Andrew Cox

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Independent investigation into
the death of Mr Andrew Cox,
a prisoner at HMP Guys Marsh,
on 2 December 2023
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
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© Crown copyright, 2026
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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.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Andrew Cox died from sudden death associated with polydrug use, on 2 December at
HMP Guys Marsh. He was 34 years old. I offer my condolences to Mr Cox’s family and
friends.
Mr Cox had a history of illicit drug use but declined to engage with substance misuse
services while in prison. Intelligence submitted by staff raised concerns about his
involvement with the illicit drug supply at Guys Marsh, but no actions were taken. Mr Cox
was last seen alive outside his cell at 4.44pm on 1 December. He was not discovered
unresponsive until 5.04pm on 2 December, nearly 24 hours later.
The investigation has found that staff failed to conduct the required checks and did not
account for Mr Cox or question why he had not been seen or why his observation panel
was covered throughout the day. The actions of staff on the wing suggest a culture of
either indifference or fear and the Governor will want to take robust action.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman October 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ......................................................................................................................... 13
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Summary
Events
1. On 7 February 2017, Mr Andrew Cox was sentenced to eight years and eight
months in prison. On 6 May 2021, he was released from prison on conditional
licence. He was recalled to prison on 31 December 2021 after he failed to abide by
his licence conditions. He was released on licence for a second time on 3 February
2023, but was recalled to prison again on 25 March 2023. Mr Cox had a history of
illicit drug use in prison.
2. On 4 May 2023, Mr Cox arrived at HMP Guys Marsh. Shortly after his arrival, a
member of the prison’s substance misuse team spoke to him, but he denied any
issues with illicit drugs and declined their help.
3. Staff submitted at least two intelligence reports within the first few weeks of Mr
Cox’s arrival at the prison, which indicated that he may be involved in illicit drug
use. Staff acted on this information.
4. Between June and September 2023, Mr Cox seriously assaulted two prisoners but
for various reasons the charges against him were dismissed.
5. Staff opened a Care, Support and Intervention plan and noted that Mr Cox was
being monitored by security staff for his suspected involvement in the illicit drug
economy. Staff submitted three intelligence reports between September and
November 2023, indicating that Mr Cox had received illicit drugs from a drone, had
been overheard discussing payment of large amounts of money for something, and
that a prisoner had asked for a transfer as they were under threat from Mr Cox due
to debt. There is no evidence that staff took any action.
6. Mr Cox was last seen at 4.44pm on 1 December. CCTV showed him on the wing
landing in his dressing gown before being locked in his cell.
7. At 7.30am on 2 December an officer completed a routine check and arrived at Mr
Cox’s door at 7.33am. Mr Cox’s observation panel was covered. The officer said
that this was ‘normal’, and he thought he had heard a response from Mr Cox.
8. At 11.19am, an officer unlocked Mr Cox’s door so that he could collect his lunch.
The officer did not look in the cell or push the door open. Mr Cox did not collect his
lunch and at 12.08pm, an officer locked his cell door. The officer did not confirm
whether Mr Cox was in the cell or that he was all right before doing so.
9. At 1.47pm, an officer unlocked Mr Cox’s door for association (social time). The
officer did not look into the cell and the observation panel was covered. Mr Cox was
not seen at any point during the afternoon.
10. At approximately 4.49pm, officers began to lock prisoners in their cells. An officer
locking Mr Cox’s door was unable to get a response from him and continued to lock
the cells along the landing. The officer then returned to Mr Cox’s cell and tried to
open the door but realised it was wedged from inside. He sought assistance from a
colleague. The officers removed the inundation point (used in the event of a cell
fire) from the door and removed the obstruction that covered the observation panel.
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On doing so, the officers saw Mr Cox lying face down on the floor and called a
medical emergency code and colleagues called an ambulance.
11. Staff used special equipment to open the cell door outwards. Officers and nursing
staff gained access to the cell at 5.04pm. It quickly became apparent that Mr Cox
was dead with extensive rigor mortis present. Staff did not attempt to resuscitate
him. At 5.45pm, the paramedics arrived and confirmed that Mr Cox had died.
Findings
12. Mr Cox was able to access illicit drugs with apparent ease at Guys Marsh.
However, he was offered appropriate support from the substance misuse team, but
he declined.
