Stuart Cordner

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Independent investigation into
the death of Mr Stuart Cordner,
a prisoner at
HMP Standford Hill,
on 1 November 2024
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 Stuart Cordner died on 1 November 2024, having been found hanged in his pod at
HMP Standford Hill. He was 48 years old. I offer my condolences to Mr Cordner’s family
and friends.
Mr Cordner had been in prison for 19 years and was at Standford Hill preparing for his
release in 2025. He had completed several successful periods of release on temporary
licence (ROTL) as part of his rehabilitation.
In the hour before Mr Cordner’s death, staff suspended his ROTL to attend a narcotics
anonymous (NA) group meeting that evening. Security information relating to this ROTL
had not been assessed and actioned swiftly, but this was due to short staffing which has
since been improved. Although Mr Cordner was upset by the decision that he could not
attend NA, my investigation found that staff could not have known that he intended to take
his own life.
I make no recommendations.
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 August 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 15
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Summary
Events
1. In 2007, Mr Stuart Cordner was sentenced to life imprisonment for the murder of his
wife, with a minimum time in prison of 19 years. He had a history of anxiety, post-
traumatic stress disorder, attention deficit hyperactivity disorder and depression. Mr
Cordner was last monitored under prison suicide and self-harm procedures, known
as ACCT, in 2017.
2. Mr Cordner was in several prisons before transferring to HMP Standford Hill, an
open prison, in December 2023. This was as part of his reintroduction to the
community and working towards his release from prison. He completed several
escorted and unescorted periods of being released on temporary license (ROTL).
3. On 5 July 2024, Mr Cordner was temporarily moved to the healthcare unit at HMP
Elmley due to psychotic symptoms and anxiety. After a week, he returned to
Standford Hill and was later allowed to resume periods of ROTL, which included
employment and family visits.
4. On 25 October, Mr Cordner attended his first Narcotics Anonymous (NA) meeting in
the community as part of his rehabilitation. Prison staff later discovered that Mr
Cordner had not fully disclosed a developing relationship he had formed with a
young woman and two young men he had met there.
5. Around 3.30pm on 1 November, staff told Mr Cordner that his ROTL was
suspended, and he could not attend the NA meeting that evening, pending a risk
review. He was unhappy with this decision. At 5.00pm, an officer found Mr Cordner
hanging from the window in his pod (individual, ensuite, self-contained residential
unit). Prison staff provided emergency care. Paramedics arrived and pronounced
Mr Cordner’s life extinct at 5.41pm.
Findings
6. We found no evidence that prison staff should reasonably have assessed that Mr
Cordner was at risk of suicide on the day he died.
7. The security information which led to the suspension of Mr Cordner’s ROTL should
have been analysed and actioned quicker. However, the security department was
short staffed at the time. This situation has since been improved.
8. The clinical reviewer found that Mr Cordner’s healthcare was equivalent to that he
could have expected to receive in the community.
9. We make no recommendations.
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The Investigation Process
10. HMPPS notified us of Mr Cordner’s death on 4 November 2024.
11. The investigator issued notices to staff and prisoners at HMP Standford Hill
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
12. The investigator visited Standford Hill in November 2024. He obtained copies of
relevant extracts from Mr Cordner’s prison and medical records.
13. The investigator interviewed six members of staff at Standford Hill in December
2024 and a further three members of staff by MS Teams in January 2025.
14. NHS England commissioned a clinical reviewer to review Mr Cordner’s clinical care
at the prison. The investigator conducted some joint interviews with the clinical
reviewer.
15. We informed HM Senior Coroner for Mid Kent & Medway of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
16. The Ombudsman’s office contacted Mr Cordner’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Cordner’s family
wanted to know about the circumstances that led to Mr Cordner’s death. We have
covered this in our report.
17. Mr Cordner’s family received a copy of the initial report. They pointed out some
factual inaccuracies. This report has been amended accordingly.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS identified one factual inaccuracy, and the report has been amended
accordingly. Their action plan is annexed to this report.
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Background Information
HMP Standford Hill
19. HMP Standford Hill is a category D open prison for men on the Isle of Sheppey in
Kent and is situated next to HMP Swaleside and HMP Elmley. It holds prisoners
nearing the end of their sentences. Open prisons have minimal security and allow
eligible prisoners to spend most of their day away from the prison on licence to
carry out work, education or for other resettlement purposes. Open prisons only
house prisoners who have been risk-assessed and deemed suitable for open
conditions. Oxleas NHS Foundation Trust provide healthcare services at Standford
Hill. Standford Hill does not have 24-hour healthcare.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Standford Hill was in October 2024. Inspectors
reported Standford Hill was a very safe prison. Self-harm and violence were rare
and all other safety outcome indicators were low or compared favourably with
findings at similar establishments. Prisoners were motivated and incentivised by the
quality of life at the prison, the clear opportunities for progression, and in particular,
the employment and resettlement opportunities release on temporary licence
provided.
