24 May 2021

Before Dr Anton van Dellen, HM Assistant Coroner
West London Coroner’s Court
10 – 21 May 2021

Winston Augustine, 43, died on Thursday 30 August 2018 at HMP Wormwood Scrubs. An inquest has concluded that multiple failures by the prison service to meet Winston’s basic needs directly contributed to his death.

Winston had a Mixed ethnic background of Black Caribbean and White British. He had been transferred to the segregation unit on 28 August 2018 and was found hanging in his cell 48 hours later. The inquest heard evidence that during his time on the segregation unit Winston’s cell door was not unlocked, he did not receive any food or exercise, was not able to shower or make a phone call, and received only one low dose of his pain relief medication.

At the time of his death Winston was in a state of ketoacidosis suggestive of starvation. The jury found that a failure to provide food was a contributing factor to Winston’s death. Following the jury’s conclusion, the coroner stated that it was a matter of ‘greatest concern’ and a ‘violation of Winston’s dignity’ that in an English prison he didn’t receive food for as long as he did.

The inquest was told by prison officers that they did not consider it safe to open Winston’s cell door to provide him with food and access to medication, describing him as non-compliant. The prison’s then Head of Safer Custody gave evidence that she was ‘amazed’ and ‘horrified’ to learn of this on the day after Winston’s death, stating that “in every prison in the country men and women are offered three meals a day”. She confirmed that the situation should have been escalated to senior officers on the 29 August and described the failures as ‘a wrongdoing’.

The jury concluded that factors contributing to Winston’s death included a lack of communication, inadequate recording and use of documentation, and no use of escalation procedures.

Winston suffered from chronic pain caused by kidney stones and was prescribed a daily slow-release dose of the strong painkiller Tramadol. A prison doctor who conducted a GP and medication round on the morning of 29 August was told by prison officers that Winston was too aggressive to be seen, therefore did not approach his cell. He told the inquest that in retrospect he should have insisted on speaking to Winston himself through the cell door and has since reflected on his practice.

Later on the afternoon of 29 August a nurse was able to dispense a single low dose of pain-relief medication by pushing it under Winston’s cell door in a situation described by the nurse as ‘inhumane’. A second nurse who conducted the medication round on 30 August was told by officers that Winston had refused his medication, although she did not hear any words from his cell. When she asked to see her patient she was again told by officers that he was too aggressive to be seen.

The jury found that the failure to provide medication was a contributing factor to Winston’s death. As a result of missing two daily doses of his pain relief Winston would have been in severe pain at the time of his death. The inquest heard evidence that he would also have been in the early stages of withdrawal from Tramadol leading to feelings of psychological distress.

Winston was found hanging in his cell at 16:47 on 30 August 2018 and was pronounced dead at the scene. Witnesses described Winston as being ‘very very cold’ and in a state of rigor mortis when he was found. Pathologists gave evidence that although calculating time of death is not an exact science, based on the observed rigor mortis and measured body temperature Winston had probably died at least 4-5 hours before he was found.

The jury found that the evidence did not fully explain whether Winston intended his act to be fatal, or if he expected to be found and rescued. The inquest heard that Winston had no significant history of mental ill health or self-harming behaviour, and that staff had no concerns that he may be at risk of suicide.

The jury found that the inadequate frequency and quality of welfare checks probably contributed to Winston’s death. National prison policy requires that welfare checks of each prisoner in the segregation unit are conducted at least hourly. The inquest heard evidence that on the day of his death Winston was not checked for four hours between 11:12am and 15:08pm. Despite this failure, on each occasion prison officers signed a cell check log to indicate that checks had been completed.

On the day of his death Winston had covered the observation panel in the door of his cell. Officers who conducted the only two welfare checks on the afternoon of Winston’s death, at 15:08 and 15:53, gave evidence that they were able to see a small portion of Winston’s upper body and head respectively in a position close to the cell door where he was later found dead. Neither officer observed movement, described by other witnesses as the minimum expectation for a welfare check. Despite this, both officers gave evidence that they had no cause for concern and did not consider opening Winston’s cell door. Evidence from the pathologists suggests that Winston was most likely to have been already dead at the time of these checks.

