Ian Keith Brown · Prevention of Future Deaths report

On 20/07/2015 I commenced an investigation into the death of Ian Keith Brown, 44 . The investigation concluded at the end of the inquest on 26 April 2016. The conclusion of the inquest was set out in the Jury's narrative conclusion set out in their answers to the questionnaire.

Mr Brown suffered from mental illness and had been on remand at HMP Woodhill since the 10th January 2015 and occupied Cell 301 in House Block 3B.At 12:10 hours on Sunday the 19th July 2015 he was locked in his cell (he was the only occupant), he pressed his bell. PO Gary Lindo responded and Mr Brown said he wanted to speak to Senior Officer Miss Jones. He was told that she was on her lunch break and could probably come and see him after her break. At 13:10 hours 19/07/2015 PO Phil Arthur started his rounds to check the cells. Mr Brown's cell was the first one. The PO looked through the hatch and saw that Mr Brown was slumped forward in his chair facing the window. There was a belt ligature tied around his neck which was connected to the window. PO Arthur called a "code blue" (prisoner not breathing) through his radio for help. He then entered the cell and cut the ligature with his fish knife and proceeded to do CPR until Healthcare arrived. An ambulance was called and Paramedics confirmed death at 14:00 hours. A short note written to his sister was found in his cell.

(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour.
(2) Deaths at the prison from suicide and self harm continue to rise.
(3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored.
(4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise.