Robert Fenlon: historic unlawful killing conclusion at inquest into self-inflicted death at Woodhill Prison


Robert Fenlon, 36, died a self-inflicted death whilst on remand at Woodhill prison on 5 March 2016. Now an inquest jury has concluded that the reprehensible failures by two senior prison officers amounted to unlawful killing by gross negligence manslaughter.

This is the first time an inquest has found that a self-inflicted death in detention amounted to unlawful killing, according to data from the charity INQUEST.

The jury found that Senior Officer (SO) Dyson and SO Cushion’s conduct was so exceptionally bad as to amount to a criminal failure. The jury also concluded that Robert’s death was contributed to by neglect (meaning a gross failure to provide Robert with basic care and attention) and that there was a serious failure by the prison to implement previous recommendations made after earlier deaths at Woodhill, which contributed to Robert’s death.

The circumstances of Robert’s death are summarised here.

As well as finding that Robert died by unlawful killing, contributed to by neglect, the jury concluded that numerous failures and inadequacies contributed to Robert’s death, including:

  • A serious failure in not putting Robert on constant supervision;
  • Failures to follow procedures for prisoners at risk of suicide or self-harm (known as ‘ACCT’);
  • A serious lack of communication between staff;
  • An inadequate system to assign ACCT case managers;
  • Inadequate training and oversight of relevant staff; and
  • A serious failure to implement any of the 43 recommendations made following previous deaths at Woodhill by the time of Robert’s death in March 2016.

The jury also concluded that the evidence suggested that SO Dyson had falsified an official ACCT case review document.

Jesse Nicholls represented Robert’s family, instructed by Jo Eggleton of Deighton Pierce Glynn.

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