Thomas Goldring

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Independent investigation into
the death of Mr Thomas Goldring,
a prisoner at HMP Winchester,
on 29 December 2022
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, 2025
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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 Thomas Goldring was found hanged in his cell at HMP Winchester on 29 December
2022. He was the fourth prisoner to take his life at Winchester in three years. He was 21
years old. I offer my condolences to Mr Goldring’s family and friends.
Mr Goldring was a young man who had never been in prison before and had been charged
with murder. My investigation found that opportunities were missed to put appropriate
support in place for Mr Goldring, both when he arrived at Winchester and after his court
appearances.
Although Mr Goldring was referred for a mental health assessment when he arrived, he
was discharged from the mental health team without ever being seen in person. In its last
inspection of Winchester in May 2022, HM Inspectorate of Prisons noted that staff
shortages had impacted on the ability to provide early days mental health assessments.
We have previously made recommendations to Winchester about improving their
assessment of newly arrived prisoners’ risk of suicide and self-harm. I am aware that the
Regional Safety Team delivered targeted awareness training to reception staff earlier this
year. The Governor should monitor whether this has led to improvements.
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 December 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. Mr Thomas Goldring was remanded to HMP Winchester on 1 August 2022, charged
with murder. It was his first time in prison.
2. Mr Goldring’s Person Escort Record (PER – a document that accompanies
prisoners between police custody, court and prison) noted that he was at risk of
suicide and self-harm due to the seriousness of his offence and that it was his first
time in prison. He also had a history of depression and he had attempted suicide by
overdose six months before. He told reception staff that he had no current thoughts
of suicide or self-harm. Staff did not start suicide and self-harm monitoring
procedures (known as ACCT) but referred him to the mental health team.
3. On 9 August, staff discussed Mr Goldring at a mental health team meeting, but they
subsequently discharged him as they noted he was awaiting a GP appointment to
discuss his depression. He was not seen in person.
4. Mr Goldring had scheduled court appearances for his alleged offence on 3 August,
24 October, 28 November and 9 December. He also had two scheduled videolink
Family Court appearances on 12 and 14 December. The only appearance
documented in his prison record was the one on 24 October. Staff did not record
what, if any, welfare checks were carried out on Mr Goldring after his court
appearances.
5. On Christmas Day, staff carried out an intelligence-led search on Mr Goldring’s cell.
Staff found a mobile phone and a piece of paper they believed to be impregnated
with illicit drugs. Mr Goldring and his cellmate were placed on a disciplinary charge
pending an adjudication.
6. On 28 December, Mr Goldring pleaded guilty to the charge of possessing illicit
items, but he said that the items did not belong to him. On the same day, Mr
Goldring’s cellmate moved to another prison, so he was left in a cell on his own.
7. On 29 December, at around 6.10am, an operational support grade (OSG) carried
out a routine check on all prisoners. He noticed that Mr Goldring’s observation
panel was covered with tissue, but he said he managed to look through a gap and
saw Mr Goldring in bed.
8. At around 7.30am, an officer carried out another routine check and, although the
observation panel was still covered, he saw through a gap that Mr Goldring was
hanging from the window bars of his cell. The officer called a medical emergency
code. Other staff attended, cut the ligature and started cardiopulmonary
resuscitation (CPR), even though they thought that Mr Goldring was dead as he
was cold and stiff. When ambulance paramedics arrived, they assessed that Mr
Goldring was dead and asked staff to stop CPR. They recorded Mr Goldring’s death
at 7.49am.
9. After Mr Goldring’s death, information came to light that the mobile phone and
drugs may have belonged to another prisoner who was involved in bringing drugs
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into the prison. Mr Goldring said in a phone call to his friend on the day before his
death, that the prisoner had demanded money from him after the items were found
in his cell during the search.
Findings
10. Reception staff did not properly consider Mr Goldring’s risk factors for suicide and
self-harm when he arrived at Winchester. While we accept that Mr Goldring took his
life several months later, we consider that this was a missed opportunity to put
support in place. Poor risk assessment by reception staff at Winchester is an issue
we have raised before.