Independent Monitoring Board
21. 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 March 2024, the IMB reported
that Standford Hill provided an excellent rehabilitative service to prisoners. It noted
that the prison provided education, training and resettlement work of a high
standard that gave prisoners the best possibility of leading fulfilling lives on release.
The prison continued to release over 100 prisoners every day to paid work.
Previous deaths at HMP Standford Hill
22. Mr Cordner was the third prisoner to die at Standford Hill since November 2021. Of
the previous deaths, both were from natural causes. Neither of these cases had any
similarities to Mr Cordner’s death. Up to the end of May 2025, there have been no
further deaths at Standford Hill since that of Mr Cordner.
Pathways Enhanced Resettlement Services (PERS)
23. Pathways Enhanced Resettlement Services (PERS) is a programme in some open
prisons (including Standford Hill) that helps prisoners who are at high risk of
reoffending or being returned to closed conditions. It encourages successful
integration into the prison and then into the community. The length of engagement
is approximately three to six months.
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Temporary release
24. Release on temporary licence (ROTL) is fundamental to resettlement plans. Each
prisoner’s needs are considered on an individual basis. They are kept fully informed
of their progress and their family members have a vital role in its success. Prisoners
are eligible for ROTL on arrival at the prison. Eligibility requires risk assessment
before any unaccompanied ROTL takes place. These processes can take up to 12
weeks to make sure each ROTL is both individually appropriate while ensuring
public safety. ROTL can be used for resettlement, day release to maintain family
ties, work, training and education. Resettlement overnight release is used for
getting prisoners back into the community and maintaining their family ties.
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Key Events
25. In July 2007, Mr Stuart Cordner was sentenced to life imprisonment for the murder
of his wife, with a minimum term of 19 years. This was his first time in prison. He
had a history of alcohol abuse and multiple mental health conditions, including
anxiety, post-traumatic stress disorder (PTSD – symptoms include flashbacks,
nightmares and anxiety), attention deficit hyperactivity disorder (ADHD –
characterised by inattention, hyperactivity and impulsivity), depression, and asthma.
Mr Cordner formerly served in the army and suffered from chronic lower back pain,
due to an injury sustained during service. He was prescribed medication to manage
his physical and mental health issues.
26. Mr Cordner spent time in several different prisons. He was monitored under suicide
and self-harm procedures, known as ACCT, five times throughout his sentence: in
2007, 2008, March and June 2010, and lastly in September 2017 for three days.
27. As a life-sentenced prisoner, Mr Cordner completed several rehabilitation and
treatment programmes, aimed at addressing his alcohol and prescribed medication
misuse, traumatic experiences and using cognitive skills to alter how his thoughts
affect his feelings and behaviours. Due to his progress and good behaviour, he was
on the enhanced level of the prison incentives scheme meaning that he had extra
privileges.
28. In October 2023, the Parole Board recommended that Mr Cordner was transferred
to an open prison to continue his sentence. His behaviour, compliance, and
engagement would continue to be monitored, with the possibility of returning to
closed conditions, if concerns arose. His sentence tariff expiry date (date of
expected release from prison) was set for October 2025, with another Parole Board
review scheduled before that date.
HMP Standford Hill
29. On 8 December 2023, Mr Cordner transferred to HMP Standford Hill, an open
prison. An officer completed Mr Cordner’s reception screen and first night interview.
Mr Cordner said that he was happy but nervous to be at Standford Hill. It was his
first time in an open prison. The officer explained the prison and wing rules and
ensured Mr Cordner had phone credit to contact his family and friends. Mr Cordner
confirmed that his mother, brother and grandma were his main support.
30. A nurse completed Mr Cordner’s reception and secondary health screen. She noted
that Mr Cordner had a history of asthma, ADHD, PTSD and depression. He was
prescribed amitriptyline (to treat nerve pain and depression), gabapentin (to treat
seizures and nerve pain), lisdexamfetamine (a treatment for ADHD) and inhalers for
his asthma. Mr Cordner denied any thoughts of suicide or self-harm. The nurse
noted no concerns. Mr Cordner was located on A Wing.
