Jury finds systemic and operational failings in death of prisoner serving IPP Sentence at HMP Woodhill
Ronnie was 47 years old when he died at HMP Woodhill on 30 April following suspected consumption of synthetic cannabinoids. Ronnie was sentenced to an IPP sentence in 2011, with a minimum tariff of 33 months. At the time of his death, he had been in prison for 13 years (over 11 years over his tariff) and had never been released. IPP sentences are a form of life sentence that was considered lawful between 2005 and 2012. In 2012, the sentence was abolished as they were widely considered to be inhumane. This meant that no more people could receive IPP sentences, however, people who were already serving IPP sentences are still stuck with their conditions. Throughout the inquest the jury heard evidence that prisoners serving IPP sentences may experience hopelessness, chronic frustration, deterioration in mental health and increased vulnerability to substance misuse and self-neglect.
The jury found in their narrative conclusion that relevant information relating to Ronnie’s drug misuse and mental health was not always reported and shared by prison and healthcare staff. It was their opinion that Ronnie was vulnerable and his IPP sentence and the requirement to complete the Kaizen course caused him distress and frustration. Additionally, they found that that the time of Ronnie’s death there were inexperienced staff on the wing and there was evidence of systemic and operational failings including: inadequate communications between staff, poor record keeping and failings to implement current policies and processes such as in relation to blocked observation panels and the passing of items from one cell to another by prison staff.
Following the conclusion of the inquest on the 17 February 2026, the Assistant Coroner for Milton Keynes, Sean Cummings, published a Regulation 28 report on the 24 March 2026 outlining 12 matters of concern. These include:
- Availability of illicit substances in custody
- Failure to consistently identify, record and respond to prisoners under the influence
- Fragmented information sharing and record keeping on information relevant to substance misuse, mental health, debt, bullying or coercion, self isolation, intelligence about threats and recent presentation under the influence
- Blocked observation panels and inadequate visual welfare checks
- Management of self isolation, debt, fear and vulnerability
- Absence of ACCT despite identifiable indicators of vulnerability
- Particular vulnerability of prisons serving IPP sentences
- Delay or insufficiency in mental health and psychiatric input
- Training and emergency response to suspected synthetic cannabinoid collapse
- Staffing, weak supervision, inadequate welfare observations and regime limitations
- Repeated systemic concerns at HMP Woodhill
- Failure of state agencies to supply all information in a timely fashion.
With respect to this last concern the PFD report outlines that information in the inquest was provided ´at the eleventh hour´. The Coroner noted that ´Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed.´
Keio Yoshida of Doughty Street Chambers Inquests and Inquiries Team represented Ronnie´s family, instructed by Rachel Tribble from Deighton Peirce Glynn.
When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123 (or from prison on 0845 450 7797) , email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