11. We found no record of what happened at Mr Goldring’s court appearances and no
evidence that anyone screened him for suicide and self-harm risk on his return as
they should have done. Furthermore, no one referred him to healthcare staff.
12. Mr Goldring had been dead for some time when he was found at around 7.30am.
The prison carried out an investigation into the OSG’s earlier check at 6.12am, but
they were satisfied that the check was adequate. However, we consider that the
guidance provided to staff on how to respond to covered observation panels is
unclear and should be reviewed.
Recommendations
• The Governor should ensure that after each court appearance, whether in person or
by videolink, staff:
• screen prisoners for suicide and self-harm risk and record their assessment; and
• refer prisoners at enhanced risk of suicide and self-harm to healthcare staff in
accordance with PSI 07/2015.
• The Governor should investigate the staff culture on B Wing, including considering
the number and nature of complaints submitted, and provide an update to the
Ombudsman.
• The Head of Healthcare should ensure that prisoners who are referred to the mental
health team by reception staff have a face-to-face triage assessment.
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The Investigation Process
13. HMPPS notified us of Mr Goldring’s death on 29 December 2022.
14. The investigator issued notices to staff and prisoners at HMP Winchester informing
them of the investigation and asking anyone with relevant information to contact
her. One member of staff responded.
15. The investigator obtained copies of relevant extracts from Mr Goldring’s prison and
medical records.
16. NHS England commissioned an independent clinical reviewer to review Mr
Goldring’s clinical care at the prison.
17. The investigator and clinical reviewer interviewed nine members of staff at
Winchester in March 2023.
18. We informed HM Coroner for Portsmouth and Southeast Hampshire of the
investigation. We have sent the Coroner a copy of this report.
19. The Ombudsman’s family liaison officer contacted Mr Goldring’s father to explain
the investigation and to ask if he had any matters he wanted us to consider. Mr
Goldring’s father wanted to know how long his son had been dead before he was
found. We have addressed this in the report.
20. We shared our initial report with HMPPS. They found no factual inaccuracies.
21. We sent copies of our initial report to Mr Goldring’s parents. They did not notify us
of any factual inaccuracies.
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Background Information
HMP/YOI Winchester
22. HMP/YOI Winchester is a local men’s prison, and holds up to 492 prisoners,
including some young adults. Practice Plus Group (PPG) provides physical and
mental health services.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Winchester was on 31 January 2022. Inspectors
reported that levels of self-harm had reduced but remained among the highest of all
local prisons, although improvements had been made to reception screening to
identify prisoners’ risk of suicide and self-harm. However, staff shortages had
impacted on the ability to provide early days mental health screening assessments
and the processes for identifying and referring those with mental health needs on
reception were not robust.
24. Inspectors found that a very restricted regime and staffing shortfalls impacted on the
development of meaningful and supportive relationships between prisoners and staff
and very little effective key work was taking place. They also noted that some staff
used shouting and yelling when talking to prisoners and that there appeared to be an
under-reporting of use of force incidents.
Independent Monitoring Board
25. 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 31 May 2022, the IMB reported that COVID-
19 had remained the overriding influence on Winchester’s efforts to deliver a
humane, fair and decent environment for prisoners. The degree to which this had
been achieved had been undermined by lack of resources, volatility and the relatively
high level of violence, although there were encouraging signs of improvement in the
latter part of the year. They noted that up to 40% of officers were inexperienced in
managing either a normal regime or the volatile nature of the population.
26. The IMB found that most staff continued to treat prisoners with care and
consideration, but too often the opportunity for meaningful interaction had been
unavailable. Key working was all but discontinued and even welfare checks occurred
only sporadically. They considered that keeping the majority of prisoners behind their
cell doors and in spaces that were designed for one rather than two occupants, for
more than 22 hours each day, could not be regarded as humane.
