Source · Prevention of Future Deaths

Gavin Wheale

Ref: 2025-0350 Date: 10 Jul 2025 Coroner: Ian Dreelan Area: Birmingham and Solihull Responses identified: 1 / 1 View PDF

The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with concealed items.

Date 10 Jul 2025

56-day deadline 4 Sep 2025

Responses identified 1 of 1

Alcohol, drug and medication related deaths State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. At the time Mr Wheale resided in HMP Birmingham, HMP Birmingham Secreted Item Policy (January 2020) was in force. An updated policy was issued after Mr Wheale’s death (dated Aug 2024). Both versions of the policy accept that ‘There is a clear risk to a prisoner’s health when an item is secreted internally’. My concern is that focus of the policy is the prevention of contraband entering the prison system and therefore it presupposes the outcome of the secreted item(s) being surrendered or disposed of by the prisoner. It does not provide clear guidance to staff on a situation, as with Mr Wheale, where an item previously concealed is then claimed to have been (or indeed a situation where it was witnessed to have been) removed and ingested without its previous packaging.

2. Evidence was heard from WMP and GEOAmey staff dealing with their required procedures where a person in their custody, in this instance Mr Wheale, was known or suspected of concealing items; both organisations required constant supervision and handcuffing. My concern is that upon handover to HMP Birmingham prisoners who have previously been under constant supervision, with their movement restricted, enter a regime with no equivalent levels of monitoring rendering HMP Birmingham unable to fully discharge their duty of care to that prisoner.

Responses

1 respondent

HM Prison and Probabtion Service Central Government

4 Sep 2025 PDF

Action Planned

HMP Birmingham will update its Secreted Items Policy to include guidance for staff on actions to take when a prisoner has ingested an item. They will also issue guidance to staff to ensure a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision. (AI summary)

View full response

Dear Mr Dreelan Thank you for your Regulation 28 report of 10 July 2025 following the inquest into the death of Gavin Wheale at HMP Birmingham on 8 August 2024. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations. I know that you will share a copy of this response with Mr Wheale’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. The first concern you raise relates to HMP Birmingham’s Secreted Items Policy and its focus on preventing contraband from entering the prison system. I can confirm that following the inquest the prison has committed to updating the local policy to include clear guidance for staff on the action they need to take where it is suspected that a prisoner has ingested an item. The guidance will cover steps such as notifying healthcare, initiating appropriate observations, and considering whether suicide and self-harm procedures should be opened. Additionally, the West Midlands Group Safety Lead will ensure that consistent guidance is implemented across all establishments within their regional area. You also raise a concern regarding the management of prisoners who enter the prison on high levels of monitoring. In response to this, HMP Birmingham will be issuing guidance to staff to ensure that a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision, whether due to secreted items or other reasons - to ensure that the individual is managed effectively and safely, clearly documenting the actions to be taken to manage any associated risks. I hope the measures outlined above provide you with reassurance that learning and appropriate action is being taken to address the issues you have identified from the circumstances of Mr Wheale’s death.

Report sections

Investigation and inquest

On 15 August 2024 I commenced an investigation into the death of Gavin James WHEALE. The investigation concluded at the end of the inquest. The conclusion of the inquest was; It is the unanimous opinion of the Jury that Mr Wheale did die due to mixed drug interactions additionally, the events examined in this inquest highlight shortcomings in the following areas at the time of Mr Wheale's death:
1. The training of custodial and medical staff at HMP Birmingham in the implementation of policies and procedures designed to facilitate the arrival, processing and housing of prisoners considered 'at risk' or vulnerable. This had no impact on Mr Wheale's death.
2. The lines of communication across custodial staff at HMP Birmingham concerning the effective transfer of information pertinent to the health and wellbeing of incoming prisoners This had no impact on Mr Wheale's death.
3. The Lines of communication between medical and custodial staff at HMP Birmingham concerning the effective transfer of information pertinent to the health and wellbeing of incoming prisoners. This had no impact on Mr Wheale's death.
4. The facilities and resources in the reception area at HMP Birmingham pertaining to custodial staff's ability to monitor and supervise incoming prisoners, particularly those considered 'at risk' or vulnerable. This had no impact on Mr Wheale's death. Conclusion of the Jury as to the death: Drug Related.

Circumstances of the death

On 6/8/24, Gavin James Wheale was arrested on a recall to prison. He remained under constant supervision and handcuffed as he was suspected to be concealing an item. He was then transported by GeoAmey on 7/8/24 to HMP Birmingham. At 12.45, Mr Wheale was handed to HMP staff, where he was no longer handcuffed or under constant supervision. Mr Wheale provided a urine sample that tested positive for cocaine, benzodiazepines, cannabinoids and opiates. He began the body scanner process at 16.00 on 7/8/24, which came back as inconclusive. A short time later, Mr Wheale was seen waving a plastic bag in the air, which was empty, but said it had contained Diazepam, and he had taken it. He was then placed in a holding cell in the Care and Separation Unit (CSU). At 14.26 on 8/824, Mr Wheale was found unresponsive in his CSU cell. He was pronounced dead at 14.39. Following a post mortem, the medical cause of death was determined to be: 1a Mixed drug interactions (Morphine, Cocaine and Diazepam) 1b

1c 1d II

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Report details

Reference: 2025-0350
Date of report: 10 July 2025
Coroner: Ian Dreelan
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Sep 2025.

Sent to

HM Prison & Probation Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.