A coroner has said he was outraged by an unlawful prison detention at HMP Woodhill jail in Milton Keynes that worsened a man’s mental health crisis.
An inquest into the death of 29-year-old Mark Culverhouse ended on Friday with the jury finding that critical failures contributed to his death.
These failures included putting Mark in segregation and unlawfully detaining him past his license expiry date.
He had spent four days in custody before he was found unresponsive in his cell in April 2019 after using a ligature. He died shortly afterwards.
Senior coroner, Tom Osborne has now indicated he will be writing a report to prevent future deaths at the prison, which was once dubbed ‘suicide jail’.
Mr Osborne said the unlawful detention had led Mark further into crisis and eventually death. He said that it was contrary to the Magna Carta of 1215.
The inquest had heard that on 17 April 2019, Mark was in serious crisis in the community. He climbed up scaffolding and threatened to jump from the third storey of a building. He was brought down by skilled negotiators but then arrested for offences directly related to the incident.
Mark was then taken to Northampton Police Station, where two doctors deemed him fit to be detained – despite the negotiator wanting him to have a formal Mental Health Act assessment.
Mark was subsequently interviewed and charged. The next day he was taken to Northampton Magistrates’ Court but then diverted to hospital because he had self harmed.
Mark repeatedly indicated that he would kill himself if returned to prison, the inquest heard. But while he was in hospital and despite the fact that he was suicidal, the probation service decided to recall Mark to prison in relation to a previous short sentence of driving while disqualified.ADVERTISING
He was still in deep crisis upon arrival and was captured on CCTV saying he had been recalled for trying to take his own life and asking to be taken to hospital.
The inquest heard that the probation services do not calculate sentences before deciding to recall someone.
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.
The jury also concluded that a defect in the system of recall and release from prison that led to Mark’s unlawful detention, and contributed to his death.
Mark was the second of four men to die in the prison in 2019. The most recent inspection of HMP Woodhill found the prison is ‘still not safe enough’.
Mark’s mother Wendy Culverhouse 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.”
Jo Eggleton of Deighton Pierce Glynn solicitors said: “The fact that a man in suicidal crisis was recalled to prison by probation officers in relation to a 16-week sentence is bad enough, but in this case it transpired that Mark had 81 unused days due to him. Had probation known that they could not have recalled him. The defect in the system meant that he spent four nights in custody, where he repeatedly expressed that he was in crisis.
“The ACCT system did not protect him – despite the exceptionality requirement, he was twice placed in segregation by officers concerned with discipline and not his obvious vulnerability. He was then able to ligature in segregation because prison officers ignored that fact he was under a sheet on the two occasions they purported to observe him through the panel.”
Deborah Coles, director of INQUEST charity, said: “Woodhill has had one of the highest numbers of self-inflicted deaths in prison in recent years, with numerous critical inquests identifying failures in their care. Despite promises that lessons will be learned after every death, they maintain unsafe practices and continue to put people at risk.”
She added: “Mark’s imprisonment and subsequent death at Woodhill should never have been allowed to happen. Not only because this prison has had ample opportunity to change, but because there was no lawful basis for his detention. For these failures Mark paid with his life.
“What would it take for this prison to prevent deaths, and for the Ministry of Justice to take effective action to prevent the imprisonment of people with serious mental ill health, and protect lives in prisons?”
These were the other deaths at Woodhill between 2018 and 2019:
- Chris Carpenter, 34, was found unresponsive in his cell in August 2018. The inquest found that his death was drug related. The jury identified a series of failures by prison and healthcare staff and concluded that the risk management of Chris, ‘a very vulnerable prisoner’ was ‘inadequate’.
- Darren Williams, 39, died a self-inflicted death in HMP Woodhill on 4 January 2019. The jury found failures relating to information sharing, ACCT processes and the handling of reports made by Darren explaining the threats he was facing due to being in debt. Media release, November 2019.
- Ryan Harvey, 23, died on 8 May 2015, after he was found hanging in his cell in HMP Woodhill five days prior. The jury found a series of systemic failures caused his death, including a failure by healthcare staff to undertake an adequate assessment of his learning disability and conduct an assessment of his mental health. Media release, January 2019.
Suicide is preventable and support is available, such as Samaritans’ helpline. When life is difficult, Samaritans are there – day or night, 365 days a year. You can call them for free on 116 123, email them at firstname.lastname@example.org, or visit their website to find your nearest branch.