“To the Governor of Belmarsh and to the Chief Executive of Oxleas”
Dated 8 Nov 2022, from the coroner for Inner South London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 3 Jan 2023. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated8 Nov 2022
- Deadline3 Jan 2023
- Published on judiciary.uk9 Nov 2022
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| HMP Belmarsh | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Oxleas NHS Foundation TrustNamed in the report as “Oxleas NHS Trust” | Response publishedPublished on judiciary.uk in November 2022. |
The coroner’s concerns
– 1. To the Governor of Belmarsh and to the Chief Executive of Oxleas. There was no clear documentation (accessible by prison staff, healthcare and social services) of the adjustments that were required for the prisoner’s disability, 2. To the Governor of Belmarsh. There was a lack of disability awareness amongst prison staff of all levels. For example, there was an assumption that a prisoner could not be disabled because he used the gym and had good upper body strength.
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, 2022-0355
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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