An inquest has found that the death of a prisoner was an unlawful killing, laying blame on the gross negligence of prison officers, the charity INQUEST reports. This is believed to be the first time a self-inflicted death in prison has been found to be an unlawful killing.

Robert Fenlon, 36, died of self-inflicted injuries at Woodhill Prison in 2016. Officers were aware of the risk to Robert; however, they failed to review the safety plan after finding him ligatured in his cell, despite evidence that he should have been placed under constant supervision. He was later found unresponsive, and died in hospital.

Senior Officers Dyson and Cushion were singled out for their conduct. Dyson lied to the jury that a review took place; healthcare workers ‘flatly denied’ this statement. Cushion failed to read the risk report, and delayed visiting Robert until he had finished his lunch. He accepted that this was ‘a very serious failing’. Without these failings, Robert’s death was preventable.

Woodhill Prison saw seven self-inflicted deaths that year, and 28 in the previous three years. The prison had received 43 recommendations following previous deaths. None of these had been implemented at the time.

Last year, the Chief Inspector of Prisons issued an ‘urgent notification’ to the government, stating that Woodhill Prison was unsafe, in particular for its lack of support for self-inflicted injuries. A few months later, the Independent Monitoring Board remained concerned that risk reviews, like that needed for Robert, are not being regularly carried out.

The family’s solicitor stated: ‘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.’

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’