31. On 11 December, Ms A, a Change Grow Live (CGL) recovery worker, saw Mr
Cordner and provided advice to him on substance misuse and harm reduction. The
next day, Custodial Manager (CM) A and Ms B, an assistant psychologist, saw Mr
Cordner for his initial Pathway Enhanced Resettlement Service (PERS)
assessment. CM A was Mr Cordner’s PERS key worker.
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32. On 18 December, Mr Cordner moved to B Wing and had a PERS session with
Supervising Officer (SO) A. By 21 December, Mr Cordner had finished his induction
and said he felt settled at Standford Hill. He said that he had improved his coping
skills compared to the past. Mr Cordner worked in the chapel, said he wanted to
stay busy, and hoped to teach other prisoners how to play musical instruments. He
also regularly attended the gym.
33. On 29 December, Mr Cordner told CM A that gaining employment was his priority
once he had been risk assessed for ROTL. Mr Cordner also said that he was
looking forward progressing onto ROTL and being able to spend time with his family
in the future.
2024
34. From January 2024 onwards, Mr Cordner attended several sessions and
workshops facilitated by PERS. These included yoga and cooking sessions and
theatre workshops.
35. On 7 January, Mr Cordner self-referred to the mental health team. The next day, a
mental health nurse saw Mr Cordner. Mr Cordner said that he wanted to see the
psychiatrist to review his ADHD medication, with the possibility of reducing the
dose. The nurse noted that Mr Cordner was agitated and fidgety and said that he
wanted to be referred to psychology for cognitive behavioural therapy. She referred
him to the GP and psychiatrist. The GP later saw him and reviewed his medication.
No change to his medication was made at this stage.
36. On 23 January, CM A spoke to Mr Cordner about his accommodation prospects at
the Royal British Legion village and employment at one of their factory sites. He had
discussed this with Mr A from the Care After Combat team. (Care After Combat is a
charity that supports veterans in custody in identifying their individual needs and
supporting their eventual release into the community.) They agreed to explore this
further.
37. On 2 February, Dr A, forensic psychiatrist, assessed Mr Cordner. He noted his
diagnosis of ADHD and that Mr Cordner was managing this well. He lowered his
medication dose. Two weeks later, he increased this again after Mr Cordner
struggled to cope.
38. SO A was reallocated as Mr Cordner’s key worker. During February, they discussed
that Mr Cordner could progress to ROTL after he had completed the Stear process.
(Stear is an escorted period of ROTL where a member of staff takes the prisoner
into the community, to provide extra support and familiarise them with life outside
prison. It is the first stage of the ROTL process, before a prisoner progresses to
unescorted ROTL.)
39. On 3 March, the offender management unit (OMU) assessed that Mr Cordner had
progressed well and could start ROTL. On 19 March, SO A and Ms C, Prison
Offender Manager (POM), held a key work session with Mr Cordner. They
confirmed that his first Stear ROTL was scheduled for 16 April. He expressed
positive views about his resettlement, mentioning support from his mother and
cousins in Sussex, and his interest in engaging with religious activities, running
support clubs, and participating in support groups in the community.
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40. On 16 April, Mr Cordner had his first Stear ROTL. This was his first time in the
community in 18 years. He was accompanied by SO A. Initially anxious, Mr Cordner
became more confident throughout the day, interacted politely with the public,
managed financial tasks (including banking), shopped, and set up a mobile phone.
(The prison encourages all prisoners to have their own phone, so that they can be
contactable when on ROTL and for emergency use. The phones are not allowed on
site and are stored in a personal locker at the prison gate lodge. The phone is
collected and deposited from the gate lodge when the prisoner departs and returns
to the prison, along with other personal items such as money and debit cards.)
41. On 26 April, during his second Stear, Mr Cordner was overwhelmed, particularly
with the prison booking in and out process. Mr Cordner planned to use a reminder
list to help. SO A recommended support during Mr Cordner’s first unescorted
resettlement day release (RDR) in the community, noting that PTSD may influence
his behaviour and that further support was needed to ensure both public safety and
Mr Cordner’s well-being.
42. On 17 May, Mr Cordner had a third Stear. SO A noted that Mr Cordner was less
anxious and showed a better awareness of his surroundings in the community.
43. On 4 June, SO A noted concerns raised by the Care and Combat Lead and the
Chaplaincy Manager regarding Mr Cordner’s increasing anxiety and paranoia
during group sessions. They observed unusual behaviour and noted that Mr
Cordner often misinterpreted supportive comments from peers as negative. In
response, SO A referred him to the mental health team and placed him on daily
safer custody checks as a precautionary support measure.
