The Ministry of Justice has apologised after a string of warnings from coroners about deaths in prison went unanswered, including after two at a troubled London jail.
Concerns were officially raised about mental health treatment for inmates, staff training in first aid, and the assistance for prisoners once they are set free from custody.
But new data shows that in 2024, 12 reports from Coroners – known as Prevention of Future Deaths reports – were not responded to by justice officials.
Coroner’s reports typically raise concerns which have emerged during an inquest, suggesting problems that need tackling and calling for a written response from those in authority within 56 days.
“We take Prevention of Future Deaths reports very seriously”, said a spokesperson for the Prisons and Probation Service, an executive agency of the MoJ.
“These reports often contain complex issues and we apologise to the families of those involved for our delayed response.”
Wandsworth Prison was put into special measures last year after a string of scandals, including the breakout of Daniel Khalife. An audit revealed rampant drug use, poor living conditions, and deep concerns about staffing levels and training.
This month, a Wandsworth guard – Linda De Sousa Abreu – was jailed for having sex with an inmate inside a prison cell, while another prisoner smoked cannabis and filmed the encounter.
Coroner Priya Malhotra raised concerns about the deaths of two inmates at the southwest London jail – Daniel Beckford and Yuri Hatton.
Mr Beckford, 39, took an overdose of his prescribed medication on June 16, 2021 while on remand, and the following day he took his own life in his cell.
Mr Hatton, 44, was found unresponsive in his cell in November 2018, and the inquest uncovered a series of failings by staff.
In both cases, the coroner raised concerns about the first aid training given to guards at the jail, when they are often the first to reach inmates whose lives are at risk.
The MoJ said the coroner’s reports in both cases were written in June but not received until November. The department said a response in Mr Beckford’s case has now been sent, and they are working on the details of Mr Hatton’s case.
One of the other cases where the coroner’s concerns went unanswered was Christopher MacGillivray, who died shortly after being remanded in custody for his own safety while facing criminal charges.
He was placed on remand in prison after being seen stood on the edge of a bridge and reported thoughts of self-harm to one of the prison guards, leading to him being placed on suicide watch.
But all safety checks were withdrawn when Mr MacGillivray was then set free on bail after a court hearing in which he appeared on a videolink. Two days later, he was found dead from suicide at home.
Matthew Braben died by suicide in August 2021 at HMP Wormwood Scrubs, and an inquest found a litany of failings in his care, including that no action was taken by the prison when concerns were raised by Mr Braben’s family.
It is understood the lack of a response to the coroner’s concerns in his case is now being looked into.
Derby Coroner’s Court (PA)
Another failure to respond was in the case of Sean Davies, a man who was locked up on an indeterminate sentence for public protection (IPP) in 2012.
He took his own life in 2023, six years after he was first eligible for parole, and left a letter behind stating that he had killed himself due to the IPP system and slow progress in his pursuit of being released.
Patricia Harding, Senior Coroner for Mid Kent and Medway, issued her report in August, calling for a “considered response” from government on IPP sentences and the risk they pose to inmates.
The MoJ was also asked to respond in the case of Darren Docherty, who died by suicide in August 2023 – six days after he had been released from HMP Stoke Heath with nowhere to live.
Mr Docherty, who had a history of mental health difficulties and self-harm, was left with no means of accessing health services, a coroner found.
Coroners often issue Prevention of Future Death reports to government departments, NHS health trusts, care agencies, and local councils.
They have no power to order anyone to take action, but the reports are published online alongside the responses received.
In 2024, it is said that South West London and St George’s Mental Health NHS Trust, the Independent Office for Police Conduct, National Highways, and the Health and Safety Executive were also among those who failed to respond to a coroner’s concerns.