Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0168, written 24 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Mar 2026 |
|---|---|
| Reference | 2026-0168 |
| Deceased | Ronald Meikle |
| Coroner | Sean Cummings |
| Coroner area | Milton Keynes |
| Category | State Custody related deaths |
| Organisation named | Central and North West London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Service , Chief Executive Officer His Majesty’s Prison and Probation 2 3 4 5 Governor, HMP Woodhill 6 Central & North West London NHS Foundation Trust , Minister of State for Prisons , HM Chief Inspector of Prisons , Prisons and Probation Ombudsman 1 CORONER I am Sean CUMMINGS, Assistant Coroner for the coroner area of Milton Keynes 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 03 May 2024 I commenced an investigation into the death of Ronald William MEIKLE aged 47 who died on 30 April 2024. The investigation concluded at the end of the inquest on 17 February 2026. The conclusion of the inquest was that: Narrative conclusion Narrative conclusion - see attached 4 CIRCUMSTANCES OF THE DEATH and had had past instances of 'debt' within the Ronald (Ronnie) lived in House Unit B Cell 201 HMP Woodhill, a single occupancy cell. He had a history with drugs, particularly unit. He had no known PMH or diagnosed MH history aside from repeated and long duration substance misuse, however a letter for a referral to the psychiatrist had been found in his cell. He was not on an ACCT, no wing restrictions and was employed by the prison in the garden and education services. He had reported to an officer on 29/04 that he had been self-isolating in his cell since 28/04, this was believed to be due to debt issues on the unit. He had work from 14:00 - 16:30 and then lock up was at 5pm. At the morning roll check at 7:15 nothing of note was recorded. A BT technician had attended the cell due to reported issues with his phone. When they didn't get a response, they asked an officer to gain entry. Ronald was found on his back, 'cold and stiff' with secretions coming from his mouth when CPR was commenced. SCAS and HMP GP attended and his death was declared at 09:43. Ronnie had minimal PMH, PNC briefly mentions asthma, an inhaler was found in his room but had no prescription details. The only medication prescribed by the prison was the antihistamine Cetirizine. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. Regulation 28 – After Inquest Document Template Updated 30/07/2021 In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Concern 1: Availability of illicit substances in custody The evidence indicated that illicit drugs, available within HMP Woodhill. Material before the court showed this was not an isolated issue but part of a wider and continuing prison safety problem at HMP Woodhill and likely other prisons. The availability of synthetic cannabinoids in custody creates a foreseeable risk of sudden collapse, respiratory compromise, cardiac arrest, psychosis, violence, self- harm and death. were readily Concern 2: Failure consistently to identify, record and respond to prisoners under the influence The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention. Concern 3: Fragmented information-sharing and record keeping The evidence demonstrated that relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams. This included information relevant to substance misuse, mental health, debt, bullying or coercion, self-isolation, intelligence about threats, and recent presentation under the influence. Where critical safety information is held in separate systems and not reliably brought together, there is a foreseeable risk that warning signs will be missed and protective action delayed with obvious risk of harm or death. Concern 4: Blocked observation panels and inadequate visual welfare checks The evidence raised serious concern that blocked observation panels were not consistently challenged or cleared, and that visual welfare checks were therefore not always effective. The jury heard evidence that officers deliberately avoided opening blocked hatches to escape abuse from the prisoners then or later. In a prison environment where prisoners may be intoxicated, unconscious, self-harming, assaulted, or otherwise incapacitated behind a locked door, failure to maintain an unobstructed observation panel creates an obvious risk of late discovery and preventable death. Concern 5: Management of self-isolation, debt, fear and vulnerability The evidence suggested that Mr Meikle had vulnerabilities connected to self-isolation, debt, fear of other prisoners, possible coercion or bullying, mental ill-health, and substance misuse. I am concerned that the systems for identifying and managing prisoners who remain behind their door because of debt, fear, vulnerability or drug-related pressures were not sufficiently robust, coordinated or escalated. Concern 6: Absence of ACCT despite identifiable indicators of vulnerability The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr Meikle was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement. This