Paul Gobell
PFD Report
All Responded
Ref: 2025-0047
All 2 responses received
· Deadline: 25 Mar 2025
Coroner's Concerns (AI summary)
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, probation staff failed to report critical disclosures, resulting in an uninformed suitability assessment.
View full coroner's concerns
1. Paul Gobell was serving a life sentence for rape. He had served fifteen years in a closed prison, most recently at HM Prison, Whatton. In August 2021, he was deemed by the Parole Board to be suitable for a move to open conditions and was therefore transferred to HM Prison Hollesley Bay on 20/10/21. He was there for just two and a half weeks. Within a few hours of his return to HM Prison, Whatton on 04/11/21 he was subject to a Control & Restraint incident. His behaviour at this time was reported to be refractory and aggressive. During the incident he received a soft tissue injury which necessitated a trip to the A&E department at the local hospital. As a result, the usual First Night Interview did not take place that evening, nor on the following day. As a result there was no welfare check and no ACCT was opened. There is no national or local policy in place stating what arrangements should be made to carry out a welfare check when, for operational reasons, the First Night Interview cannot take place.
2. Paul Gobell was assessed as being suitable to share a cell in June 2021, having previously been considered high risk. He was not informed off this change until immediately prior to the C&R incident on 04/11/21 and had never had to share a cell before. The Cell Sharing Risk Assessment carried out by Healthcare and Reception staff upon his return to HM Prison, Whatton on 04/11/21 deemed him to be a standard risk. He felt that he should have been designated as high risk. He was concerned for the safety of whoever he might be required to share a cell with, due to the fact that he (Gobell) 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.
3. Whilst at HM Prison, Hollesley Bay, Paul Gobell rang the Probation Officer (who had dealt with his Parole Board hearing in August 2021) and told her that he felt he was a poor fit in open conditions, that the environment there was hostile and unpleasant and that he had let slip to another prisoner that he was serving a term of imprisonment for offences of a sexual nature. The Probation Officer concerned did not see fit to report these disclosures to the Offender Management Unit. An Open Conditions Suitability Assessment ('OCSA') was subsequently held at HM Prison, Hollesley Bay on 02/11/24, after Mr. Gobell spoke to an Orderly Officer and asked to be returned to HM Prison, Whatton. Despite the multi-disciplinary nature of the OCSA, no input was obtained or requested from Probation staff at HM Prison, Hollesley Bay or elsewhere. Had the relevant Probation staff been involved this would have better informed the OCSA and steps could have been taken to offer Mr. Gobell additional support, designed to encourage him to remain in the open conditions of a 'D' category prison rather than taking the regressive step of being returned to closed conditions. Consideration should be given to imposing a requirement that the input of Probation (both from the Offender Management Unit and outside) is obtained whenever a OCSA is undertaken.
2. Paul Gobell was assessed as being suitable to share a cell in June 2021, having previously been considered high risk. He was not informed off this change until immediately prior to the C&R incident on 04/11/21 and had never had to share a cell before. The Cell Sharing Risk Assessment carried out by Healthcare and Reception staff upon his return to HM Prison, Whatton on 04/11/21 deemed him to be a standard risk. He felt that he should have been designated as high risk. He was concerned for the safety of whoever he might be required to share a cell with, due to the fact that he (Gobell) 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.
3. Whilst at HM Prison, Hollesley Bay, Paul Gobell rang the Probation Officer (who had dealt with his Parole Board hearing in August 2021) and told her that he felt he was a poor fit in open conditions, that the environment there was hostile and unpleasant and that he had let slip to another prisoner that he was serving a term of imprisonment for offences of a sexual nature. The Probation Officer concerned did not see fit to report these disclosures to the Offender Management Unit. An Open Conditions Suitability Assessment ('OCSA') was subsequently held at HM Prison, Hollesley Bay on 02/11/24, after Mr. Gobell spoke to an Orderly Officer and asked to be returned to HM Prison, Whatton. Despite the multi-disciplinary nature of the OCSA, no input was obtained or requested from Probation staff at HM Prison, Hollesley Bay or elsewhere. Had the relevant Probation staff been involved this would have better informed the OCSA and steps could have been taken to offer Mr. Gobell additional support, designed to encourage him to remain in the open conditions of a 'D' category prison rather than taking the regressive step of being returned to closed conditions. Consideration should be given to imposing a requirement that the input of Probation (both from the Offender Management Unit and outside) is obtained whenever a OCSA is undertaken.
Responses
Noted
HM Inspectorate of Prisons acknowledges the concerns raised and states that the issues are covered in their inspection criteria. They will keep the findings on file for future inspections of HMP Whatton and HMP Hollesley Bay. (AI summary)
HM Inspectorate of Prisons acknowledges the concerns raised and states that the issues are covered in their inspection criteria. They will keep the findings on file for future inspections of HMP Whatton and HMP Hollesley Bay. (AI summary)
View full response
Dear Mr. Burge,
Paul Martin GOBELL – Prevention of Future Deaths Report
Thank you for sharing your regulation 28 report to prevent future deaths with His Majesty’s Inspectorate of Prisons (HMI Prisons). We are saddened to learn of the findings of your investigation.
HMI Prisons is an independent inspectorate. We provide scrutiny of the conditions for and treatment of prisoners and other detainees and report publicly on our findings.
