Roy Sinclair

Dear Mr Cummings, Re: Regulation 28: Report to prevent future deaths Thank you for your Regulation 28 report dated 13 May 2026 following the inquest into the death of Mr Roy Richard Sinclair, which concluded on 19 March 2026. Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr Sinclair, and we extend our sincere condolences to his family. We write to address your concerns detailed below having reviewed our governance and clinical practice and working closely with HMPPS colleagues at HMP Woodhill. Oversight of the actions arising from this case is maintained through Trust governance processes. Concern 1: ACCT documentation and operation We have made changes to our handover process with a revised clinical handover template requiring explicit discussion of all open ACCTs, confirmation of whether reviews have been completed and documentation of outcomes and agreed actions with named clinician responsible for follow-up. We ensure that there is a healthcare contribution to the ACCT process. Clinical staff provide risk assessment and relevant clinical information to inform ACCT care planning and review. This is supported by multidisciplinary oversight. All patients returning from hospital following a serious self-harm incident, are receiving a full mental health assessment by a registered clinician. Findings are shared in the ACCT and risk management processes. Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700

[Page 2] We are regularly reinforcing the importance of accurate and complete documentation through staff communication and staff are aware of the need to record consistently on both Systmone and in ACCT documentation. We undertake spot-check audits to ensure this is occurring. We have also audited documentation of clinical contact in the prison ACCT document and on SystmOne. We have held a staff session on ACCT processes, documentation standards, care planning and the recording of key risk factors, including debt, vulnerability and medication-related risk and provided bespoke training for the mental health team with prison colleagues, on risk formulation and vulnerability factors in ACCT care planning. Concern 2: Management of suspected paracetamol overdose We have introduced an overdose clinical pathway. This provides guidance on Toxbase, assessment, monitoring, escalation and transfer and is supported by visual flowcharts displayed in all clinical areas. We have trained staff on the pathway and undertaken scenario-based learning and have seen this implemented in practice in a recent event. We have reinforced the pathway through team meetings and supervision, and it is incorporated into staff induction materials. We have reviewed incident data and undertaken an audit and are assured that the pathway is being complied with. Concern 3: Failure to raise intelligence reporting and investigate source The healthcare handover process now includes a prompt to consider whether any clinically relevant concerns need to be escalated to prison colleagues including issues around medication access and potential hoarding of medication. This has been reinforced through team discussions focussing on the key role staff play in identifying and communicating relevant information arising from clinical contact and is included within staff induction processes reinforcing the role staff play in supporting wider risk management within the prison. Concern 4: Debt, vulnerability and safeguarding Staff have been reminded to consider these risk factors, document and incorporate into both clinical assessment and ACCT care planning. A recent debt awareness session delivered jointly with prison safer custody and security teams is being incorporated into healthcare training. We have also completed targeted mental health training and reinforced across the wider clinical team. Concern 5: Wider operational context HMP Woodhill has been operating within a challenging operational environment, including high levels of self-harm and wider safety pressures. The Trust continues to escalate risks through established governance routes and to work collaboratively with prison colleagues and commissioners to improve patient

[Page 3] safety. We will continue to take all reasonable steps within our control to reduce harm and improve outcomes. We recognise that improvement in this area requires sustained focus and effective joint working with our prison partners. We are monitoring the impact of the actions described and will take further steps where required. Thank you for bringing these matters to our attention and again I would like to reiterate our condolences for the loss of Mr Sinclair. Should you require any further information, please do not hesitate to contact me.