Previous deaths at HMP Winchester
27. Mr Goldring was the 17th prisoner to die at Winchester since December 2019. Of the
previous deaths, 12 were from natural causes, three were self-inflicted and one was
drug related. We have previously made recommendations to Winchester about
properly assessing prisoners’ risk of suicide and self-harm when they arrive.
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Key Events
28. Mr Thomas Goldring was remanded to HMP Winchester on 1 August 2022, charged
with murder. It was his first time in prison.
29. Mr Goldring’s Person Escort Record (PER – a document that accompanies
prisoners between police custody, court and prison which sets out the risks they
pose) noted that he was at risk of suicide and self-harm as it was his first time in
prison, and he was remanded for a serious offence. The PER also stated that he
had a history of anxiety and depression and had attempted suicide by overdose in
February 2022.
30. A Supervising Officer (SO) was working in reception when Mr Goldring arrived. She
recorded that Mr Goldring was a potential category A prisoner (due to his alleged
offence) but that he presented well and had no thoughts of suicide or self-harm.
When interviewed, she told the investigator that she had been aware of the suicide
and self-harm warning on the PER but that as Mr Goldring said he had no current
thoughts of suicide or self-harm, she did not think he required the support of suicide
and self-harm prevention procedures (known as ACCT).
31. The reception nurse noted Mr Goldring had a history of depression and anxiety but
that he had no current thoughts of suicide or self-harm. The nurse referred Mr
Goldring to the mental health team.
32. On 3 August, healthcare staff assessed that Mr Goldring was medically fit to attend
court. Prison staff did not record what happened at court and we found no evidence
that Mr Goldring’s suicide and self-harm risk was assessed when he returned to the
prison.
33. On 9 August, staff discussed Mr Goldring at a mental health team meeting. Staff
noted that they had insufficient information about the level of mental health support
he required. Staff later discharged Mr Goldring from the mental health team, noting
that he was awaiting an appointment with a GP to discuss his depression. Mr
Goldring did not see anyone from the mental health team face-to-face.
34. On 24 August, Mr Goldring had an appointment with a GP at Winchester. He told
the GP that it was his first time in prison, but he was coping better than he thought
he would. He said he was previously prescribed antidepressants in the community
but had not taken them and he did not feel he needed any. He reported good mood,
appetite and sleep and said he had support from family and friends. The GP
advised him how to get support from healthcare if he felt he needed it. Mr Goldring
had no further input from healthcare in relation to his mental health.
35. On 22 September, Mr Goldring was allocated a work placement which involved
fitting and fixing various items as well as general maintenance around the prison.
We heard from others that the work is highly sought after and considered a
privileged position. An officer, who had responsibility for prisoners on the work
placement, described Mr Goldring as a hard worker with a strong work ethic who
got on well with everyone in the team.
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36. On 27 September, Mr Goldring had an assessment with a substance misuse
worker. He told her that he wanted help with a cannabis habit and disclosed that he
was dealing with bereavement and other issues.
37. On 29 September, staff found a mobile phone in the cell occupied by Mr Goldring
and his cellmate. Mr Goldring received an adjudication and, for safety reasons, was
moved to a different cell the following day after a disagreement with his cellmate. Mr
Goldring pleaded not guilty to the charge of having a mobile phone and, although
the matter was referred to the police, no sanctions were imposed on Mr Goldring in
relation to this incident.
38. On 24 October, Mr Goldring attended court. Prison staff made no record of what
happened at the hearing, and we found no evidence that Mr Goldring’s suicide and
self-harm risk was assessed when he returned to prison.
39. On 9 November, Mr Goldring received a negative behaviour entry from Officer A.
Officer A said that Mr Goldring had been abusive towards him in the canteen and
that he and a colleague had to return him to his cell. He said that staff later met with
Mr Goldring to discuss his behaviour, along with the custodial manager of the wing.
40. Officer A said that Mr Goldring’s behaviour was not acceptable for a worker in his
position and staff considered whether he should be dismissed from his job. Officer
B said he attended this meeting and objected to dismissing Mr Goldring from his
job. Others present agreed that it was an isolated incident and Mr Goldring could
keep his job. Officer B said Mr Goldring told staff at the meeting that he had
received bad news about his father’s medical condition and felt he was unfairly
treated by Officer A.
