A man’s prison suicide was recorded as unlawful killing by the Milton Keynes inquest

The death of a man who committed suicide in prison in Buckinghamshire has been recorded as an unlawful killing, in what is believed to be the first finding of its kind by an inquest jury.

The family of Robert Fenlon – who has been campaigning since his death while on remand at Woodhill Prison in March 2016 – called on authorities for ‘serious reflection’ after the inquest findings, which told of a range of failures.

The jury at Milton Keynes coroner’s court found that the conduct of two prison officers was so exceptionally bad that it amounted to a criminal failure.

The jury also concluded that authorities had seriously failed to implement previous recommendations made following previous losses of life at Woodhill, which had the highest number of self-inflicted deaths of any prison in the country at the time Fenlon died.

He was the second of seven men to commit suicide in prison, a category A men’s prison in Milton Keynes, in 2016, and one of 28 since 2013.

Fenlon, who was described by his family as a man with a big heart who would help anyone, had a long history of substance abuse and mental health problems. Four months after being returned to HMP Woodhill, he passed a note under his cell door saying he was in complete despair and considering suicide. His mental health deteriorated but no referral was reportedly made to the mental health team in the lead up to his death.

His family said in a statement: “We knew from the beginning that he had failed badly, but we were not prepared for how badly and how many people failed in their duty.”

They also accused the prison service of trying to prevent the jury from ruling on unlawful killing. “This is an opportunity for the prison service to think seriously and change their approach,” they said. “We hope, for our sake and for other relatives, that they seize that opportunity.”

The jury concluded that Fenlon died of unlawful killing caused in part by neglect. Failures and deficiencies found to have contributed included failure to follow procedures and inadequate staff training.

Jo Eggleton, a lawyer at Deighton Pierce Glynn who is representing Robert’s family, said: “The jury’s findings could not be more serious: it reflects the appalling way in which Robert was repeatedly let down by senior prison officers at a time when staff were well aware of the high number of self-inflicted deaths in Woodhill.

“Those running the prison were aware of the repeated failings and should have taken urgent steps to prevent this.”

Although Fenlon died eight years ago, Eggleton said an urgent notice last year by the Chief Inspector of Prisons after finding Woodhill unsafe suggested the concerns were still relevant.

The finding marks the first time an inquest has found that a self-inflicted death in custody amounted to unlawful killing, according to data collected by Inquest, a charity in England and Wales that provides expertise in state-related deaths and their investigation to relatives. .

Selen Cavcav, an associate at Inquest, said: “We have been saying for years that state neglect and the failure to learn lessons is deadly. This jury conclusion finally recognizes this in the strongest possible terms.”

The Prison Service has been contacted for comment.

• In Great Britain and Ireland, you can contact Samaritans on freephone 116 123, or by email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline at 988, chat at 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service is Lifeline 13 11 14. Other international helplines can be found at befrienders.org