occurred in an establishment where HM Inspectorate of Prisons had already identified weaknesses in ACCT management and welfare checking during an unannounced inspection in 2023 and had issued an Urgent Notification which included reference to "frailties in ACCT case management". I later became aware of a Regulation 28 – After Inquest Document Template Updated 30/07/2021 second Urgent Notification issued in March 2026, shortly after completion of Mr Meikle's inquest that once again identified "frailties in ACCT case management". I am concerned that prisoners presenting with cumulative indicators of vulnerability may not be escalated into safer custody procedures when required, thereby increasing the risk that deteriorating welfare is not recognised or managed. Concern 7: Particular vulnerability of prisoners serving IPP (Imprisonment for Public Protection) sentences The evidence showed that prisoners serving IPP sentences may experience hopelessness, chronic frustration, deterioration in mental health and increased vulnerability to substance misuse and self-neglect. I am concerned that Mr Meikle's IPP status was not sufficiently recognised as a material risk factor requiring structured support, regular review and coordinated care. Concern 8: Delay or insufficiency in mental health and psychiatric input The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review. Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and death. Concern 9: Emergency response to suspected synthetic cannabinoid collapse The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause. Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment. Concern 10: Staffing, supervision and regime limitations The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention. Concern 11: Repeated systemic concerns at HMP Woodhill Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time. I am concerned that repeated identification of these issues has not resulted in sufficient or sustained remedial action, creating an ongoing risk of further deaths. Concern 12: Failure of state agencies to supply all information in a timely fashion. In this Inquest I was presented with material information at the eleventh hour. Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 19, 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the Regulation 28 – After Inquest Document Template Updated 30/07/2021 timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to - Preventable Death Tracker, Kings College London who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 24/03/2026 Sean CUMMINGS Assistant Coroner for Milton Keynes Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Executive Office 18 May 2026 Sean Cummings HM Assistant Coroner for Milton Keynes HM Coroner’s Office Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ Dear Mr Cummings, Re: Regulation 28: Report to prevent future deaths Thank you for your Regulation 28 report dated 24 March 2026 following the inquest into the death of Mr Ronald Meikle at HMP Woodhill. I write to provide the Trust’s response to the concerns you have raised. Central and North West London NHS Foundation Trust (CNWL) deeply regrets the sad death of Mr Meikle, and we extend our sincere condolences to his family. We have reviewed the issues identified in your report and have examined our governance and clinical practice, working closely with HMPPS colleagues at HMP Woodhill. I have sought and received assurance that learning from this case is embedded. We have implemented improvements, and our executive team continues to oversee this work. Concern 1: Availability of illicit substances in custody We have worked with our staff to ensure that they recognise their key role in mitigating harm and responding to associated clinical risks of illicit substances. We have increased addictions support and staff are contributing to prison safety arrangements, including weekly Safety Intervention Meetings (SIM) and monthly drug strategy/priority meetings. Concern 2: Identification, recording and response to prisoners under the influence. We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700 www.cnwl.nhs.uk identifies and prioritises individuals at highest risk. Intoxicated prisoners are being immediately referred to the addictions team for review within 48 hours. Concern 3: Information sharing and record keeping. Handover documentation has been revised. This has improved identification and escalation of concerns to prison colleagues. We are ensuring that healthcare attend multidisciplinary forums, weekly Safety Intervention Meetings, and daily wing briefings. We have added a prompt to our handover to ensure that staff consider what information needs to be share with prison colleagues. Concern 4: Blocked observation panels and inadequate visual welfare checks We are supporting prison colleagues by escalating concerns about vulnerable patients including making recommendations for enhanced observation where necessary. Concern 5: Management of self-isolation, debt, fear and vulnerability We are