Warning more could die after missed opportunities to stop prisoner's suicide
A coroner has warned that more people could die at a Nottinghamshire prison after an inmate took his own life in his cell. Paul Gobell was found with a ligature around his neck at HMP Whatton while he was serving a life sentence for rape.
The discovery was made at 6.55am on November 6, 2021. However, an inquest into Gobell's death in November 2024 revealed he hanged himself at some time between 7.45pm on November 5 and the time of the discovery. A report published by the Prisons and Probation Ombudsman in December 2024 said that the man "had clearly been dead for some time" when he was found.
Gobell also covered the observation panel of his cell with his adjudication papers so that he could not be seen. Two days before he was pronounced dead, he had returned from two and a half weeks in an open prison in Hollesley Bay, Suffolk, having asked to be returned to closed conditions.
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Concluding the jury inquest at Nottingham Coroner's Court into Gobell's death in November 2024, coroner Simon Burge said: "There were obvious risks that Paul might harm himself and there were missed opportunities to respond to those risks. Concerns flagged to probation staff by Paul by telephone should have been passed to the staff at HM Prison Hollesley Bay."
Gobell had been in a closed prison for 15 years, most recently at HMP Whatton, when he was deemed by the Parole Board to be suitable to move to open conditions in August 2021. He was then transferred to HMP Hollesley Bay on October 20, 2021, but he was there for only two and a half weeks.
He returned to HMP Whatton on November 4 and he was subject to a control and restraint incident. This was because his behaviour was "refractory and aggressive".
During the incident, he received a soft tissue injury which resulted in a trip to A&E. Because of this, the usual first night interview did not take place on that evening, nor on the following day.
Therefore, no welfare check was performed and no ACCT (assessment, care in custody and teamwork) was opened. Coroner Burge said: "An ACCT should have been raised at any of these points at HM prison Watton: during the reception process, following the control and restraint procedure, following the serving of adjudication papers, after the final conversation during the medical rounds.
"Key information about Paul was not shared adequately on multiple occasions and contributed to Paul's death. Cumulative factors were not considered. Increased professional curiosity should have been exercised throughout the period leading up to Paul's death."
Immediately prior to the restraint incident, Gobell was informed that he had been assessed as being suitable to share a cell, which he had not done before. A Prevention of Future Deaths (POFD) report released by coroner Burge on Tuesday, January 28, stated: "He was concerned for the safety of whoever he might be required to share a cell with, due to the fact that he suffered from parasomnia.
"Despite protesting to staff, he was told that he would have to share and it was this that sparked the incident leading to the use of control and restraint techniques. Had he been pre-warned of the change to his cell sharing status this incident would not have happened.
"Consideration should be given to ensuring that any such change of cell sharing risk is communicated promptly to the prisoner concerned." Gobell had also described to his probation officer the environment at HMP Hollesley Bay as "hostile and unpleasant" and let slip to another prisoner there that he was serving a sentence for offences of a sexual nature.
The probation officer did not see fit to report these disclosures to the Offender Management Unit. Additional support should have been provided to encourage Gobell to remain in open conditions, the POFD report added.
Addressing the report to the Ministry of Justice (MoJ) and HM Inspectorate of Prisons (HMIP), coroner Burge said: "During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken."
A response to the report from MoJ reads: "HMP Whatton will update their induction policy so that, when a normal induction cannot be facilitated, the prisoner will be asked to complete the 'late arrivals form'. This form asks the prisoner to provide information that can then be used to consider the prisoner's welfare until a face-to-face interview can be conducted."
A response to the report from HMIP reads: "We will keep your findings on file so that, when we next inspect HMP Whatton and HMP Hollesley Bay, inspectors are aware of this information and can follow up as appropriate."