41. Mr Goldring made a complaint against Officer A relating to the incident on 9
November, which was subsequently upheld on 12 November.
42. On 24 November, Mr Goldring had a further review with the substance misuse
worker. He said that he was enjoying his work and making the best of a bad
situation. They spoke about his baby daughter, and he expressed remorse that he
could not be there for her. He said that his father and sister were trying to get
custody of his daughter. Mr Goldring told her that he had a plea hearing scheduled
at court on 9 December and a trial was planned for 23 January 2023.
43. On 27 November, an officer wrote in Mr Goldring’s prison record that he had been
abusive to staff.
44. Mr Goldring had three further court appearances on 28 November, 9 December and
12 December. We found no record of what happened at any of these court
appearances or whether anyone assessed his suicide and self-harm risk
afterwards.
45. On 6 December, Officer A noted that Mr Goldring attended a meeting with staff,
where he received a final warning for his negative behaviour. He noted that Officer
B was also at that meeting, but Officer B said he was not in work on that day so he
would not have attended. Officer A’s perception was that Mr Goldring often lost his
temper and was aggressive and rude to staff. He said Mr Goldring had received a
number of negative behaviour warnings, but we found only two in his prison record
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prior to this meeting, one of which resulted in him making a complaint against
Officer A, which was later upheld. Officer A said that staff do not always record
negative behaviour incidents in prisoners’ records.
46. On 22 December, Mr Goldring’s court appearance was cancelled. We found no
record of what this court appearance related to or if anyone checked on Mr Goldring
to see if the cancellation had any impact on his wellbeing.
47. On Christmas Day, staff carried out an intelligence-led search on Mr Goldring’s cell.
A mobile phone and paper, which staff believed was impregnated with illicit drugs,
were found during the cell search. Mr Goldring and his cellmate were placed on
report pending an adjudication.
48. On 28 December, Mr Goldring pleaded guilty at the adjudication to having the
prohibited items, but he said the items did not belong to him. On the same day, his
cellmate transferred to another prison and Mr Goldring was left in a cell on his own.
Events of 29 December
49. CCTV shows that at 6.12am on 29 December, during a routine check, an
operational support grade (OSG) noticed that Mr Goldring’s observation panel was
covered with tissue. He said he was able to see through a gap and could see Mr
Goldring lying in bed. He said he had no concerns about him.
50. At around 7.30am, an officer was carrying out another routine check when he
looked into Mr Goldring’s cell and saw him hanging from the window bars by a
sheet. (The officer said the observation panel had been covered with tissue but that
the top part had come away so he could see through.) He immediately called a
code blue (a medical emergency code used when a prisoner is unconscious) but
waited for other staff to arrive before going into the cell and cutting the ligature. He
said he thought that Mr Goldring was dead, but a custodial manager (CM) said they
should start CPR, which they did.
51. Healthcare staff arrived shortly afterwards and continued CPR, even though Mr
Goldring was cold to the touch and there were signs of rigor mortis (stiffening of the
body that occurs roughly two to six hours after death). A nurse said that she thought
Mr Goldring was dead, but the CM said he did not feel comfortable to stop CPR.
Ambulance staff arrived shortly afterwards and assessed that Mr Goldring was
dead. They recorded his death at 7.49am.
Information received after Mr Goldring’s death
52. After Mr Goldring’s death, information came to light that the mobile phone and
drugs may have belonged to another prisoner who was involved in bringing drugs
into the prison. Mr Goldring said in a phone call to his friend on the day before his
death, that the prisoner had demanded money from him after the items were found
in his cell during the search.
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Contact with Mr Goldring’s family
53. Around 8.40am on 29 December, the prison’s family liaison officer and a prison
chaplain, visited the home address of Mr Goldring’s mother to break the news of her
son’s death. The prison contributed to the funeral expenses in line with national
instructions.