working with staff to ensure that individuals identified as experiencing prolonged isolation are subject to structured review processes, including mental health assessment and ongoing welfare monitoring, where required. Concerns relating to isolation, debt and vulnerability are raised by staff within regular multidisciplinary forums and more complex cases are reviewed regularly. Concern 6: Absence of ACCT despite identifiable indicators of vulnerability Healthcare are aligned with the prison’s Suicide and Self-Harm Prevention policy, We have added an ACCT prompt to our handover sheet. All staff complete SASH and ACCT training and we monitor this. Concern 7: Vulnerability of IPP prisoners We are explicitly considering IPP status within clinical risk assessment and referral processes. Because this is an explicit vulnerability, we can structure our clinical support packages and ensure regular reviews by the MDT. Concern 8: Delay or insufficiency of mental health and psychiatric input We have worked on our waiting list management, setting clearer escalation thresholds, and increasing the use of remote clinics. The mental health and clinical leads review waiting lists every week and prioritise patients based on clinical risk and time waiting to ensure timely assessment and follow-up. We have also expanded clinical capacity by introducing advanced clinical practitioner roles to support routine reviews, while escalating more complex cases directly to consultant psychiatrists. Recruiting to substantive consultant posts remains a key priority for the service. Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison‑led first aid and emergency response training to improve recognition of medical emergencies and ensure prompt, appropriate escalation. Concern 10: Staffing, supervision and regime limitations Escalation of healthcare concerns related to reduced engagement, restricted regimes or health deterioration is conducted through established governance and safer custody processes such as SIM meetings, ACCT reviews, clinical handovers, and mental health zoning meetings. Concern 11: Repeated systemic concerns at HMP Woodhill Governance oversight of Health and Justice services at HMP Woodhill has been improved. We are undertaking a focused review of incident themes. We have looked at ensuring escalation is effective and how we implement learning to ensure that it is consistent. Concern 12: Failure of state agencies to supply all information in a timely fashion. CNWL takes its role in any inquest very seriously and will continue to endeavour to supply all information requested in a timely fashion. Thank you for bringing your concerns to our attention. While healthcare services alone cannot mitigate all risks within custody, the Trust is committed to learning from Mr Meikle’s death and to strengthening how vulnerability is identified and responded to across Health and Justice services. Should you have any questions or comments, please do not hesitate to contact me. Yours sincerely, Chief Executive
OFFICIAL HM Deputy Chief Inspector of Prisons MARTIN LOMAS Sean Cummings Assistant Coroner HM Coroner’s Office Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ Dear Mr Cummings, HM INSPECTORATE OF PRISONS 3rd floor 10 South Colonnade Canary Wharf London E14 4PU 4th June 2026 RONALD WILLIAM MEIKLE – Prevention of Future Deaths Report Thank you for sharing your regulation 28 report to prevent future deaths with HM Inspectorate of Prisons. We are saddened to learn of the findings of your investigation. I acknowledge the delay in HMI Prison’s response and sincerely apologise for any inconvenience caused. Please be assured that we take these matters very seriously. 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. Many of the issues highlighted in your report are areas covered via our Expectations and are therefore matters which our inspectors will consider at each inspection. For example, in relation to safety, our expectations state: “Prisoners are safe from exposure to substance misuse and effective drug supply reduction measures are in place.” Other issues raised in your report such as the management of self-isolation, debt, fear and vulnerability and delay or insufficiency in mental health and psychiatric input are also covered in our Expectations. Some of the particular concerns you raise in Mr Meikle’s case around staffing shortages and operational pressures are sadly issues on which we have reported all too often recently and on which we have raised concerns in our most recent annual report. OFFICIAL OFFICIAL As you will be aware, the Chief Inspector invoked the Urgent Notification process following our unannounced inspection of HMP Woodhill in March 2026. During this inspection, we noted that drugs were far too easily available and that the prison was fundamentally unsafe. We will keep your findings on file so that, when we next inspect HMP Woodhill, inspectors are aware of this information and can follow up as appropriate. Yours sincerely, OFFICIAL
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