Urgent review ordered after death of man unlawfully detained at Milton Keynes prison
Coroner issues Prevention of Future Deaths report
A tragic death of an inmate who should never have been in prison at all has prompted a stern warning from the Milton Keynes Coroner.
Tom Osborne conducted the inquest earlier this month of 29-year-old Mark Culverhouse, who took his own life in a segregation cell at Woodhill Prison, MK, in April 2019.
Mark had been suffering a mental health crisis and had come to the attention of police after threatening to jump from the third storey of a building.
He was arrested due to arrested for offences directly related to the incident and the decision was made to commit him to prison.
But it transpired that he had no time left to serve on his licence and should in fact have been immediately released, the inquest heard.
However, no administrative staff were present to calculate his release date over the Easter bank holiday weekend, so he remained incarcerated and in four days was twice removed to segregation.
Mark was on an ACCT and subject to suicide and self-harm monitoring throughout his time in the prison and was moved to segregation. On 19 April he was was taken to hospital after self harming again.
On 23 April 2019, after an altercation with another prisoner, Mark was restrained and again taken to segregation, although still on an ACCT. Observations that day reported him being 'under a sheet' in the cell..
Earlier that same day, administrative staff had been alerted to the fact that Mark might be due for immediate release. This was not communicated to him. By the time they confirmed the calculation he had taken his own life.
The inquest jury concluded that the decision to transfer Mark to the Segregation Unit on 23 April contributed to his death. They found that the manner of observations, with his body obscured by a sheet during the observations, were insufficient.
Mr Osborne has now issued a Prevention of Future deaths report and has sent copies to HMP Woodhill, the Chief Coroner, Northants police and the government legal department.
The report states: "During the course of the inquest into the death of Mark Culverhouse it became apparent, and indeed was accepted that his detention at HMP Woodhill from the 18th of April 2019 until the 23rd of April 2019 was unlawful."
It adds: "He had been recalled under the terms of his license having been released from Peterborough prison on the 12th of April 2019. The calculation of his release date was not conducted by the offender management unit at the prison until the 23rd of April 2019, after the extended Easter bank holiday.
"I was told that there was no process in place whereby a prisoner’s release is calculated until such time as they come back into custody. The prison and probation ombudsman brought this matter to the attention of the prison service recommending that the release date calculation should take place within one working day of the prisoner arriving in prison.
"I cannot see how that can be acceptable particularly where, in Mr Culverhouse’s case, it would have made no difference because of the bank holiday. I consider that there was a clear link between his unlawful detention and his eventual death on the 24th of April 2019."
The report adds: "In order to prevent similar deaths in the future, I believe an urgent review is required and the system changed to ensure that the calculation of the release date is made prior to the decision to recall being taken. This will avoid the possibility of anyone being unlawfully imprisoned in this country under similar circumstances."
Woodhill jail must now respond to the report within 58 days.
Mark's mother Wendy said: “Mark is the light in my life. He just wanted some help. He should have been taken care of, not sent to prison. The coroner and the jury know Mark should not have been in prison. I hope that changes will be made so no family ever has this terrible experience.”