Support for prisoners and staff
54. A 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.
55. The prison posted notices informing other prisoners of Mr Goldring’s death and
offered support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Goldring’s death.
Post-mortem report
56. The post-mortem and toxicology reports were not available at the time of issuing
this initial report.
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Findings
Assessment and management of Mr Goldring’s risk
Reception screening
57. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others or from others (Safer Custody), requires that all staff who have
contact with prisoners are aware of the risk factors and triggers that might increase
the risk of suicide and self-harm and manage prisoners identified as at risk under
ACCT procedures. The PSI lists several risk factors and states that potential
triggers should be continually assessed.
58. Mr Goldring was 20 years old when he arrived at Winchester, had never been in
prison before and was remanded for the most serious offence of murder. He arrived
at the prison with a suicide and self-harm warning form, having attempted suicide
by overdose six months previously. We consider that his risk factors were sufficient
for reception staff to start ACCT monitoring. Staff told us that as Mr Goldring said
that he had no current thoughts of suicide or self-harm, they concluded that ACCT
monitoring was not necessary.
59. It is important that staff consider a prisoner’s objective risk factors for suicide and
self-harm and not rely on what the prisoner tells them. Staff should also record the
risk factors considered, including any suicide and self-harm warnings, and set out
their reasoning for not starting ACCT procedures if there are significant risk factors
present. This was not done in Mr Goldring’s case. While we accept that Mr Goldring
took his life nearly five months after his arrival at Winchester, we note that poor risk
assessment by reception staff is an issue we have raised in several previous
investigations into deaths at the prison. In response to a previous recommendation,
we were told that in November 2022, the Regional Safety Team had delivered
targeted awareness training to reception staff, including supervising officers. Given
Mr Goldring arrived after this, we do not make a recommendation, but the Governor
should monitor whether the training has led to improvements.
Screening following court appearances
60. PSI 07/2015: Early Days in Custody, sets out guidance and mandatory actions for
prison staff on reception procedures. This includes that all prisoners passing
through reception must be risk assessed for potential harm to themselves, to others
and from others. It makes it clear that this process is the same regardless of
whether the prisoner is entering the prison for the first time or is returning after a
temporary absence, such as after attending court. The PSI says that the PER and
any other available information, including suicide and self-harm warning forms,
must be examined by reception staff and the prisoner must be interviewed to
assess their risk of suicide and self-harm. The PSI says that prisoners at enhanced
risk of suicide and self-harm, including those in prison for the first time and those
who have committed particularly violent offences, should be referred to healthcare
staff each time they return to the prison after a temporary absence.
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61. According to records provided by the Offender Management Unit (OMU), Mr
Goldring had court appearances scheduled for 3 August, 24 October, 28 November,
9 December and 22 December in relation to his offence. He also had two Family
Court appearances by videolink scheduled for 12 and 14 December. We found
evidence that Mr Goldring had concerns about custody of his child, his offence, and
the outcome of his trial.
62. Although the investigator requested details of these appearances and the
outcomes, the prison did not provide them during the investigation. From Mr
Goldring’s prison record, only one court appearance was recorded on 24 October
but there was no clear evidence of any welfare check after his return. None of the
other scheduled appearances were documented in his prison record.
63. We found no documented evidence that anyone checked on Mr Goldring’s welfare
or assessed his risk after any of his court appearances, nor that he was offered an
appointment with healthcare staff. We make the following recommendation:
The Governor should ensure that after each court appearance, whether in
person or by videolink, staff:
• screen prisoners for suicide and self-harm risk and record their
assessment; and
• refer prisoners at enhanced risk of suicide and self-harm to healthcare
staff in accordance with PSI 07/2015.
Staff culture and complaints
64. During the investigation, we heard concerns from some staff members that Mr
Goldring was unfairly treated by certain members of staff. Although we found no
conclusive evidence of this, we identified discrepancies in how Mr Goldring was
perceived by some staff members – most referred to mainly positive behaviour, but
a small group of wing staff viewed his behaviour very negatively. We found plenty of
evidence of positive behaviour, but we found little recorded evidence of negative
behaviour in his prison record.