13. There is no evidence that staff acted upon intelligence which indicated Mr Cox was
involved in the illicit drug culture at the prison and staff completed only one
intelligence led search of his cell. Although Guys Marsh have attempted to put in
place extra measures to reduce illicit drug supply since Mr Cox’s death, there are
still weaknesses in the processes including the lack of staffing resource.
14. Staff completing the routine and welfare checks on 2 December 2023, should have
removed the obstruction from Mr Cox’s observation panel. It is shocking that
processes in place at Guys Marsh meant that Mr Cox had not been seen alive for
24 hours when he was discovered. We consider that staff actions suggest a culture
of either indifference or fear.
15. The clinical reviewer concluded that the clinical care Mr Cox received at Guys
Marsh was equivalent to what he could have expected to receive in the community.
Recommendations
• The Director General of Prisons should consider what additional support can be put
in place to address staffing at Guys Marsh and consider, as a matter of urgency,
how it can be expected to deliver an effective drug strategy and reduce the supply
of illicit drugs with the resources currently available.
• The Governor and Head of Security should continue in the efforts to identify and
address weaknesses and measures to prevent supply of drugs into Guys Marsh
and ensure all intelligence is acted upon and outcomes recorded.
• The Governor should re-issue the operational order from 2021 and a notice to
prisoners which informs both staff and prisoners about the process that must be
followed when unlocking a cell door and ensure that there are robust quality
assurance processes in place to check compliance.
• The Governor should commission a disciplinary investigation into the actions of all
staff working on Gwent unit on 2 December and inform the PPO of the outcome.
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The Investigation Process
16. HMPPS notified us of Mr Cox’s death on 3 December 2023.
17. The investigator issued notices to staff and prisoners at HMP Guys Marsh informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
18. The investigator visited Guys Marsh on 21 December 2023. He obtained copies of
relevant extracts from Mr Cox’s prison and medical records, along with CCTV and
Body Worn Video Camera (BWVC) footage. The investigator also viewed Mr Cox’s
cell and spoke with prisoners that had known him.
19. The investigator interviewed seven members of staff and one prisoner at Guys
Marsh on 30 and 31 January 2024.
20. NHS England commissioned an independent clinical reviewer to review Mr Cox’s
clinical care at the prison. The independent clinical reviewer and the investigator
jointly interviewed nursing staff on 31 January 2024.
21. We informed HM Coroner for Dorset of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
22. The Ombudsman’s office wrote Mr Cox’s family to explain the investigation and to
ask if they had any matters, they wanted us to consider. Mr Cox’s family asked why
Mr Cox had not been discovered until Saturday afternoon and asked for a copy of
this report.
23. Mr Cox’s family received a copy of the initial report. They did not raise any further
issues, or comment on the factual accuracy of the report.
24. HMPPS responded to the initial report on 1 October and accepted all
recommendations made. A copy of the action plan to address these is attached to
the final report.
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Background Information
HMP Guys Marsh
25. HMP Guys Marsh is a medium security prison that holds male prisoners. Practice
Plus Group provides primary and secondary mental healthcare and commissioned
EDP to provide integrated substance misuse services. Healthcare services are
available on weekdays and at weekends from 8.30am to 6.00pm and there is a
doctor on duty on Saturday mornings.
HM Inspectorate of Prisons
26. The most recent full inspection of HMP Guys Marsh was in July 2022. Inspectors
identified 14 key concerns, including three priority ones: the high number of violent
incidents which were not investigated in sufficient depth to understand the causes,
high levels of illicit drugs coming into the prison, despite improved security
measures, and not enough being done to reduce the drug supply. Other key
concerns included offender management and key work, which lacked focus and
frequency.
Independent Monitoring Board
27. 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 November 2022, the IMB
reported that with Guys Marsh being a rural establishment with a significant
perimeter to patrol, organised crime groups (OCG’s) continued to ‘bombard’ the
establishment with throwovers and drone deliveries of drugs and mobile phones.
The Board said that there needed to be more sophisticated ways of combatting
these destabilising deliveries rather than the current patrols around the
establishment and asked HMPPS to provide extra support to the prison in order to
tackle OCG activities.
Previous deaths at HMP Guys Marsh
28. Mr Cox was the fourth prisoner to die at Guys Marsh since July 2020. Of the
previous deaths, one was self-inflicted and two were drug related. Up to the end of
April 2024, there had been one drug-related death since Mr Cox’s death, which is
still under investigation.