Dear Mr Cummings, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR ROY SINCLAIR Thank you for your Regulation 28 report of 13 May 2026 addressed to the Governor, HMP Woodhill and the Minister of State for Prisons, Probation, and Reducing Reoffending following the inquest into the death of Roy Sinclair at HMP Woodhill on 25 November 2025. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS) and the aforementioned recipients. I know that you will share a copy of this response with Mr Sinclair’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 the management of Assessment, Care in Custody and Teamwork (ACCT) and other processes within the wider operational context of the establishment. HMP Woodhill has developed a comprehensive Safety Action Plan, which is due for implementation in July 2026, which incorporates recommendations from internal audits, external scrutiny and inspection activity. The plan focuses on improving the quality of ACCT documentation, reviews and care planning by ensuring records clearly reflect individual risks, triggers and protective factors. The plan supports staff to produce meaningful, personalised care maps informed by prisoner engagement and multidisciplinary input, while tools such as Know Your Prisoner summaries and one-page plans promote consistency across departments. To improve the quality of ACCTs, residential managers will undertake regular

[Page 2] quality assurance checks, allowing issues relating to reviews, risk identification and care planning to be identified and addressed in real time. Post-closure oversight has also been strengthened through a central quality assurance process managed by the local safety team. A database is used to identify trends, highlight areas for improvement and inform targeted training and development, ensuring learning is systematically captured, recurring issues are addressed promptly, and feedback is provided to both staff and managers. Findings are reviewed through monthly Priority One meetings, which is a joint Safety, Security and Drug Strategy governance forum chaired by the Deputy Governor. The purpose of the meeting is to provide strategic oversight of these key functions, ensuring a joint approach to working. The meeting is designed to ensure that safety, security and drug strategy risks are managed through a whole prison approach, with learning, assurance findings and emerging concerns informing operational and strategic decision making, where additional interventions can be considered where necessary. The establishment is further enhancing staff understanding of the ACCT process through monthly training on risks, triggers and protective factors, regular ACCT and Suicide and Self- Harm (SASH) training, with non-operational prisoner-facing staff receiving ACCT training as part of induction. The formal training is reinforced through operational briefings, supervision, and ongoing support from the safety team. Safety Single Points of Contact (SPOCs) are allocated to residential units, providing advice, guidance and informal coaching through daily engagement and attendance at case reviews. In addition, every serious self-harm incident is subject to a safety team fact-finding exercise, with actions overseen by the Deputy Governor. Where policy or procedural failings are identified, decision logs are commissioned to capture learning and provide targeted guidance. Safety team governance is also being strengthened through a review of structures and accountability. This includes the introduction of a dedicated ACCT lead at custodial manager level and a revised assurance framework that separates oversight of open ACCTs from post- closure quality assurance and thematic review. Performance is monitored through established governance forums, including Daily Risk Reduction Meetings, Performance and Risk meetings, Safety Intervention Meeting (SIM) and the weekly Priority One meeting, ensuring senior leaders maintain oversight of both individual cases and emerging trends. Communication between prison and healthcare staff has been strengthened through established multidisciplinary forums. Daily Risk Reduction meetings, weekly SIM and Priority One meetings ensure that relevant risk information is shared, discussed and acted upon collaboratively. Where healthcare cannot attend key meetings, senior-level liaison arrangements ensure information continues to flow effectively. Clear escalation pathways are also in place, enabling healthcare staff to raise concerns through orderly officers and, where necessary, directly to duty governors, supporting a coordinated and consistent response to prisoners at risk of harm.

