“(brief summary of matters of concern) In the course of this inquest, I heard evidence…”

The coroner’s concerns

(brief summary of matters of concern) In the course of this inquest, I heard evidence giving rise to concern that there is a risk of future deaths unless action is taken. This inquest concerned the death of Roy Richard Sinclair, aged 45, who died on 25 November 2023 at Bedford Hospital following paracetamol toxicity. 1.ACCT documentation and operation The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation. After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed. Relevant mental health and welfare information was recorded on System 1 but not entered on the ACCT. Risk factors, including debt and vulnerability, were not consistently reflected in the care plan. There was accepted evidence that post-closure monitoring did not occur. The evidence also suggested wider and recurring difficulty in ensuring ACCT documentation accurately recorded risk, care planning, review, closure, and post-closure actions. I am concerned that the ACCT process may not reliably communicate relevant risk information between prison and healthcare staff, creating a risk that vulnerable prisoners will not be managed safely. I have presided over many death in custody Inquests and a universal feature is the ACCT process is not sufficiently taught, understood or completed. 2. Management of suspected paracetamol overdose The evidence disclosed deficiencies in the management of the first reported overdose in October 2023. There was no formal policy then in place governing paracetamol overdose. Blood samples were not obtained after refusal and no effective further attempt was made overnight. Toxbase / Poisons Information advice was not sought. The jury found this represented a lack of professional curiosity. A handover failure contributed to delayed medical follow-up on 14 October 2023. Although evidence was given of later changes, including a Toxbase flowchart, training, and revised practice, I am concerned that the systems in place at the material time did not provide a sufficiently clear and robust framework for the management of suspected overdose in custody. 3.Failure to raise intelligence reporting and investigate source No prison intelligence report was raised after the first reported overdose. The evidence established that such a report should have been submitted and that, had it been, a search of the cell would likely have followed within 24 hours. The failure reduced the opportunity to investigate how Mr Sinclair had obtained the paracetamol. 4.Debt, vulnerability, and safeguarding The evidence showed that Mr Sinclair had debt to other prisoners connected with vapes and that this formed part of his vulnerability. Although attempts were made to support him, the debt remained outstanding when the ACCT entered post-closure review on 15 November 2023, was not consistently incorporated into the ACCT care plan, and there was uncertainty as to whether managing it outside the ACCT process provided sufficient safeguarding. I am concerned that where prisoner debt is linked to vulnerability, distress, self-harm risk, or exploitation, it may not be identified, recorded, and managed in a sufficiently integrated way. 5.Wider operational context Regulation 28 – After Inquest Document Template Updated 30/07/2021 The evidence referred to serious staffing shortages, recruitment and retention difficulties, and heavy operational pressures at HMP Woodhill during 2023. I am concerned that wider operational pressures may increase the risk of failures in information-sharing, safeguarding, incident response, and the management of vulnerable prisoners. The court learned only at the conclusion of the inquest of a concurrent HMIP inspection and urgent notification concerning the prison while the Inquest was proceeding, appearing to contradict evidence given by prison staff. Where such information is not provided to the court in a timely manner there is a realistic prospect of the court being misled.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0385

Added to Minute Book

7 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0