29. We have previously made a recommendation about appropriate checks on
prisoners when a cell door is unlocked. In response to this recommendation, HMP
Guys Marsh said that an operational order and a notice to prisoners was issued in
December 2020 to inform both staff and prisoners about the process that must be
followed when unlocking a cell door. It reinforced the message that when unlocking
a cell door staff must obtain a verbal response from each prisoner. If a response is
not obtained, then staff should access the cell to check on the prisoner’s welfare.
Following completion of unlock staff must sign the wing diary to state they have
undertaken these checks. Both orders were reissued in October 2021 and staff’s
understanding of the order was to be checked following the reissue.
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Incentives and Earned Privileges (IEP) Scheme
30. Each prison has an Incentives and Earned Privileges scheme which aims to
encourage and reward responsible behaviour, encourage sentenced prisoners to
engage in activities designed to reduce the risk of re-offending and to help create a
disciplined and safer environment for prisoners and staff. Under the scheme,
prisoners can earn additional privileges such as extra visits, more time out of cell,
the ability to earn more money in prison jobs and to wear their own clothes. There
are three levels: basic, standard and enhanced.
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Key Events
31. On 7 February 2017, Mr Andrew Cox was sentenced to eight years and eight
months in prison for criminal damage (causing explosions) endangering life. He was
initially released from HMP/YOI Portland on conditional licence on 6 May 2021, but
his licence was revoked on 31 December 2021 after he failed to abide by his
licence conditions, and he was taken to HMP Bristol. On 19 January 2022, Mr Cox
was transferred to HMP Erlestoke, and released on licence on 3 February 2023. He
again failed to abide by his licence conditions and committed further offences
(burglary) leading to his licence being revoked on 25 March 2023. He returned to
Bristol. Mr Cox was due for release on 25 August 2025.
HMP Bristol
32. An officer spoke with Mr Cox on his arrival at Bristol as part of the first night
reception procedures. She recorded that Mr Cox had previously been at Bristol and
said that he was happy and had no concerns. He denied any thoughts or intentions
of harming himself.
33. On 28 March 2023, staff at Bristol reported a strong smell of illicit drugs coming
from Mr Cox and his cellmate (also his co-defendant) cell and that other prisoners
had been seen gathering around and entering the cell.
34. On 4 April, the prison’s search team searched Mr Cox’s cell and found cannabis,
tobacco paper, a lighter and suspicious paper (there is no record as to whether this
was tested or whether it was impregnated with illicit substances). Staff placed
Mr Cox on report. Staff recorded that he and his cellmate should not share a cell
and a note was placed on their prison records. There were no other reported drug
incidents involving Mr Cox while at Bristol, but there were entries related to his
threatening and abusive behaviour toward staff.
HMP Guys Marsh
35. On 4 May, Mr Cox was transferred to HMP Guys Marsh.
36. Officer A completed the first night documentation with Mr Cox and recorded that
healthcare staff had seen him in reception and that he had no physical issues and
was not receiving any prescribed medication. The officer recorded that Mr Cox had
no self-harm history, made him aware of the dangers of using illicit substances and
the consequences of engaging in illicit drug use.
37. Following the first night process, Mr Cox was allocated a cell on Anglia unit, where
he would remain for the first 48 hours. Mr Cox was placed in a shared cell with his
cellmate despite the marker on his record indicating that they should not share a
cell.
38. On 5 May, a member of staff from the prison’s substance misuse team (Change,
Grow, Live) spoke with Mr Cox. He told her that he did not use illicit drugs or alcohol
and declined any further interventions.
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39. On 8 May, a member of staff submitted an intelligence report that information had
been received that suggested Mr Cox and his cellmate were in possession of two
ounces of cannabis and were being visited at their cell window by other prisoners.
The report noted that Mr Cox and his cellmate had previously shared a cell at
Bristol, and their adjudication history showed they had used cannabis together.
40. The next day, staff submitted a further intelligence report, indicating that Mr Cox
and his cellmate’s cell was popular with other prisoners and that there had been a
strong smell of cannabis coming from the cell, with occupants and visitors
constantly appearing 'stoned' when leaving. In response, staff searched their cell.
They found a small quantity of tobacco along with tobacco smoking papers.
Smoking is prohibited in prisons and tobacco is a contraband substance. There was
also information that a phone was being concealed in the cell, but staff recorded
that a full search was not conducted for operational reasons.