44. On 26 June, SO A accompanied Mr Cordner and two other prisoners (also
veterans) to the Royal British Legion Village (RBL). The purpose of the visit was to
establish future employment and training opportunities for ex-veterans in custody as
well as for them to be considered for future accommodation within the village which
is overseen by Care after Combat.
45. Also in June, Mr Cordner had his first RDR supported by a representative from Care
and Combat team. On his second RDR, Mr Cordner met his mother and
grandmother. Mr Cordner said that he had a good time and had started to feel more
relaxed when out in the community.
46. On 1 July, CM A noted that Mr Cordner had been accepted to start community work
for East Parish Council on 4 July. On 4 July, Mr Cordner told SO A that he thought
his anxiety had increased due to an ear infection for which he was being prescribed
antibiotics. The next day, Dr A reviewed Mr Cordner, who appeared to be
experiencing psychotic symptoms. He reported feeling electric currents in his cell
and body and believed someone was using a generator beneath his floor to
electrocute him. He exhibited unusual behaviour by lying under a table and refusing
to return to his cell, eventually becoming verbally aggressive. Due to his condition,
the mental health team arranged for his temporary transfer to the inpatient
healthcare wing at HMP Elmley (a closed prison). Healthcare staff stopped his
lisdexamfetamine as they suspected it was a possible trigger for the psychosis.
47. On 8 July, a psychiatrist assessed Mr Cordner who was no longer demonstrating
any evidence of psychosis. He declined antipsychotic medication. On 12 July, Mr
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Cordner returned to Standford Hill. Mr Cordner said he felt much better since he
had stopped taking his ADHD medication. Dr A saw Mr Cordner and noted that he
appeared well, calm and relaxed. Mr Cordner said he had no thoughts of suicide or
self-harm.
48. Due to Mr Cordner’s psychotic symptoms, he had to be risked assessed again for
ROTL, and any previously arranged dates were cancelled. On 16 July, Mr Cordner
attended the PERS office and spoke to SO B who noted that Mr Cordner appeared
paranoid. He was also upset that his ROTL had been cancelled and he could not
return to his community work placement. He believed it was his ear infection which
had caused his psychotic symptoms and was worried that if any concerns were
raised about him, staff would send him back to a closed prison.
49. On 19 July, Mr Cordner attended healthcare and said that he thought his ear
infection had returned. On 22 July, a GP examined Mr Cordner’s ears and
prescribed him antibiotics for an infection. The following day, Mental Health Nurse A
assessed Mr Cordner. He asked to resume medication to manage his anxiety and
continued to report issues related to an ear infection, including hearing noises. The
nurse told him that he had been referred to an Ear Nose & Throat (ENT) specialist
and was also booked to see the psychiatrist on 26 July to review his medication.
50. On 26 July, Dr A reviewed Mr Cordner, who was agitated and anxious. Although Mr
Cordner had no thoughts of self-harm, he continued to believe that electricity was
being passed into his cell and onto surfaces. Dr A discussed antipsychotic
medication, but Mr Cordner refused this, insisting his anxiety stemmed from ADHD
and requested anxiety medication instead. Dr A diagnosed a psychotic condition
and prescribed atomoxetine (for ADHD) and promethazine (for anxiety and related
symptoms) and planned to review him again in the coming weeks.
51. Over the following days, Mr Cordner’s behaviour appeared to settle. On 4 August,
PERS staff told Mr Cordner that the OMU would be deciding about his ROTL soon.
On 11 August, Mr Cordner told healthcare staff he had felt better since being
prescribed atomoxetine but felt that the medication wore off by lunchtime and then
he felt agitated and angry. Dr A saw Mr Cordner the next day and increased the
dose of his medication. He noted that Mr Cordner had good insight into taking his
medication and had no psychotic or suicidal thoughts.
52. For the remainder of August, Mr Cordner attended several key work sessions with
SO A. Mr Cordner progressed well and seemed much calmer. He was still keen to
restart his ROTL and was disappointed that this had not happened yet. He was told
that he would have to have a Stear in the community first.
53. On 29 August, Mental Health Nurse B saw Mr Cordner. Mr Cordner said that he
was experiencing anxiety and disappointment related to issues surrounding the
prison regime. When asked if he had any thoughts of suicide or self-harm, Mr
Cordner denied this and said that he “never” thinks of this and had a very
supportive family network.
54. On 6 September, SO A accompanied Mr Cordner on his Stear ROTL. He noted that
Mr Cordner was calmer and less anxious than he had been on previous Stears.
Later, OMU approved that Mr Cordner could restart his RDR ROTL.
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55. On 10 September, Nurse B saw Mr Cordner. Mr Cordner said he was doing well.