[Page 3] In relation to intelligence reports and investigating, all incidents and occurrences are reported to the orderly officer and reviewed through the comprehensive daily briefing sheet presented at the morning meeting. This records all incidents from the previous 24 hours, including under the influence (UTI) and suspected overdose events, together with the actions taken, such as the submission of security intelligence reports (IRs). For UTI incidents, specific follow-up actions are required, and the security department uses CCTV and other available intelligence sources to identify and investigate the likely source of supply of substances wherever possible. Staff awareness and understanding of intelligence reporting are reinforced through two annual security fayres, which provide refresher training and upskilling opportunities for both operational and non-operational staff. In addition, security staff attend residential unit morning briefings on a weekly basis to promote the importance of intelligence gathering and reporting. To strengthen assurance and intelligence triangulation, the security principal officer conducts nightly reviews of residential unit observation books to verify that all relevant information has been appropriately recorded and reported. This includes confirming that the necessary security intelligence reports, Incident Reporting System (IRS) reports and Digital Prison System (DPS) case notes have been completed, ensuring that incidents are fully documented, investigated and acted upon. The establishment recognises the need to strengthen the identification and management of prisoner debt where it contributes to vulnerability, distress, self-harm risk or exploitation. To address this, a comprehensive debt strategy is being developed and is due for publication by the end of August 2026. The strategy will provide clear guidance on identifying, recording and responding to debt-related concerns, including recognised indicators of risk, referral pathways into safety team, security and support services, and stronger links between debt management, violence reduction and the drug strategy to ensure a coordinated response. In the meantime, staff are trained to recognise the signs of debt, exploitation and coercion through ACCT, SASH, and monthly risks and triggers training. Concerns can be raised through a range of channels, including intelligence reports, safeguarding referrals, ACCTs and Challenge, Support and Intervention Plans (CSIP), ensuring that potential risks are identified through multiple routes. Where debt is linked to vulnerability, distress, self-harm risk or exploitation, it is considered as part of assessment, care planning and safeguarding processes. Staff are trained to explore potential drivers of vulnerability, including debt and coercion, during ACCT assessments and reviews, as well as when prisoners choose to isolate themselves from the wider population, as this can indicate perceived vulnerability regardless of the underlying cause. This approach supports the early identification, recording and management of debt-related risks within a broader, multidisciplinary safeguarding framework. Joint working between safety, security and other key functions has been strengthened to ensure a coordinated response. Daily Risk Reduction Meetings, SIM, Priority One meetings

[Page 4] and the monthly Tactical Tasking and Coordination Group (TTCG) provide regular oversight of prisoners whose debt may be linked to exploitation, violence, drug-related harm or safeguarding concerns. Plans to co-locate safety and security staff, alongside the introduction of an additional safety analyst role, will further strengthen information sharing, risk identification and analytical oversight. Equally, targeted key work, SASH-trained staff, regular welfare reviews and access to specialist services, including mental health, psychology, neurodiversity and substance misuse support provide additional safeguards for vulnerable prisoners. Together, these measures aim to ensure that debt-related vulnerability is identified early, recorded appropriately and managed through a coherent, multidisciplinary approach. HMP Woodhill, like many establishments, has faced challenges in recruiting and retaining sufficient operational staff. To strengthen staffing levels and support the safe delivery of regimes, a range of targeted recruitment and retention initiatives are in place. These include prioritisation within the national recruitment campaign, level transfer and alumni schemes to attract experienced staff, the conversion pathway from operational support grade to prison officer, and participation in the prison officer first deployment scheme. Newly recruited officers receive enhanced support through additional consolidation training and job- shadowing opportunities to improve confidence, competence and retention. Efforts are also focused on attracting custodial managers from across the estate to reduce the need to promote operational staff into management roles and maintain frontline resilience. While the prison continues to rely on detached duty staff, this dependency is reducing as recruitment and retention improve. In the context of ongoing staffing pressures, HMP Woodhill prioritises residential stability by maintaining minimum staffing levels on residential units to support a safe and predictable regime. This ensures the delivery of essential welfare and security functions, including roll checks, welfare checks, ACCT observations, incident response and key safety meetings. Safety SPOCs continue to support the effective management of risk, while prisoners retain access to core activities such as domestic routines and exercise. This approach promotes stability, improves staff confidence and ensures appropriate oversight of prisoner welfare. Staffing resources are managed through a weekly Regime Management Planning Meeting, supported by daily meetings, enabling dynamic deployment decisions and ensuring available resources are directed where they are most needed. At the time of the inquest, the prison had been issued with its second Urgent Notification (UN) by HM Inspectorate of Prisons, information which I apologise was not disclosed due to an oversight. The resulting UN Action Plan provides a comprehensive programme of work to address longstanding and systemic challenges and deliver sustainable improvement. Many of the measures outlined within this response form part of that work, which remains subject to regular external scrutiny and monitoring to ensure that improvements are embedded and effective.

[Page 5] Thank you for bringing these matters to my attention. I trust that this response provides assurance that appropriate and proportionate action is being taken to address the concerns identified.