41. However, while a member of staff was conducting an external patrol of the unit
during the afternoon, partly smoked ‘joints’ were found around the outside of
Mr Cox and his cellmate’s cell. More intelligence reports were submitted on 11 and
27 May, suggesting that Mr Cox and his cellmate were using cannabis, but there is
no evidence that staff took any further action.
42. On 15 June, Mr Cox punched and knocked unconscious another prisoner while on
the exercise yard. Mr Cox was taken to the segregation unit and placed on report.
However, the charge was dismissed because the victim refused to give evidence.
(The incident was referred to the police who took no further action.) Mr Cox was
placed on the basic level of the incentives and earned privilege scheme (meaning
he had reduced access to some in-cell items and other privileges). A challenge,
support and intervention plan (CSIP) was also opened on Mr Cox. (A CSIP is used
to support and manage prisoners who consistently display challenging and violent
behaviour.)
43. On 16 June, Mr Cox was moved to a single cell on Gwent unit.
44. Mr Cox appeared to settle on Gwent unit, and there were positive entries in his wing
record about his behaviour and adhering to the regime. He gained employment
assisting servery workers and collecting the meal trolley from the kitchens.
Following a review of his incentives and earned privileges on 27 June, Mr Cox was
moved up to the standard level.
45. Also on 27 June, staff reviewed Mr Cox’s CSIP (with some incorrect information
recorded). Staff told the investigator that there was no specific monitoring in place
and that intelligence reports submitted that named Mr Cox were collated to build a
bigger picture.
46. On 3 August, Mr Cox was upgraded to the enhanced incentives level. Staff
recorded that he had been doing his job to a good standard.
47. On 16 September, Mr Cox assaulted another prisoner and was placed in his cell
pending a disciplinary hearing. The disciplinary hearing was initially heard on 18
September, and Mr Cox pleaded not guilty. The case was adjourned twice. When
heard again on 1 December, the charge was dismissed as witnesses were
‘unavailable’.
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48. Between 27 September and 8 October, staff submitted three intelligence reports.
The first noted that two prisoners said that a drone package had been collected that
morning and the contents were for Mr Cox. The second report said that a prisoner
had overheard a conversation between Mr Cox and another prisoner, who was
heard to say to Mr Cox ‘I’ll pay two grand for it’. The third report indicated that a
prisoner had asked for a prison transfer because he said he had ‘a lot of money on
his head’ and was under threat from Mr Cox and two other prisoners. There is no
evidence that staff took any further action in response to these intelligence reports.
49. On 25 November, a prison manager asked Officer B to collect Mr Cox from the
grounds because he had been seen wandering around after returning the meal
trolley. The officer approached Mr Cox and another prisoner, and it was clear that
Mr Cox had something concealed under his jumper. When he saw the officer
approaching, he walked in a different direction. The officer stopped and searched
him and found two packets of crisps, and on searching the area, recovered two
multi packets of crisps that had been stolen from the kitchens. Mr Cox was sacked
from his job and placed on report. There were no further intelligence reports about
Mr Cox’s behaviour or his involvement in drugs in the weeks prior to his death.
Events of Friday 1 and Saturday 2 December
50. At around 4.44pm on 1 December, CCTV shows Mr Cox on the landing outside his
cell, dressed in a dressing gown. He walked down to the ground floor and returned
to his cell with his evening meal. He then went back on the landing and spoke to
other prisoners before he and all prisoners on the wing were locked in their cell for
the routine count at around 4.55pm. Mr Cox went into his cell and a piece of fabric
can be seen at the top of his door. Mr Cox’s observation panel remained obscured
(later found to be by a dressing gown hung over the back of the cell door) for the
remainder of the night and on 2 December.
51. Operational Support Grade (OSG) A was on night duty on Gwent unit on 1
December and conducted a routine check of prisoners when he started his shift.
The OSG could not be interviewed during the investigation as he was on long term
leave of absence from the prison. However, he made a written statement on 31
January 2024, and said that he was not able to remember details from the night.
However, he said that it was normal for prisoners to cover their observation panels
and that this made it hard to conduct routine checks. The OSG said that most
prisoners would not only cover their observation panels but also the door frame,
making it almost impossible for staff to see down the sides of the doors.
52. Mr Cox did not press his emergency cell bell during the night of 1and 2 December
and staff had no reason to check him.
53. OSG A said that he completed the morning routine check at around 5.30am on
Saturday 2 December, and had struggled to gain responses from several prisoners.
