What happened
Paul Gobell, 59, was serving a life sentence. He had spent fifteen years in closed prisons, most recently at HMP Whatton. In August 2021 the Parole Board found him suitable for open conditions, and on 20 October 2021 he was transferred to HMP Hollesley Bay for two and a half weeks.
He returned to HMP Whatton on 4 November 2021. Within a few hours of his return he was involved in a control and restraint incident. His behaviour at the time was reported as refractory and aggressive. During the incident he suffered a soft tissue injury that required a trip to the local hospital’s accident and emergency department.
The first-night interview did not take place that evening or the following day. No welfare check was carried out and no ACCT was opened, so the suicide and self-harm monitoring that goes with it never started. He died later in November 2021.
The outcome
An inquest before Simon Burge, Assistant Coroner for Nottingham City and Nottinghamshire, concluded on 18 November 2024. The conclusion and circumstances are attached to his Regulation 28 report as a separate document, so neither the finding nor the medical cause of death is in the sources held here. No prosecution is recorded.
The coroner sent a prevention of future deaths report, reference 2025-0047, dated 3 December 2024, to the Ministry of Justice and HM Inspectorate of Prisons, requiring a response within 56 days. Both recipients published responses.
What went wrong
There was no national or local policy setting out what should happen to a welfare check when a first-night interview cannot take place for operational reasons. A man who had just been restrained was left unchecked because the appointment that would have set the checks in motion was displaced by a hospital trip.
The restraint had its own cause. In June 2021 he had been assessed as suitable to share a cell, having previously been considered high risk. He was not told until immediately before the incident. He had never shared a cell, and he was worried about a cellmate’s safety because of his parasomnia. The coroner found that had he been told in advance, the incident would not have happened.
What it teaches
A restraint is not finished when the hold is released. The welfare check, the ACCT decision and the first-night interview are part of the intervention, and they go missing on a bad night. Somebody has to own the check that did not happen, by name.
The upstream lesson is about information. A change to cell-sharing status is risk information, and delivering it at the cell door to a man who had never shared is how a quiet evening becomes a control and restraint.
Questions for the room
- He was restrained and taken to A&E on his first night back. What should have happened to the checks due that evening, and who decides when a check can be deferred?
- You are the officer telling him he must share a cell. What would you do differently, and what would it change?
- He was assessed as suitable to share a cell in June. What should that have done to the plan for his return?
Evidence and limits
Confidence: probable. There is one primary source, the coroner’s Regulation 28 report. It sets out the circumstances and the concerns but refers the inquest conclusion to an attachment that was not retrieved, so this page cannot say how he died, only that a restraint preceded a failure to check on him. Proceedings concluded on 18 November 2024, and the page may be cited with the conclusion itself unstated.
No member of staff is named. No finding is made about any individual officer.
Our vulnerable and volatile persons training covers de-escalation, and what has to happen in the hours after a restraint ends.
Sources
Reviewed 20 October 2026.