On this same day, SO A saw Mr Cordner for a key work session. They discussed
his upcoming RDR, taking place the following day, when he would be allowed out of
the prison, unescorted, for a five-hour period.
56. On 11 September, staff carried out a well-being check upon Mr Cordner’s return
from his RDR. Mr Cordner said that his RDR had gone well and he had been able
to spend time with his family. Staff discussed with Mr Cordner the possibility of him
changing jobs and moving to C Wing. C Wing has 80 individual pods (self-
contained, ensuite housing units), a servery, and meals are taken into the prisoners’
individual pods. Prisoners are located on C Wing because they work outside prison
and return there to sleep. Their work hours are often flexible, and some may work
through the night.
57. At his key work session on 18 September, SO A agreed that Mr Cordner could start
working with the Community Voluntary Service Enterprise work party (CVSE – they
complete various jobs in the community such as gardening). This was progress
towards Mr Cordner living in a pod on C Wing. Mr Cordner said that he was also
keen to engage with Narcotics Anonymous (NA) in the community. CGL had
provided him with the necessary ROTL paperwork to apply for this.
58. On 20 September, Mr Cordner met with Mr B from the CVSE work party. He
explained more about the role and what was required. Mr Cordner was accepted
onto the party. In the meantime, Mr Cordner continued to carry out his job as the
prison litter picker.
59. On 24 September, Mr Cordner had another RDR ROTL. Over the next week, staff
reported positive interactions with Mr Cordner. He continued to engage with PERS
workshops and activities. On 30 September, he started working with CVSE,
Monday to Friday, in the community. Mr Cordner told staff that he enjoyed his job.
60. On 8 October Mr Cordner moved to a pod on C Wing which he was pleased about.
On 11 October, Mr Cordner attended a drop-in session in the healthcare unit.
Healthcare staff noted no concerns. Mr Cordner shared his past experiences of
attending fellowship community groups (gatherings to support individuals recovering
from addiction) and said he had found them supportive. Staff told him that they were
arranging his ROTL so that he could attend NA meetings.
61. On 15 October, Nurse B reviewed Mr Cordner and noted that he had not displayed
any symptoms of psychosis for the past two months. The nurse had no concerns
about him.
62. Ms A saw Mr Cordner on 17 October for a substance misuse support session. Mr
Cordner spoke about his time at Standford Hill and his alcohol issues.
63. On 18 October, during a key work session with SO A, Mr Cordner said that he had
settled well in his pod, was enjoying working for CVSE and liked the regular routine
this provided. Mr Cordner said that he was aware that the PERS team were
available to support him.
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25 October – 31 October
64. On Friday 25 October, Mr Cordner attended his first NA meeting in the community.
On 27 October, at 6.10 pm, prison staff submitted a Security Intelligence Report
(SIR) raising concerns regarding Mr Cordner’s potentially inappropriate
communication with a young woman he had reportedly met during the NA meeting.
During a conversation in the B Wing office, Mr Cordner had told staff that he had
been speaking with a young woman who, according to him, “looked 30 but said she
was 19.” Staff observed that Mr Cordner appeared to be “quite infatuated”, speaking
about her for five to ten minutes. Mr Cordner disclosed that he had been
communicating with the woman via a WhatsApp group chat, as well as through one-
to-one messaging. He also mentioned being part of a separate group chat that
included the woman and two of her male friends, also NA attendees.
65. In one of the direct messages, Mr Cordner reportedly referred to the woman as
“beautiful”. Given the nature of Mr Cordner’s original offence, staff challenged him
regarding the appropriateness of this interaction. Mr Cordner responded and said
that he had informed Ms A about the situation. However, staff assessed that Mr
Cordner may have said this to mitigate concern, as it appeared that he recognised
he had disclosed more than was appropriate. (At interview, Ms A told us that, given
the timing of the incident and the unavailability of CGL staff over the weekend, such
a conversation did not take place.)
66. At 6.17pm, Mr Cordner phoned his mother. During the call, he said that he had
recently begun attending NA meetings and had spoken to a young woman about
her personal experiences, while her boyfriend was present. Mr Cordner said that he
found the NA meetings beneficial and intended to continue attending. He mentioned
exchanging text messages with the woman, including one in which he described her
as a “gorgeous, brave young lady” in reference to her openness during the meeting.
The woman's boyfriend had questioned the appropriateness of this comment, but
Mr Cordner said that he had not meant to cause offence. Mr Cordner also noted
that the woman had invited him to go out for a meal following a future NA session.
