Wayne Boughen · Prevention of Future Deaths report

On 21st November 2018, Senior Coroner, Kevin McLoughlin commenced an investigation into the death of Wayne Boughen, aged 40. The investigation concluded at the end of the Inquest on Thursday 3rd June 2021. The conclusion of the Inquest was that Wayne Boughen deliberately suspended himself with a ligature around his neck, but the jury were unable to determine his intention in doing so. The medical cause of death was 1a. hypoxic-ischaemic encephalopathy, 1b. hanging.

Wayne Boughen was detained in HMP Leeds at the time of his hanging. He was found suspended from a ligature in cell D2-42 at 00:42 hours on 16th November 2018 and died in Leeds General Infirmary on 17th November 2018. Wayne deliberately suspended himself from a ligature and no one else was involved in his death. As to Wayne’s intentions the evidence is inconclusive.

The wider circumstances of Wayne’s death are as follows:

1. Recent (within the 5 weeks leading up to his death) incidents of self-harm, threats of suicide and a claimed suicide attempt.
2. A missed visit from his mother in the days before his death. The reasons for the cancellation of this visit were unclear. Wayne had stated the importance of this relationship to his well-being.
3. The psychiatric evaluation planned for 14th did not take place. No reason has been established.
4. There was an open ACCT requiring among other things (at the time of the hanging) hourly irregular observations.
5. Prison officers differed in their interpretation of ‘hourly irregular observations’ eg whether that required a maximum of 60 minutes between observations.
6. Wayne was in a standard cell.
7. There were no cells in HMP Leeds meeting the national guidelines for safer cells.
8. Family members and fellow prisoners had raised concerns about Wayne’s mental health in the weeks before his death.

1. At the time of Wayne Boughen’s death, HMP Leeds did not have any cells which were certified safer cells (anti-ligature cells) in accordance with national standards.
2. HMP Leeds still does not have any such certified safer cells.
3. HMP Leeds has a small number of cells which have an increased level of safety as compared with the majority of cells within the prison, but even they do not comply with the certified safer cell standards.
4. In an ordinary cell, Wayne Boughen was able to suspend himself using a ligature fashioned from a prison issue jumper.