He could not recall spending any longer at Mr Cox’s cell than any other. CCTV
shows the OSG standing outside Mr Cox’s cell for longer than he appeared to at
other doors. In his statement, the OSG said that if he had spent more time at the
door, he did so to try and get a response by banging and shouting. CCTV footage
does not show the OSG banging on Mr Cox’s door. The OSG said that although he
could not definitely recall, he would not have moved on from Mr Cox’s cell if he had
not got a response.
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54. Gwent wing was locked down during the morning period, meaning that all prisoners
remained in their cells, unless they were working as wing cleaners or unlocked to
collect medication or attend the gym. Officer C, Officer D and Officer E were on
duty.
55. Officer C began his duty at 7.30am. As the first officer to arrive, he completed the
morning routine check. CCTV shows him arriving at Mr Cox’s cell at 7.33am, he
appears to open the observation panel cover to an open position, but does not stop
to look in. The officer was unavailable for interview due to long term leave of
absence but provided a written statement. He said, ‘…during the count I thought I
heard a ‘yeah’ response from his cell due to him being covered up [his observation
panel being obscured] which was normal, but I cannot be sure now that it came
from his cell or the next cell along…’
56. During the morning period both Officer D and Officer E can be seen on CCTV
outside Mr Cox’s cell, either talking to other prisoners or posting canteen sheets
and lunch menus. They did not look into Mr Cox’s cell. However, Mr Cox’s friends
had gone to his door that morning but got no response. Mr Cox’s friend, told the
investigator that the last time that he saw Mr Cox was the previous afternoon when
he had collected his meal. CCTV shows him at Mr Cox’s door at 9.40am, but he
got no response. He said that he called Mr Cox’s name, but thought that he must
have been asleep, so decided he would speak to him later that day. He said that he
had attempted to look into the cell, but the observation panel was covered.
57. CCTV shows at 11.19am, Officer E unlocked Mr Cox’s door. She did not push the
door or look into the cell at any point. The unlock was to enable prisoners to collect
their lunch, which was served at around 11.34am. Between 11.35am and 11.57am,
Mr Cox’s friends can be seen on CCTV listening at his door. Another one of
Mr Cox’s friend, told the investigator that he was trying to get a response from
Mr Cox along with others and confirmed that the observation panel was covered.
Mr Cox did not come out from his cell and did not collect his lunch. Although staff
mark off prisoners as they collect meals, the investigator was told that it was not
usual for staff to check on or chase up those who failed to collect meals.
58. The physical education instructor, was helping out on Gwent unit at around
11.45am, during the lunch period. He went onto Mr Cox’s landing and began
locking prisoners in their cells after they had collected their lunch. Officer E was
also on the landing with the physical education instructor.
59. The physical education instructor said that he secured one side of the landing, while
Officer E did the other. He said that there were doors that had the observation
panels covered, so he either knocked on the door or kicked the door and said that
he got a verbal response. He said that he did get a response from Mr Cox but could
not recall what this was. The physical education instructor said that he was not
completing a routine check, and as far as he was concerned, he was ‘just locking
doors’. The physical education instructor secured Mr Cox’s door at 12.08pm and
closed the (still obscured) observation panel.
60. That afternoon, all prisoners on Gwent unit were unlocked for social time and
exercise. CCTV shows Officer D unlocked Mr Cox’s door at 1.47pm. He kicked the
door as he unlocked it and then walked away. The officer said that he believed he
had received a response from Mr Cox and if he had not, he would have kicked the
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door again or shouted, and would not have moved straight on, although he could
not recall with any certainty whether he had definitely heard Mr Cox respond. The
officer said that he had opened Mr Cox’s door enough for the bolt to ‘shoot’ out
which meant the door would remain open, but he did not attempt to look in.
61. Officer E and Officer D can be seen on CCTV walking past Mr Cox’s cell. CCTV
also shows prisoners gathered outside his cell socialising, and on occasions they
can be seen trying to look into the cell down the side of the door or gain a response
from Mr Cox. Mr Cox is not seen at any point during the afternoon.
62. At around 4.49pm, officers began to lock prisoners in their cells. CCTV shows
Officer D locking Mr Cox’s door, and then speaking to Mr Cox’s friend, a prisoner,
who was in the cell next door. Officer D said that he had not been able to get a
response from Mr Cox so he asked the prisoner if he could call to him and see if he
had any success, but there was still no response.