His mother advised him to maintain appropriate boundaries. She cautioned him
against becoming involved with the woman or her boyfriend. In response, Mr
Cordner described the pair as part of his support network and said he would
discuss the situation with the woman at the next meeting. He also said he planned
to seek guidance from the CGL team the following day and ask the NA group leader
whether socialising with other members outside of meetings was appropriate.
67. On 29 October at 11.00am, Mr Cordner met Ms A. During the meeting, he
expressed some anxiety regarding his interactions with members of the NA group.
He stated that he had developed a friendship with two young males and a young
female, with whom he had exchanged contact details and had begun
communicating via text message. Mr Cordner said that he was particularly
impressed by the young woman’s mature attitude towards substance use. Ms A told
us that Mr Cordner did not disclose any information that raised concern about the
nature or content of his communication with the group members. Despite the
absence of any explicit concerns, Ms A reminded Mr Cordner about the importance
of maintaining appropriate friendship boundaries. She advised him to ensure that
his interactions remained safe and in line with both prison regulations and the
conditions of his licence. She also reminded Mr Cordner that one of his licence
conditions required him to inform prison staff of any developing relationships. She
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clarified that this requirement applied not only to romantic relationships but also to
friendships.
68. At 3.15pm, Mr Cordner phoned his mother. Mr Cordner said that he appreciated the
support he was receiving through the NA group and said that staff were aware of
his contact with a female group member. Mr Cordner’s mother expressed concern
about his ongoing text communication with the woman and her boyfriend and
reminded him that the woman was in a relationship. In response, Mr Cordner
reassured her, and stated that both individuals were “nice people” and that,
although they were young, they had “adult minds.” He told his mother not to worry.
69. At 3.41pm, Mr Cordner again spoke to Ms A as he was anxious about the
friendships he had made at the NA group. Ms A advised Mr Cordner to speak to
OMU staff to confirm what information he needed to inform them about regarding
his new friendships. She also advised Mr Cordner to speak to his key worker and
the NA group lead.
70. On 30 October, Mr Cordner told Ms A that he had spoken to the safer custody
officer on A wing, B Wing officers and had returned messages with the NA group
members, and said he felt more comfortable about the interactions he was having
with them. Mr Cordner provided no further details.
71. On the morning of 31 October, Mr Cordner told Officer A that he was no longer
completely happy with his current employment and felt paranoid about the group
that he worked with. He said that he was considering other working alternatives. He
also said that he was in phone contact with a member of the support group he
attended on Fridays, who was supporting him. Mr Cordner provided no further
details.
Events on 1 November
72. The investigator watched closed circuit television (CCTV) and body worn video
camera (BWVC) footage. He also reviewed information from NHS Southeast Coast
Ambulance Service. The following account has been taken from all sources.
73. On the morning of 1 November, Mr Cordner confided in CM A, expressing concern
that he may have done something wrong, though not necessarily bad. He explained
that he had recently attended a NA meeting, where he met a young woman, her
boyfriend, and another male friend. Believing he could offer support due to his
maturity, he instead found himself receiving support from the woman. They
exchanged phone numbers and texted over several days. Mr Cordner also
encountered her outside the NA setting and noted her appearance. CM A grew
concerned about the nature of this relationship and the intentions of the young
people involved.
74. At interview, CM A said that Mr Cordner seemed flattered by the young woman’s
appearance, and believed her effort was for his benefit. CM A informed Mr Cordner
that his actions suggested he was forming a relationship, which could breach his
licence conditions. Mr Cordner claimed he had informed other staff, but not his
offender managers, who he said were unavailable at the time. CM A emphasised
that he should have told them and expressed concern that the young people might
be trying to exploit him.
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75. CM A told Ms D, Functional Head of OMU, what Mr Cordner had told him. She
suspended Mr Cordner’s ROTL for that day’s NA meeting until she was able to
obtain more information.
76. Worried about his disclosure of information, Mr Cordner returned to see CM A in the
office. He insisted that he needed to attend the NA meeting that evening. CM A
then accompanied him to the OMU office to speak with Ms D.
77. At 3.25pm, Mr Cordner attended the OMU office with CM A. Also present were Ms
D and Ms E, a senior probation officer. Ms D explained that Mr Cordner would not
be allowed to attend the NA meeting that evening. The primary reasons included
concerns about the safety and appropriateness of the meeting environment, the
presence of a young woman accompanied by two men, raising safeguarding
concerns, and the potential vulnerability of attendees, including Mr Cordner, to
exploitation. Ms D had also tried to contact CGL for their input but they had already
left the prison for the day.
