'Reprehensible failures' of two senior prison officers amounted to unlawful killing at Milton Keynes jail

Two senior officers at Woodhill Prison in Milton Keynes have been accused of unlawful killing by gross negligence manslaughter.In a groundbreaking inquest verdict, Milton Keynes coroner Dr Sean Cummings found the behaviour of the officers was “exceptionally bad”.

Dr Cummings had been conducting a lengthy inquest into the death of 36-year-old Robert Fenlon, who was on remand at HMP Woodhill.

The dad-of-one was found in his cell with a ligature around his neck in March 2016. At the time, Woodhill 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 28 since 2013.

His family tried unsuccessfully to instigate a prosecution against Woodhill after his death and this delayed the inquest for many years.

Now, finally, they have the verdict they wanted against the two prison workers, Senior Officer Dyson and Senior Officer Cushion after the inquest jury’s verdict was ‘unlawful killing contributed to by neglect’.

A family spokesperson said this week: “We have waited a very long time to get justice for Robert...We knew from the outset that he was badly failed but we weren’t prepared for just how badly and how many people failed in their duty.”

Jo Eggleton of Deighton Pierce Glynn represented Robert’s family. She said: “Robert's daughter alongside her mother has fought tirelessly for eight years to uncover the truth about her dad's death. This conclusion shows why she was right to do so.”

She added: “The jury's findings could not be more serious: it reflects the appalling way Robert was repeatedly failed by senior prison officers at a time when staff were well aware of the high number of self-inflicted deaths at Woodhill.“Those running the prison were on notice of the repeated failings and should have taken urgent steps to stop this from happening. Although Robert died eight years ago, HMIP's Urgent Notification issued last year after finding Woodhill unsafe, suggests that many of the issues raised during this inquest are still ongoing today.”

Robert, who came from Northampton, had a long history of substance misuse and mental ill-health. In February 2016 he passed a note under his cell door saying he was in total despair and contemplating suicide.

Subsequently, a safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place but over the following week, Robert’s mental health deteriorated. He became distressed, extremely paranoid, delusional and afraid that other prisoners might harm him.

But no referral was made to the mental health team, a failing that was described as serious by multiple witnesses at the inquest.

He had already attempted to hang himself once in the 48 hours before his death but was discovered in time, the inquest heard.

However, the Senior Officer on duty – SO Cushion – finished his lunch before returning to the wing to see Robert. He told the inquest he did not conduct the necessary case review but had “a chat” with Robert instead.

The officer took none of the steps required by the ACCT, recorded no change to Robert’s risk, and he took no further action to keep Robert safe, the inquest heard. He accepted in evidence that these were very serious failures.

Witnesses at the inquest accepted that Robert should have been put under constant supervision. Instead, his risk was marked as ‘raised’ and his observations set to two per hour. Senior Officer Dyson accepted he did not even read the ACCT and that his approach was fundamentally flawed and woefully inadequate.

The jury found that SO Dyson and SO Cushion’s conduct was so exceptionally bad as to amount to a criminal failure. They concluded that Robert’s death was contributed to by neglect (meaning a gross failure to provide Robert with basic care and attention).The jury also concluded that there was a serious failure by the prison to implement previous recommendations made after the earlier deaths at Woodhill, and that this serious failure contributed to Robert’s death.

This is the first time an inquest has found that a self-inflicted death in detention amounted to unlawful killing, according to data from the charity INQUEST.Selen Cavcav, caseworker at INQUEST, said: “We have been saying for years that state neglect and failure to learn lessons kills. This jury conclusion finally recognises this in the strongest possible terms. It was nothing short of criminal that so many vulnerable people in Woodhill were allowed to die preventable deaths.

"Today we think of all 28 of the people who have died in this prison since 2013, and their families who have fought for justice and change.“We know that the problems are not confined to HMP Woodhill. Our overcrowded, understaffed and squalid prisons are not working in cutting down crime and reducing re-offending. Instead of going ahead and building more prison spaces, the focus needs to be on diverting people away from custody and investing in community alternatives.”

INQUEST is calling for a National Oversight Mechanism to challenge the failures of institutions like Woodhill to enact potentially lifesaving recommendations arising from inquests and other inquiries and investigations.