63. Officer D continued along the landing locking doors before he returned to Mr Cox’s
cell at 4.51pm. He knocked on Mr Cox’s door, tried to get a response and tried to
open the door but was unable. He then left the landing and returned at 4.53pm with
Officer C.
64. Officer F had been assisting on Gwent unit during the afternoon. In her statement
she said that at around 4.50pm, she was on the ground floor completing the
evening routine check. She was approached by Officer D who said that he had
been unable to get a response from Mr Cox. The officer said that she told Officer D
to try and enter the cell to check his welfare and that she would follow him upstairs.
The officer said that when she arrived, Officer D and Officer C were banging on the
door, she looked through the observation panel, but it was blocked. The officer said
that it became apparent that the door had been wedged from inside and they were
unable to gain access.
65. While Officer D and Officer C continued to kick and push on Mr Cox’s door, Officer
F went to the landing office and collected the key to remove the inundation point on
the cell door. (The inundation point is used in the event of a fire and allows staff to
insert a hose.)
66. Once the inundation point was removed, Officer F moved the obstruction covering
the inside of the door to one side. Initially she could see that Mr Cox was not on his
bed and on looking to the other side, saw him lying face down on the floor. The
officer immediately told Officer D to call a code blue (indicating that a prisoner is
unconscious or is having breathing difficulties). The call was made at 4.58pm. The
officer said that she instructed Officer D to collect the anti-barricade keys, which
would allow the staff to remove the lock on the outside of the door and open it
outwards allowing entry. However, Officer F said that the screw heads were
blocked, and she also needed ‘picks’ (small metal items used to remove blockages
from the anti-barricade screws), before staff could remove them from the door.
67. Officer G responded to the code blue and helped to force the door open. He noted
that there was something wedged in the top of the door, and he tried to pull this
over the top. The officer said that he tried to look around the sides of the door
where there is usually a small gap and through the observation panel, but it
remained covered from the inside.
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68. By 5.01pm there were around twelve members of staff outside Mr Cox’s cell, trying
to remove the anti-barricade screws. Healthcare staff were ready to enter the cell
once the door was opened. Staff finally gained entry to the cell at 5.04pm.
69. Body Worn Video Camera (BWVC) footage was initiated at the cell and provided to
the investigator. Officer G and Officer H were first to enter the cell, closely followed
by a nurse and paramedic (the paramedic was an agency member of staff working
at Guys Marsh at that time.)
70. Officer G said that when he entered the cell, Mr Cox was lying face down on the
floor, he was dressed only in a pair of boxer shorts, his feet were pointed towards
the window at the back of the cell and his head towards the door at the front of the
cell. Officer G moved Mr Cox onto his back and said that there was a large amount
of blood coming from his nose, his body indicated that he had been in this position
for a prolonged period of time and that Mr Cox was dark purple in colour.
71. Officer G said that he instinctively started chest compressions and completed about
two, before the paramedic entered and indicated CPR should stop.
72. The nurse told the investigator that as soon as she and the paramedic began
checking Mr Cox, it was clear that he was in a state of rigor mortis.
73. At 5.45pm, emergency paramedics arrived at Guys Marsh and after completing
their own observations they confirmed that Mr Cox had died.
Events following Mr Cox’s death.
74. While in the cell, staff noted that the meal Mr Cox had collected the evening before
was still on the side and was untouched. An unidentified powder was also noted on
the table along with a makeshift tube, usually used for snorting illicit drugs.
75. Intelligence reports submitted following Mr Cox’s death detailed information
received from a number of prisoners suggesting that Mr Cox had been using illicit
drugs during that weekend and he had also received a package from a drone in the
days prior to his death.
76. The substance recovered from Mr Cox’s cell by the police was tested and identified
as cocaine.
Contact with Mr Cox’s family.
77. A prisoner at Guys Marsh used an illicit mobile telephone and told Mr Cox’s family
that he had died before staff were able to make contact.
78. Mr Cox’s family contacted the prison and spoke to a prison manager, and asked if
she could confirm what they had been told. The prison manager told the
investigator that while this was not the way such news should be relayed, she
confirmed that Mr Cox had died.
79. On 3 December, the Governor, visited Mr Cox’s family at their home and offered his
sympathy and explained what was known at that stage and the process that would
follow.
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80. The prison contributed to funeral expenses in line with national policy.
Support for prisoners and staff
81. After Mr Cox’s death, the 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. The staff care team also offered support. However, it
does not appear that Guys Marsh followed the principles of the HMPPS postvention
process in providing support to staff and prisoners following a death in custody.