78. Ms D noted that Mr Cordner’s emotional state fluctuated throughout the
conversation. Initially he was calm but became increasingly distressed and began
pleading to be allowed to attend the NA meeting. He repeatedly stated, “I need to
sort it out,” which prompted the staff to question what he meant. Mr Cordner said
that he felt let down by CM A and said that he had now lost his external support. Mr
Cordner also mentioned that he wanted to inform the young woman involved that
they could no longer communicate and that he had already identified a female
sponsor in the group. (A sponsor is usually someone who has been in recovery for
a significant period, who mentors and supports someone newer to the recovery
process). These statements raised further concerns with staff, as NA sponsors are
typically of the same gender, and the woman in question, was not qualified to be a
sponsor.
79. Ms D reiterated that the suspension was temporary and only applied to that
evening. She assured Mr Cordner that further inquiries would be made with CGL
and that he could potentially resume attendance at the NA meeting the following
Friday. She emphasised that the decision was based on safeguarding concerns and
was not of a punitive nature. CM A addressed Mr Cordner’s feelings of betrayal and
explained that he had a duty to report the situation. Mr Cordner then left the room.
80. Ms D phoned C Wing, spoke to Officer A and updated him that Mr Cordner’s ROTL
had been temporarily suspended. She told Officer A that Mr Cordner was not happy
with the decision and asked staff to “keep an eye” on him.
81. At 3.57pm, Mr Cordner got to C Wing. He stopped in the C Wing office and spoke to
Officer A. Officer A noted that Mr Cordner was slightly agitated and told him about
his ROTL being suspended that evening. He stated that he would no longer talk to
staff, as he now felt let down by them. Mr Cordner then left the office. At 3.59pm, Mr
Cordner walked back to his pod. Officer A recorded what had happened in the C
Wing observation book.
82. At interview, Officer A said that at no point during his conversation with Mr Cordner
did he indicate or present as if he intended to take his own life. Officer A said that
he also asked Officer B, who started his evening shift at 4.30pm, to check Mr
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Cordner given his disappointment at not being able to attend the NA group. Officer
A’s shift ended around 4.30pm and he left C Wing at 4.40pm
Emergency response
83. Shortly before 5.00pm, Officer C and Officer B started carrying out the routine roll
checks on the C Wing pods. At 5.00pm, Officer B checked Mr Cordner’s pod. When
he knocked on his door, Mr Cordner did not respond. Officer B opened the door and
went in. He saw Mr Cordner suspended by a ligature (made from string that is used
to close/open shutters) attached to the window. Mr Cordner’s knees were laying to
one side and his body was resting on a plastic container. Officer B radioed a code
blue (an emergency code indicating that a prisoner has either stopped or is having
difficulty breathing) at 5.00pm and staff in the control room called an ambulance
immediately. Officer B supported Mr Cordner’s body to alleviate the tension of the
ligature. Officer C arrived at this point, cut the ligature and they laid Mr Cordner on
the floor.
84. Mr Cordner showed no signs of life. Officer B started cardiopulmonary resuscitation
(CPR). Officer D and CM E arrived with a defibrillator which staff attached and
followed its instructions. Paramedics arrived at 5.14pm and took over Mr Cordner’s
care. A second ambulance crew and doctor arrived at 5.22pm. At 5.42pm,
paramedics declared Mr Cordner’s life extinct.
Contact with Mr Cordner’s family
85. Mr Cordner had named his mother as his next of kin but had only provided her
telephone number. Staff then discover that Mr Cordner had been in contact with his
mother and that her address had been approved as his ROTL address. They
decided to inform her at her home address. Officer B was Standford Hill’s duty
family liaison officer (FLO) and given his role in the emergency response Ms F, the
on-call manger, contacted neighbouring prisons for support. Due to their closer
proximity to Mr Cordner’s mother’s address, HMP Ford assisted and deployed a
family liaison officer. They went to Mr Cordner’s mother’s house at 10.30pm and
broke the news of his death and offered support.
86. Standford Hill appointed Mr C as the FLO, who remained in contact with Mr
Cordner’s family over the following days, offering support and advice. The prison
contributed to the cost of Mr Cordner’s funeral in line with national policy.
Support for prisoners and staff
87. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Standford Hill followed postvention procedures including holding a hot
debrief, chaired by a prison manager, for staff involved in the emergency response
and Listeners (prisoners trained by the Samaritans to provide confidential peer-
support) being engaged to identify prisoners most affected by Mr Cordner’s death.
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Post-mortem report
88. The post-mortem report concluded that Mr Cordner’s cause of death was
multiorgan system failure and cerebral hypoxia (when the brain does not get
enough oxygen) caused by ligature neck strangulation.