65. Furthermore, we found a high number of prisoner complaints about staff on B Wing
between October 2022 and March 2023. Mr Goldring made one complaint about
Officer A in November 2022, which was upheld. Our investigation has uncovered
evidence that merits further consideration to ensure that there is not a problematic
culture among some staff on B Wing. We recommend:
The Governor should investigate the staff culture on B Wing, including
considering the number and nature of complaints submitted, and provide an
update to the Ombudsman.
Clinical review
66. The clinical reviewer concluded that the standard of healthcare Mr Goldring
received was only partially equivalent to that which he could have expected in the
community due to the lack of mental health support. She considered that there were
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missed opportunities to assess and engage Mr Goldring from a mental health
perspective, especially in relation to the lack of a face-to-face triage assessment.
We recommend:
The Head of Healthcare should ensure that prisoners who are referred to the
mental health team by reception staff have a face-to-face triage assessment.
Governor to note
Early morning check and covered observation panels
67. Mr Goldring had rigor mortis when he was found hanged at around 7.30am. Rigor
mortis normally sets in around two to six hours after death, but it can vary
depending on, for example, the air temperature at the time. The OSG checked Mr
Goldring at 6.12am. He said that Mr Goldring’s observation panel was partially
covered with tissue, but he could see through a gap and saw Mr Goldring in bed.
He did not use a torch but said the cell light was on, so he was able to see.
68. The prison carried out an investigation into the 6.12am check. They concluded,
from a review of the CCTV, that the check was adequate. They noted that they
would review this decision if further information came to light about the exact time of
death. The OSG has since resigned from the Prison Service. We cannot reach any
conclusion about the quality of his check, or whether Mr Goldring was in fact
hanging at the time of the check, but clearly, the fact that rigor mortis was
established at 7.30am, casts doubt on his account.
69. Observation panels should not be covered by prisoners, even partially, and staff
need to know what they should do to ensure obstructions are removed and what
actions they need to take if prisoners ignore requests to remove the obstruction.
HMPPS’s Safety Briefing on Observation Panels states that prisons should have
local safety measures in place to this effect.
70. Winchester’s new local guidance on roll checks, issued after Mr Goldring’s death,
says, “if the observation panel is obstructed and the cell occupant cannot clearly be
seen, in the first instance gain a verbal response…if there is no response then the
Orderly Officer must be contacted immediately”. This suggests that if a panel is
partially covered but the prisoner can still be seen (as was the case according to the
OSG), then no further action is necessary. This is not in line with the guidance
contained in HMPPS’s Safety Briefing referred to above. If an observation panel is
covered, even partially, the prisoner should be asked to remove the obstruction.
Local guidance should then go on to say what staff should do if the prisoner
refuses. The Governor should review the guidance on roll checks and covered
observation panels.
Key work
71. The Head of Safety at Winchester told us that there had been no key work sessions
at the prison since he took up post in November 2021 and it is likely there had been
none for some time before this. He said this was due to key work being a non-
essential part of the regime and, where there were staff shortages, it was not seen
as a priority over other aspects of the prison regime. Although we found that Mr
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Goldring had very supportive relationships with one officer and the substance
misuse worker, we consider that he may have benefitted from having an allocated
key worker. We understand that staffing levels have increased since Mr Goldring’s
death and are soon to be at full complement. As staffing levels improve, the
Governor will wish to consider the priority given to key work to ensure that prisoners
receive consistent and meaningful support in the future.
Emergency response
72. Despite Mr Goldring having rigor mortis, staff started CPR and healthcare staff were
reluctant to stop it when they arrived. While we recognise the challenging
circumstances in which decisions such as this are made, there is clear guidance
from the Royal College of Nursing (RCN) that CPR should not be performed when it
would be futile. The Governor and Head of Healthcare may wish to remind staff of
this guidance.
Inquest
73. At the inquest, held from 1 to 9 December 2025, the jury concluded that Mr Goldring
died by suicide.
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