Board. However whilst in prison, Steven was finding it extremely difficult to progress. The family heard evidence at the inquest that the mental health support Steven  received was inadequate: Steven had a history of self harm, he was being prescribed medication without any clear diagnosis or treatment plan, and had been seriously destabilised by the unexpected closure of HMP Blundeston and his transfer between two successive prisons immediately before Christmas 2013. He was very anxious about his forthcoming Parole Board review which had been delayed. At HMP Highpoint Steven spoke to staff about his thoughts of suicide, including one lengthy conversation two days before his death, but there were problems in passing key information about risks between prison staff.

The Coroner has warned the Prison’s Minister that action needs to be taken to reduce the risk of other IPP prisoners dying in similar circumstances in the future.  He has reported his concern that there are other vulnerable prisoners still on IPP’s, who are at significant risk of continuing self harm due to the prison system being inadequate to meet their needs. He noted the infrequent nature of Parole Board hearings, occurring only every two or three years, as the only means of assessing whether the prisoner should be released, as well as the lack of availability of specific treatments for complex mental health needs which may be the cause of continued risk resulting in extended detention. The Coroner has called on the Prisons Minister to consider assessing all prisoners currently still within the prison service on IPP’s to see if they have mental health needs more appropriately managed with the mental health service rather than the prison service. 

The Prison’s Minister is due to respond in August, at which point the report and the response will be published.

IPP sentences were abolished by the Legal Aid Sentencing and Punishment of Offenders Act in 2013 following widespread concern that they had been misused by over-cautious judges and there were now thousands of prisoners stuck in the system without release date, or the means by which they could demonstrate their readiness for release.

People serving an IPP have one of the highest rates of self-harm in the prison system. For every 1,000 people serving an IPP there were 550 incidents of self-harm. This compares with 324 incidents for people serving a determinate sentence, and is more than twice the rate for people serving life sentences.

Steven’s mother Jennie Buckle said: Steven’s family are disappointed that after 3 weeks of evidence the jury took just 1½ hours to come to a conclusion.  We are shocked and saddened that despite evidence given under oath showing that mistakes were made, the jury chose to ignore this. 

We take comfort that since Steven’s sad death a number of new practices have been implemented at HMP Highpoint to help prevent future deaths.

We are also glad that the Senior Coroner for Suffolk, Dr Peter Dean, has recognised that despite IPP sentences being abolished there are still prisoners on IPP sentences serving time above their tariff that could be vulnerable to mental health issues.  We are very pleased with the Prevention of Future Death Report that he has written to the Prisons Minister requesting changes be made to the current system that failed Steven.  The aim of this proposal would be to ensure that the appropriate level and form of mental healthcare can be provided to prisoners serving IPP sentences  in the most suitable environment in order to manage their underlying condition and reduce the risk of suicide, reduce future risk to the public and provide care that might enable them to be more safely released in future, while still providing current public protection by virtue of the security of the unit.

We hope and pray that the new practices are followed and don’t just become a “tick box exercise”.  The only way to help prevent future deaths is to make real changes and give people the help and care needed.”

Deborah Coles, Executive Director of INQUEST said: INQUEST welcomes the report of the Senior Coroner for Suffolk Dr Peter Dean. The statistics for self harm of prisoners serving IPP sentences are truly shocking and while it was a positive step that such sentences were abolished, changes must be made urgently to ensure the safety and protection of those still serving IPP sentences within the prison system.


INQUEST has been working with the family of Steven Trudgill since 2014. The family is represented by INQUEST Lawyers Group member Sara Lomri from Bindmans solicitors and Jesse Nicholls from Doughty Street Chambers.