After Mr Cordner’s death
89. Following Mr Cordner’s death, Standford Hill suspended all fellowship meetings in
the community, due to security intelligence issues. Fellowship meetings have since
resumed but now take place at Standford Hill and are either face to face or online.
Inquest
90. The Coroner’s inquest held on 16 February 2026 determined the medical cause of
death to be cerebral hypoxia with multiorgan system failure, due to mechanical
asphyxiation, due to ligature neck strangulation, due to hanging, with pulmonary
congestion and oedema, congested liver with fatty change, hypertensive heart
disease, congestive cardiac failure, chronic obstructive pulmonary disease, and
polydrug misuse listed as contributory conditions.
91. The jury returned a narrative conclusion, stating that Mr Cordney died as a
consequent of his own action, with his intention unclear.
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Findings
Assessment of Mr Cordner’s risk to himself
92. Prison Service Instruction (PSI) 64/2011, Safer Custody, was in place at the time of
Mr Cordner’s death (replaced in January 2025 by the Prison Safety Policy
Framework), sets out the risk factors and triggers that might increase a prisoner’s
risk of suicide and self-harm and the procedures (known as ACCT) that staff must
follow when they identify a prisoner at risk. Mr Cordner had a number of these risk
factors: he had had been convicted of a violent offence against a family member,
had a history of alcohol abuse, anxiety, PTSD, ADHD, depression, and suffered
from chronic lower back pain.
93. However, Mr Cordner had no recent history of attempted suicide or self-harm and in
the weeks leading up to his death, displayed no overt signs of distress or anxiety
that gave staff concerns that he may harm himself.
94. In the week preceding his death, Mr Cordner appeared to be experiencing internal
conflict regarding the extent of information he should disclose to staff. He seemed
aware that his actions were likely to be considered inappropriate and potentially in
breach of his licence conditions. Of particular concern was his apparent decision to
withhold, and possibly downplay, the nature of developing relationships, especially
one involving a young female.
95. When staff discovered the nature of the developing relationships at the NA group
Mr Cordner attended, they were concerned about both the appropriateness of the
relationships, Mr Cordner’s capacity for sound judgement and his own vulnerability.
We consider the decision to suspend Mr Cordner’s ROTL was appropriate.
96. Staff were aware that Mr Cordner was not happy following this decision. In
response, wing staff were advised to maintain appropriate monitoring. They also
tried to reassure Mr Cordner that it was only a temporary suspension, he could
hopefully attend the following week, and it was not intended as a punitive measure.
We found no evidence that staff should have assessed Mr Cordner as being at
imminent risk of suicide when he died.
Intelligence Report Handling and Risk Communication
97. Concerns regarding Mr Cordner’s potentially inappropriate behaviour were formally
raised one week before he died when staff submitted a SIR. We found that Mr
Cordner appeared to have selectively shared versions of the situation with various
staff members. Despite the seriousness of the concerns, no further action was
taken to investigate the matter, nor was the information shared with the OMU, who
are responsible for assessing and managing prisoners’ risk. Although OMU staff
eventually became aware of the information through an alternative source, the initial
failure to act on and communicate the intelligence undermined the prison’s risk
management processes.
98. Following Mr Cordner’s death, Ms D discussed the SIR with Ms G, Head of
Security. Ms G explained that, at the time, the security team was experiencing
significant staff shortages, with only one analyst available due to sickness absence.
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This resulted in delays in reviewing, disseminating, and actioning SIRs. Since then,
additional custodial managers have been recruited to the security department. We
also note that prisoners are no longer allowed to attend fellowship meetings in the
community.
99. While we make no recommendation on this matter, the Governor will wish to ensure
all staff are aware of their risk-related responsibilities. This should include that a
clear, consistent protocol is in place, to ensure that any information with potential
implications for prisoner or public safety, is promptly communicated to the
appropriate departments.
Clinical care
100. The clinical reviewer concluded that the clinical care Mr Cordner received was of a
good standard and was equivalent to that which he would have received in the
community.
Good practice
101. Mr Cordner spent 16 years in closed prisons before his transfer to Standford Hill, an
open prison. This transition represented a significant shift in his prison experience,
bringing with it challenges that were both complex and, at times, overwhelming. The
adjustment required was considerable. It is noteworthy that Standford Hill provided
Mr Cordner with consistent and meaningful support through their healthcare
services, regular key work and resettlement sessions. These interventions were
instrumental in facilitating his adaptation to the new environment and contributed
significantly to him experiencing successful reintegration during his ROTL periods.
Staff should be commended for the consistent efforts they made with Mr Cordner.
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