Paul Gobell

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Paul Gobell,
a prisoner at HMP Whatton,
on 6 November 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Paul Gobell was found hanged in his cell at HMP Whatton on 6 November 2021. He
was 59 years old. I offer my condolences to Mr Gobell’s family and friends.
Mr Gobell had returned to Whatton on 4 November 2021, after two weeks at an open
prison. He had asked to move back and appeared happy with the move. I am satisfied
that Mr Gobell gave staff at Whatton no indication that he was at risk of suicide and that
they could not have foreseen his actions.
During the morning roll check on 6 November, an officer found that Mr Gobell had covered
his observation panel and she could not get a response from him. I am concerned that
Whatton does not have a local policy on what staff should do in this situation and this
resulted in a delay in entering Mr Gobell’s cell. While I am satisfied that this did not affect
the outcome for Mr Gobell, it could make a difference in future emergencies.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman July 2022
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. In November 2006, Mr Paul Gobell was sentenced to life in prison for rape. In July
2019, he was moved to HMP Whatton.
2. On 20 October 2021, Mr Gobell was moved to HMP Hollesley Bay, a category D
open prison. Mr Gobell was at Hollesley Bay for just over two weeks when he told
staff that he could not cope in open conditions and wanted to go back to Whatton.
Mr Gobell was taken back to Whatton on 4 November.
3. At around 6.50am on 6 November, during the morning roll check, an officer found
that Mr Gobell’s observation panel was covered. When she could not get a
response from Mr Gobell, she contacted the Night Orderly Officer (the officer in
charge of the prison at the time) who told her to open the inundation point (a hole in
the cell door that a fire hose can be put through) so she could see into the cell.
When the officer looked through the inundation point, she saw Mr Gobell hanging.
4. The officer called a medical emergency code and asked the Night Orderly Officer
for permission to enter the cell, which was granted. She went in with another
officer. They cut Mr Gobell down and laid him on the floor. He was clearly dead as
he was stiff and cold so staff did not start CPR.
5. Paramedics arrived at Mr Gobell’s cell at 7.31am and confirmed that Mr Gobell had
died.
Findings
6. We are satisfied that Mr Gobell gave no indication to staff that he was at risk of
suicide or self-harm and that they could not have foreseen his actions.
7. We are concerned that Whatton does not have a local policy on what staff should
do when they find a prisoner has covered their observation panel. National
instructions say that staff should call the Night Orderly Officer who should deploy
staff to the cell. There is nothing in the policy about opening the inundation point.
We are also concerned that once the officer saw Mr Gobell hanging, she asked the
Night Orderly Officer for permission to enter the cell. This is not necessary where
there appears to be an immediate threat to life.
Recommendations
• The Governor should ensure that a local protocol is developed and shared with staff
to instruct them on what to do if they find a cell observation panel obscured.
• The Governor should ensure that all prison staff are made aware that where there is
an immediate threat to life, they can enter a cell at night without seeking permission
from the Night Orderly Officer if it is safe to do so.
• The Governor should ensure that staff receive adequate support following a death
in custody.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
8. The investigator issued notices to staff and prisoners at HMP Whatton and HMP
Hollesley Bay informing them of the investigation and asking anyone with relevant
information to contact her. Four prisoners responded and the investigator spoke to
each of them on the telephone.
9. The investigator obtained copies of relevant extracts from Mr Gobell’s prison and
medical records.
10. NHS England commissioned an independent clinical reviewer to review Mr Gobell’s
clinical care at the prison. The clinical reviewer conducted joint interviews with the
investigator.
11. We informed HM Coroner for Nottingham City and Nottinghamshire of the
investigation. The coroner gave us Mr Gobell’s cause of death. We have sent the
coroner a copy of this report.
12. The Ombudsman’s family liaison officer contacted Mr Gobell’s next of kin, his sister,
to explain the investigation and to ask if she had any matters she wished the
investigation to consider. She asked some questions about how Mr Gobell’s move
from closed conditions to open conditions was managed which have been
answered in separate correspondence.
13. We shared our initial report with HM Prison and Probation Service (HMPPS). They
pointed out two minor factual inaccuracies which have been amended in this report.
They provided an action plan which is annexed to this report.
14. We sent a copy of our initial report to Mr Gobell’s sister. She did not notify us of
any factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Whatton
15. HMP Whatton is a medium security prison in Nottinghamshire which holds up to
801 prisoners convicted of sex offences. Practice Plus Group provides healthcare
services. The healthcare centre is open from 7.30am to 6.30pm from Monday to
Friday and from 8.30am to 6.30pm on weekends and bank holidays. There is an
out-of-hours service at other times. There are no inpatient beds but there is a
palliative care suite in the healthcare centre for end-of-life care.