82. The prison posted notices informing other prisoners of Mr Cox’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 the death.
Post-mortem report
83. The post-mortem report gave Mr Cox’s cause of death as sudden death associated
with polydrug use (Cocaine, MDMB-4en-PINACA & pregabalin). Toxicology tests
indicated that Mr Cox had used a large amount of cocaine prior to his death, and
the levels found in his system were associated with cocaine toxicity. Mr Cox had
also used cannabis, synthetic cannabis, and pregabalin (used to treat anxiety but
often illicitly used). Mr Cox was not prescribed pregabalin in prison.
Inquest
84. An inquest into Mr Cox’s death was concluded on 16 July 2026 and a jury returned
a verdict of misadventure.
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Findings
Drugs strategy at HMP Guys Marsh
85. Mr Cox was able to access illicit drugs with apparent ease; however, he was offered
appropriate support from the substance misuse team, but he declined. While there
was intelligence around Mr Cox’s involvement with the use and supply of illicit
drugs, he was never reported as being under the influence of drugs while at Guys
Marsh.
86. We acknowledge the huge challenges inherent in preventing drugs entering Guys
Marsh. The prison has a large perimeter and is situated in an open and accessible
rural area vulnerable to throwovers and drones. The illicit drugs market in prison is
controlled by organised crime gangs and the scale of the problem requires a co-
ordinated approach. The threat from drugs is constantly evolving and more can
always be done.
87. Temporary Deputy Governor at Guys Marsh told us that the demand for illicit drugs
at Guys Marsh was high, and there were various means for them to be conveyed
into the prison due to its rural location, which also made it more difficult to
effectively challenge attempts. She said that deterrents were often hindered by a
lack of resources. She said that the high number of prisoners linked to organised
crime groups and gangs from around the Southwest area were also drivers for the
high demand for illicit drugs in the prison. She said that Guys Marsh also had a
problem with prisoners’ access to mobile phones, which were often used to direct
both throwovers and drones. Nevertheless, several important measures have been
introduced including:
• trees and hedges were cut back to improve coverage of CCTV.
• additional portable fences were used to fence off areas where ‘throwovers’
were coming in, so prisoners were unable to retrieve items.
• a Code Orange radio call was introduced, to be used by communications
officers or others if someone was seen attempting to throw an item over the
wall. (When a Code Orange is called, staff will stand at fixed post points
around the perimeter and should be able to see if anything is thrown over
and challenge and stop any prisoner that attempts to collect any package.)
• The prison plans to introduce a clear bag policy, to limit items brought in by
staff and visitors.
• Robust measures were in place for checking post and parcels.
88. However, many of the initiatives to reduce drug supply and demand at Guys Marsh
are undermined by staff shortages. Around 60% of staff in post at Guys Marsh have
under two years’ experience, and there are no experienced officers to offer support
and guidance. This was evident during interviews or in statements where staff
spoke about prisoners using illicit drugs, covering observations panels, and
wedging cell doors to prevent staff entry as normal occurrences which went
unchallenged.
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89. The investigator also raised these concerns with the Governor. The Governor said
that while he was aware that the prison had faced issues with the ingress of illicit
drugs for a variety of reasons and that staffing had been a particular issue, since
taking up his post at Guys Marsh he had focused on ways to tackle the illicit drug
problem.
90. The Governor said that several measures had already been put in place to increase
activity levels in the establishment, including the core day being revised to allow for
people attending activity to have adequate domestic and association time, new
workshops introduced to offer more varied work and more activity spaces, and the
reintroduction of unemployment pay so that those that have been removed from
employment have some financial support until they can gain new employment, so
that they do not resort to debt creating behaviour.
91. The Governor said that he had decided to not conduct Mandatory Drug Testing
(MDT, routine testing of a proportion of prisoners) and use other methods to track
and address the issues in the establishment around illicit substances, such as
voluntary testing and suspicion testing. He said that resources would focus on
reducing the supply and demand of illicit substances. In addition, he said that he
was introducing units offering enhanced living conditions and regime for those
willing to adhere to substance free living. A new full Body-Scanner had been
located in the reception area for testing those under suspicion and new arrivals to
the establishment, and all mail is now photocopied, to prevent the ingress of
psychotic substances. The Governor cited other interventions being introduced at
Guys Marsh to tackle the issues with the illicit economy.