Winston’s family describe him as a loving and caring man who adored his family, especially his mum. He was an active and caring stepfather to his partner’s children, attending her son’s football matches every Sunday. For many years Winston worked with the arts charity Safe Ground, focused on using drama to support current and former prisoners. He accepted the Longford Prize on their behalf. Winston had been in Wormwood Scrubs previously and was released in January 2017.

After the ten day inquest, the jury found that Winston’s death was caused by hanging. In a narrative the jury found that the following factors contributed toward Winston’s death:

  • The failure to fulfil his basic requirements of a statutory regime and provision of food and medication.
  • Inadequate supervision such as the frequency and quality of welfare checks.
  • That the people responsible for Winston’s direct care were not adequately informed of vital information in order to provide for his welfare needs.
  • Inadequate recording and use of documentation; lack of communication between healthcare, custodial staff and managers; and no use of escalation processes that were available.
  • That the operational direction [of the segregation unit] did not reflect the individual care of the residents.
  • Inadequate training of segregation staff, including the use of staff cross-deployed from other units and those still on probation.
  • In conclusion, that Winston relied on the prison service for his basic needs which were not met.

On behalf of the family, Winston’s cousin Diane Martin said: “As a family we knew Winston to be so loving and caring. This is the side many people did not see. Unfortunately, Winston carried out crimes to feed an addiction that came from being in physical pain. He was more than remorseful afterwards. We have concerns about how a prison is run. It shouldn't have taken Winston’s death for things to be rewritten. Policies should have been in place and carried out correctly. We will miss Winston greatly and wish to thank our solicitor and barrister, the coroner jury and INQUEST.”

Deborah Coles, Director of INQUEST, said: “In Wormwood Scrubs a man racialised as Black is locked in solitary confinement for 48 hours, with no access to food or prescribed pain medication. Left for days, starving, in pain and increasing distress. This sounds like a story from the 1800s when this prison was built. This was August 2018.

The evidence of the inquest into Winston’s death exposes basic failures at every level. This was a healthy man who was labelled as aggressive, written off, and driven to his death. Prison staff lost sight of Winston’s humanity and of their duty to keep him safe. This shocking treatment is part of a pattern of inhumanity uncovered at inquests, particularly into the deaths of Black and racialised people, in prisons and detention. It must not be allowed to continue.”

Tim Lloyd of Matthew Gold & Co. who represent the family said: “It is truly shocking that in the twenty-first century Winston died isolated in a prison cell without food, medication, or even a shirt. The evidence and the jury’s conclusions paint a grim picture of a dysfunctional unit marked by a basic lack of care and dignity. My clients thank the jury and coroner for bringing attention to these issues. We will never know how many men faced similar treatment which has not been brought to light by an inquest.

The management of Wormwood Scrubs assured the inquest that immediate improvements were made to the segregation unit following Winston’s death. My clients hope that Winston‘s death will lead to a real and lasting cultural change, however they remain concerned that avoidable deaths continue to occur at Wormwood Scrubs and across the prison estate.”


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected] or Tim Lloyd of Matthew Gold & Co. on 0204 445 9268 or [email protected]

Winston’s family are represented by INQUEST Lawyers Group members Tim Lloyd of Matthew Gold & Co. solicitors and Anita Davies of Matrix Chambers. They are supported by INQUEST caseworker Bola Awogboro.

Other Interested persons represented are the Ministry of Justice, Practice Plus Group (formerly Care UK), the Forward Trust, and Barnet Enfield and Haringey Mental Health NHS Trust.

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

The latest statistics on deaths and self-harm in prison in England and Wales (published 29 April 2021) showed a record high of 154 deaths in prison in the past quarter, and a 42% increase in deaths in the past 12 months.

Since 2015 there have been 23 deaths of men at HMP Wormwood Scrubs, of which 11 were reported by the prison to be self-inflicted. The most recent death was in March 2021.