6th July 2017

Before HM Senior Coroner Tom Osborne
Milton Keynes Coroner's Court
26 June – 5 July 2017

The inquest into the death of Thomas Morris, known as Tom, yesterday concluded with the jury finding that prison authorities failed to take all reasonable precautions to prevent Tom from committing suicide. The 31 year old was found hanging in his cell in HMP Woodhill on 26 June 2016. 

His death was fourth of seven self-inflicted deaths in the prison that year, and is one of 18 since 2013. Following a recent unpublished report by Stephen Shaw, former Prison and Probation Ombudsman, which was highly critical of the unacceptable situation at Woodhill, the prisons main function is to change from a local remand prison to a Category B training prison.

The jury found that the following all contributed to Thomas’s death:

  • a failure properly to assess Thomas’s mental health
  • a failure to appropriately carry out the ACCT procedures and reviews
  • a failure to share and use relevant information concerning Thomas Morris
  • that it was not appropriate after Thomas had thrown his television on 19 May to transfer him off the detox wing to a different unit; to allocate him to a single cell or to reduce him back to basic privileges;
  • a failure by the prison properly and appropriately to implement previous recommendations;

The inquest heard that in the days prior to his death Tom had complained about things crawling under his skin and had thrown his TV from a second floor landing, claiming that it was speaking to him. The prison decided to discipline Tom, placing him on a basic regime as punishment and moving him off the detox wing. Evidence showed that his deteriorating mental health condition was not taken into account, despite a prison nurse warning that any decision to move him off the wing should  be deferred until he was assessed by a mental health team.

Tom had attempted to take his own life only a month before when he was discovered with a ligature by other prisoners and officers intervened by cutting the ligature. Throughout his time in Woodhill he had been a subject of three separate suicide and self harm management programmes but the evidence heard at the inquest showed that the procedures followed were not adequate and serious problems were identified by the jury in relation how his risk of suicide was managed.  Officers repeatedly relied on what he was telling them in relation to plans to take his own life rather than considering the bigger picture and ignoring trigger points such as being on the basic regime and the move to a single cell.   Tom told an officer on 22 June that he had made numerous  ligatures and was  continuing to express a sense of helplessness and despair.  The jury found that there were multiple missed opportunities to keep Tom safe.

Following his death 67 fellow prisoners compiled and signed a letter to the Governor, raising serious concerns about the shortcomings of the prison that led to Tom’s death and sending condolences to his father. 

The family of Tom Morris said: “The inquest process has answered the questions we had about Thomas’s care. We are grateful to the jury for confirming our thoughts about the various failings we have heard about. We are glad to hear that there have been changes made and the fact that there have been no self-inflicted deaths in the prison this year brings us some comfort.  We agree with the Coroner that it is vital that lessons are learnt immediately. If they had been Thomas might still be with us.”

Jo Eggleton, the solicitor for Mr Morris, and who has acted in many of the Woodhill cases, said: “The failings in this case are sadly all too familiar, although the scale and breadth of them is particularly shocking, especially as they came in June 2016 at a time when the prison was already under scrutiny and aware of most of these problems. The inquest heard that a recent report by Stephen Shaw (a former Prison & Probation Ombudsman)  commissioned by the Secretary of State because of the Judicial review brought by some Woodhill families concluded that staffing difficulties has resulted in a completely unacceptable situation at Woodhill that has been allowed to persist for far too long.  In this context the decision to drastically change Woodhill’s main function from a local remand prison to a Category B training prison is a welcome step to ensuring the safety of men incarcerated there.”

Selen Cavcav, the family’s caseworker at INQUEST said: “As the rate of self inflicted deaths in our prisons continues to rise, it is particularly frustrating to see that same failures are repeated over and over again.  Whilst we welcome the changes being made in HMP Woodhill we know that the problems are not going to go away by shifting the prison population from one prison to another.  The current system for learning lessons and implementing change is not fit for purpose.  The government must urgently introduce a national oversight mechanism to ensure lessons from deaths like Tom’s, and the many who died before and after him at Woodhill, stop falling on deaf ears “

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

INQUEST has been working with the family of Thomas Morris since his death. The family is represented by INQUEST Lawyers Group member Jo Eggleton of Deighton Pierce Glynn Solicitors & Nick Armstrong of Matrix Chambers.

1. Background information is available here in the release issued at the opening of the inquest.

2. INQUEST have been calling for a national oversight mechanism on state related deaths for over ten years. The Joint Committee on Human Rights put forward this recommendation in their recent interim report on mental health and deaths in prison. More information here.

3. A total of 18 self-inflicted deaths have taken place in Woodhill since early 2013, when concerns were first raised. Since then families were granted a judicial reviewaiming to address the high number of self-inflicted deaths in Woodhill.

4. The high court rejected this claim, however since then an inquest jury concluded that failure by HMP Woodhill to learn from previous suicides caused the death by neglect of Daniel Dunkley who died just five weeks after Tom.

5. The number of self-inflicted deaths in prisons across England and Wales has more than doubled since 2013. More information on the record number of self-inflicted deaths in prisons is available here, or in the Ministry of Justice Safety in Custody statistical bulletins.

6. A list of the 17 self-inflicted deaths in HMP Woodhill between May 2013 and November 2016 can be found here. The 18th death was that of Jason Basalat, aged 52 who was found hanging in his cell on 11 December 2016.


Closing remarks from HM Senior Coroner Tom Osborne:

"It can't have been easy, as parents, to have sat and heard what you have. I repeat what said in April regarding Daniel Dunkley. I am absolutely convinced that every prison officer when he/she attends to start work do so with the intention to keep prisoners safe and treat them with humanity, however they are often overtaken by events, as they were with Thomas, when the number of ACCTs at that point meant they were no longer working.The situation cannot be allowed to continue. I hope under the leadership of  Governor Marfleet things will change. It is essential she is supported by the prison service and government otherwise all the other deaths (Thomas’s, Daniel’s and Kevin Scarlett’s) will have been in vain.

I am pleased the use of ACCTs is under review now that recognition that with such large numbers of prisoners on ACCTS is becomes unworkable. It is essential lessons are learned and changes implemented immediately. We must learn from our mistakes and change when systems inadequate. Failure to learn from mistakes one of the single greatest obstacles to human progress. Unless learn and implement change other lives will be lost and in my view that cannot and will not be allowed to happen. I hope this inquest, and investigation will add to that body of work to ensure lessons learnt and prions safer as a result. Small consolation to you and your family but let’s hope we are not back here in 6 months time with another death in similar circumstances."