HM Inspectorate of Prisons
16. The most recent full inspection of HMP Whatton was in August 2016. Inspectors
reported that Whatton remained an overwhelmingly safe prison. Very good work
had been undertaken to improve reception, risk assessment and induction
arrangements upon arrival, and there was comparatively little violence or anti-social
behaviour. Levels of self-harm had increased in recent times, but overall care for
those in crisis was good.
17. HMIP conducted a scrutiny visit to Whatton in August 2020 (in line with its COVID-
19 methodology) and reported that managers and staff at Whatton were keeping
prisoners relatively safe and motivated during challenging times.
18. Recategorisation processes were being kept up to date. There were 46 category D
prisoners in the establishment, of whom about half had been returned from open
conditions and had work to do before they could return. Moves to open prisons,
other than HMP Haverigg, had been very difficult during lockdown; HMP North Sea
Camp had recently offered spaces to enable Whatton prisoners to progress.
19. Even though the establishment was strongly focused on and resourced for
interventions, HMIP’s survey found that almost a third of prisoners did not know
what their custody plan objectives or targets were. Of the 70% who did know their
objectives or targets, only 41% said that staff were helping them to achieve them. It
was unclear how much of this negative feedback was due to the restricted contact
and limited services available during the pandemic.
Independent Monitoring Board
20. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to May 2021, the IMB found that for
over two-thirds of this reporting year, HMP Whatton has been operating in the
context of COVID-19. This had meant drastic changes to the operation of the
prison. The regime had been severely restricted, with prisoners confined to their
cells for most of the day and many activities and functions suspended.
21. The IMB also found that there was a backlog of prisoners waiting to complete the
accredited programmes for which they had been transferred to HMP Whatton to
undertake. Many prisoners had expressed their concerns about the impact that this
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
would have on their sentence plan, parole hearings and subsequent release. There
continued to be delays in transferring category D prisoners to suitable prisons.
Previous deaths at HMP Whatton
22. Mr Gobell was the 15th prisoner to die at Whatton since November 2019. All the
previous deaths were from natural causes. There were no similarities between the
circumstances of Mr Gobell’s death and previous deaths at the prison.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
23. In November 2006, Mr Paul Gobell was sentenced to life in prison for rape. In July
2019, he was moved to HMP Whatton.
24. On 24 September 2021, the Parole Board held a review to decide if Mr Gobell could
be released from prison on licence. The panel decided that Mr Gobell was not
ready to be released from prison but as he had completed all the recommended
courses, he met the criteria to be a category D prisoner and could be moved to an
open prison. The panel agreed that his release would be reviewed in a year’s time.
Mr Gobell told his key worker that he was pleased with this and was looking forward
to being moved to an open prison.
25. On 20 October, Mr Gobell was moved to HMP Hollesley Bay, a category D prison.
When he arrived at Hollesley Bay he was given an induction and the rules and
expectations of an open prison were explained to him.
26. On 1 November, Mr Gobell told an officer at Hollesley Bay that he could not cope in
open conditions and wanted to move back to Whatton. A prison manager at
Hollesley Bay spoke to Mr Gobell and asked if there was anything that they could
do to support him. He said that there was nothing they could do and he did not feel
comfortable and wanted to go back to Whatton.
27. On 2 November, the prison duty governor held a multi-disciplinary meeting where it
was agreed that Mr Gobell could return to Whatton.
28. On 4 November, Mr Gobell returned to Whatton. When he arrived, he had an initial
reception health screen with a nurse. The nurse recorded that Mr Gobell did not
want to see a GP as he had only left the prison days earlier. Prison staff and
healthcare staff also completed a cell share risk assessment (CSRA – used to
assess whether a prisoner would pose a risk to a cellmate), where it was
documented that Mr Gobell was a low risk prisoner and therefore could share a cell
with another prisoner.
29. When prison staff took Mr Gobell to the wing, he said that he was a high-risk
prisoner and had never shared a cell with anyone before and was unable to share
because he had a medical condition.
30. Prison staff tried to reason with Mr Gobell but the situation escalated which led to
Mr Gobell being restrained and located in a cell (on his own).
31. That evening Mr Gobell complained of a pain in his knee. He was taken to hospital
where he was diagnosed with a sprained knee. He returned to prison later that
evening.
32. On 6 November, at 6.47am, an officer was completing the morning roll check.
When she reached Mr Gobell’s cell she could not see into the cell because the
observation panel was covered. She called Mr Gobell’s name but did not get a
response. She called the Night Orderly Officer, a Custodial Manager (CM) (who
was the manager in charge of the prison at the time), on the radio but did not get a
response. She asked an Operational Support Grade (OSG) to go to the office and
call the CM on the phone to tell her that she was unable to get a response from Mr
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Gobell and that the observation panel was covered. The CM said that the officer
should open the inundation point (a hole in the cell door that is used to put a hose
into the cell if there is a fire) so that she could look into Mr Gobell’s cell. When the
officer opened the inundation point, she could see that Mr Gobell was hanging. She
immediately called a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties).