HMI Prisons’ inspections are carried out against published inspection criteria known as Expectations. The Inspectorate sets its own inspection criteria to ensure transparency and independence. Many of the issues highlighted in your report are covered via our Expectations, and therefore matters which our inspectors will consider on each inspection. For example, in relation to first night interviews, one of our safety expectations states:
“Prisoners are safe and treated with respect on their reception and first night in prison. Risks are identified and prisoners are supported according to their individual needs.”
Other issues raised in your report such as the importance of prisoners being appropriately and safely located, the need for these decisions to be conveyed to prisoners, and the importance of prisoners being held in the appropriate security conditions, with all relevant departments involved in reviews, are also covered via our Expectations.
Where we identify concerns that need to be addressed by leaders and followed up by inspectors at the next inspection or independent review of progress, these are set out in our published reports. In line with agreed protocols, inspected prisons then provide an action plan three months after publication of the report.
17/01/25
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.
For completeness, it would also be helpful if your office could please share the circumstances of the death, which we understand are set out in a separate attachment.
Paul Martin GOBELL – Prevention of Future Deaths Report
Thank you for sharing your regulation 28 report to prevent future deaths with His Majesty’s Inspectorate of Prisons (HMI Prisons). We are saddened to learn of the findings of your investigation.
HMI Prisons is an independent inspectorate. We provide scrutiny of the conditions for and treatment of prisoners and other detainees and report publicly on our findings.
HMI Prisons’ inspections are carried out against published inspection criteria known as Expectations. The Inspectorate sets its own inspection criteria to ensure transparency and independence. Many of the issues highlighted in your report are covered via our Expectations, and therefore matters which our inspectors will consider on each inspection. For example, in relation to first night interviews, one of our safety expectations states:
“Prisoners are safe and treated with respect on their reception and first night in prison. Risks are identified and prisoners are supported according to their individual needs.”
Other issues raised in your report such as the importance of prisoners being appropriately and safely located, the need for these decisions to be conveyed to prisoners, and the importance of prisoners being held in the appropriate security conditions, with all relevant departments involved in reviews, are also covered via our Expectations.
Where we identify concerns that need to be addressed by leaders and followed up by inspectors at the next inspection or independent review of progress, these are set out in our published reports. In line with agreed protocols, inspected prisons then provide an action plan three months after publication of the report.
17/01/25
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.
For completeness, it would also be helpful if your office could please share the circumstances of the death, which we understand are set out in a separate attachment.
Action Taken
HMP Whatton will update their Induction policy to include a "late arrivals form" for prisoners when a normal induction cannot be facilitated, and has amended their local safety strategy to ensure prisoners are informed in writing when their CSRA levels change. HMP Hollesley Bay will seek POM attendance at local stability meetings where OCSAs are being discussed wherever possible. (AI summary)
HMP Whatton will update their Induction policy to include a "late arrivals form" for prisoners when a normal induction cannot be facilitated, and has amended their local safety strategy to ensure prisoners are informed in writing when their CSRA levels change. HMP Hollesley Bay will seek POM attendance at local stability meetings where OCSAs are being discussed wherever possible. (AI summary)
View full response
Dear Mr Burge, Thank you for your Regulation 28 report of 3 December 2024 following the inquest into the death of Paul Gobell at HMP Whatton, which was sent to the Ministry of Justice. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations. I know that you will share a copy of this response with Mr Gobell’s’ family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have raised concerns regarding welfare checks when the first night interview cannot take place, communicating changes to Cell Sharing Risk Assessments (CSRA) to prisoners and the involvement of probation whenever an Open Conditions Suitability Assessment (OCSA) is undertaken. All prisons have well established first night induction processes and policies in place to ensure that prisoners receive appropriate care when entering prison custody. Welfare checks and conversations form part of this process and, in most cases, prisoners coming into reception are inducted in line with existing national and local policies. However, there may be exceptional circumstances when this does not happen, such as in the situation you have described involving Mr Gobell. 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. The HMPPS CSRA policy is currently under review and is due to be reissued during 2025. As part of this review, we will ensure that the need to inform prisoners as soon as possible of
changes to their CSRA status is made clear. In support of this HMP Whatton have amended their local safety strategy to now include the line Prisoners must be informed in writing when their CSRA levels change following a CSRA review. HMP Hollesley Bay have provided assurance that wherever possible (for example where an immediate OCSA for public protection reasons is not required) they will seek Prison Offender Manager (POM) attendance at local stability meetings where OCSAs are being discussed. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
changes to their CSRA status is made clear. In support of this HMP Whatton have amended their local safety strategy to now include the line Prisoners must be informed in writing when their CSRA levels change following a CSRA review. HMP Hollesley Bay have provided assurance that wherever possible (for example where an immediate OCSA for public protection reasons is not required) they will seek Prison Offender Manager (POM) attendance at local stability meetings where OCSAs are being discussed. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Sent To
- HM Inspectorate of Prisons
- Ministry of Justice
Response Status
Linked responses
2 of 2
56-Day Deadline
25 Mar 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 18 November 2021 I commenced an investigation into the death of Paul Martin GOBELL aged 59. The investigation concluded at the end of the inquest on 18 November 2024. The conclusion of the inquest was that: See attached
Circumstances of the Death
See attached
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.