92. Clearly, there is targeted activity to address the problem of drugs at Guys Marsh,
which we welcome. However, we consider the prison’s response to intelligence
about Mr Cox’s involvement in illicit drug use and supply at Guys Marsh was
insufficient. Mr Cox was only ever subject to one cell search. He was allowed to
share a cell with his cellmate, despite intelligence that they should not do so. We
make the following recommendations:
The Director General of Prisons should consider what additional support can
be put in place to address staffing at Guys Marsh and consider, as a matter of
urgency, how it can be expected to deliver an effective drug strategy and
reduce the supply of illicit drugs with the resources currently available.
The Governor and Head of Security should continue in the efforts to identify
and address weaknesses and measures to prevent the supply of drugs into
Guys Marsh and ensure all intelligence is acted upon and outcomes recorded.
Blocked observation panels
93. An HMPPS Safety Briefing on Observation Panels, issued in February 2018, says
that local safety measures should explain what staff should do if the occupant of a
cell cannot be seen due to the panel being covered or blocked. It goes on to say
that when staff discover that a panel has been blocked, and the prisoner does not
comply with instructions to remove the blockage, they must take immediate action
to remove the obstruction and check on the prisoner’s welfare.
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94. We consider that the actions of multiple staff on 1 and 2 December suggest that
there is a systemic issue in the tackling of blocked observation panels at Guys
Marsh. CCTV and officer accounts indicate that Mr Cox’s observation panel was
blocked from late afternoon on 1 December until he was discovered unresponsive
24 hours later.
95. The Governor told the investigator that following Mr Cox’s death the Notice to Staff
regarding obscured observation panels re-issued in 2021 had been reissued again.
In addition senior managers had been tasked with monitoring compliance during
wing visits. We welcome the actions already taken but given the severity of the
problem evident at Guys Marsh.
96. We are not making a recommendation whilst the new process beds in at Guys
Marsh, but have brought he issue to the attention of His Majesty’s Inspectorate of
Prisons (HMIP) to consider at their next inspection.
Routine checks and welfare checks
97. Routine checks are primarily a visual security check to count prisoners to ensure
that they are present in their cells, but they are also an opportunity for any concerns
about a prisoner’s safety to be identified and managed. HMPPS’ National Security
Framework expects welfare checks to take place at routine checks including that
staff are able to see the prisoner’s face and satisfy themselves that they are alive
and well.
98. Daily cell fabric checks (to ensure a cell’s physical condition is up to standard) are a
security measure and should be completed daily. No checks took place on 2
December.
99. Mr Cox was not seen alive after he went into his cell at around 4.55pm on 1
December. Despite several staff conducting routine checks, locking or unlocking the
door, he was not checked at any point. As noted earlier, staff were aware that his
observation panel was covered, but this did not raise concerns. Staff said that they
had received a verbal response when checking Mr Cox’s cell, although when
interviewed they said that they could not be certain that the response had in fact
come from Mr Cox.
100. It is not possible to say when Mr Cox became unwell or died but evidence (including
the presence of rigor mortis) would suggest it was a significant period. Staff on duty
on Gwent unit on 1 and 2 December failed in their duty of care towards Mr Cox to a
shocking extent. The evidence suggests that there was a staff culture of either
indifference about what prisoners were up to on the unit and whether they were
safe, or fear (specifically of Mr Cox, or more generally of prisoners on the unit).
Either way, staff made no efforts to challenge Mr Cox for his blocked observation
panel or conduct more than rudimentary checks on him. We consider it likely that
Mr Cox died at some point in the evening of 1 December. We make the following
recommendations:
The Governor should re-issue the operational order from 2021 and a notice to
prisoners which informs both staff and prisoners about the process that must
be followed when unlocking a cell door and ensure that there are robust
quality assurance processes in place to check compliance.
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The Governor should commission a disciplinary investigation into the actions
of all staff working on Gwent unit on 2 December and inform the PPO of the
outcome.
Clinical care
101. The clinical reviewer concluded that the clinical care Mr Cox received at Guys
Marsh was of a good standard and was equivalent to what he could have expected
to receive in the community.
102. Mr Cox denied using any illicit substance and declined support or input from drug
services. Mr Cox was provided with the necessary information to refer himself to
mental health and drug and alcohol services.
103. The clinical reviewer also noted that during the emergency response the situation
was assessed accurately and was managed with dignity and respect.
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