33. The officer then radioed the CM to ask for permission to enter the cell, which was
granted. At 6.57am, the officer and a second officer entered Mr Gobell’s cell. They
cut down Mr Gobell and laid him on the cell floor. Mr Gobell was cold and rigid and
there were no signs of life. Staff did not start CPR as it was clear that Mr Gobell
had rigor mortis (stiffening of the body that occurs two to six hours after death).
34. Paramedics arrived at Mr Gobell’s cell at 7.31am and confirmed that Mr Gobell had
died.
Contact with Mr Gobell’s family
35. At 9.30am on 6 November, the prison appointed an officer to act as family liaison
officer (FLO). Mr Gobell’s sister was listed as his next of kin so the FLO and a
prison manager went to her house to break the news of his death.
36. Mr Gobell’s funeral was held on 9 December. In line with national guidance, the
prison contributed towards the cost of Mr Gobell’s funeral.
Support for prisoners and staff
37. After Mr Gobell’s death, a prison manager, debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. When the CM was interviewed, she said that she did
not feel that she was supported by the care team and that they had not contacted
her.
38. The prison posted notices informing other prisoners of Mr Gobell’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Gobell’s death.
Post-mortem report
39. A pathologist concluded that Mr Gobell had died from hanging.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Management of Mr Gobell’s risk of suicide and self-harm
40. We are satisfied that Mr Gobell gave no indication to staff that he was at risk of
suicide or self-harm. He was moved back to Whatton from an open prison at his
own request.
41. After Mr Gobell’s death, two prisoners told staff that Mr Gobell had previously said
that if he returned from open conditions he would kill himself. We are satisfied that
staff were unaware of this until after Mr Gobell died. We consider that they could
not have foreseen his actions.
42. We reviewed the incident that led to the use of force on Mr Gobell on 4 November.
We are satisfied that staff tried to de-escalate the situation and that the use of force
was appropriate when Mr Gobell continued to refuse to comply. The correct Control
and Restraint techniques were used and Mr Gobell was checked by healthcare
staff.
Entering a cell during night state
43. During the morning roll check on 6 November, an officer noticed that Mr Gobell’s
observation panel was covered. She contacted the Night Orderly Officer, a CM,
who told her to open the inundation point so she could see into the cell. It was then
that the officer saw Mr Gobell hanging.
44. PSI 24/2011, Management and Security of Nights, says that where observation
panels are covered, the Night Orderly Officer should be informed immediately, and
staff deployed to the cell.
45. We are concerned that Whatton’s local night operating instructions do not specify
what staff should do if they find that a prisoner has covered their observation panel.
An officer contacted the Night Orderly Officer which is in line with PSI 24/2011, but
we are concerned that rather than sending staff to the cell, the CM told the officer to
open the inundation point to check on Mr Gobell.
46. When interviewed, the CM said that if a prisoner’s observation panel was covered,
she would always advise the officer to open the inundation point or to go to the
outside of the cell and look through the window. The CM said there was not a local
policy with instructions on what to do if a prisoner covers his observation panel.
47. Once the officer saw that Mr Gobell was hanging, she called a code blue and asked
the CM for permission to enter the cell. PSI 24/2011 says that authority to unlock a
cell at night must be given by the Night Orderly Officer and no cell will be opened
unless a minimum of two/three (subject to local risk assessment procedures)
members of staff are present, one of whom should be the Night Orderly Officer.
However, it goes on to say that the preservation of life must take precedence and
that where there appears to be an immediate danger to life, cells can be unlocked
without the authority of the Night Orderly Officer, where staff consider it safe to
enter the cell. We consider that once the officer saw Mr Gobell hanging, she should
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
have entered the cell and did not need permission from the Night Orderly Officer in
those circumstances.
48. We accept that the delay in entering Mr Gobell’s cell did not affect the outcome for
Mr Gobell, who had clearly been dead for some time when he was found. However,
it could make a significant difference in future emergencies. We make the following
recommendations:
The Governor should ensure that a local protocol is developed and shared
with staff to instruct them on what to do if they find a cell observation panel
obscured.
The Governor should ensure that all prison staff are made aware that where
there is an immediate threat to life, they can enter a cell at night without
seeking permission from the Night Orderly Officer if it is safe to do so.
Staff support
49. The CM said that she had not received any formal support from the care team and
that no one had been in contact with her since Mr Gobell’s death. We would have
expected some formal support to have been offered to her. We therefore make the
following recommendation:
The Governor should ensure that staff receive adequate support following a
death in custody.
Clinical care
50. The clinical reviewer concluded that the clinical care Mr Gobell received at Whatton
was equivalent to that which he could have expected to receive in the community.
Inquest
51. The inquest, held on 18 November 2024, concluded that Mr Gobell died by suicide,
to which a failure to respond to an obvious risk of self-harm contributed.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE