A Wandsworth prison officer falsified a dying man’s suicide-watch record. When the watchdog caught him, he was given a written warning. The officer who falsified the same man’s records alongside him got nothing at all: he had already resigned.
That case is the sharpest example behind an argument the Prisons and Probation Ombudsman is now making in public. It is also the latest entry in a pattern we have tracked for two years. In his third annual report, published later last week, Adrian Usher wrote that “HMPPS is the largest public service body that I can bring to mind that has no independent oversight of staff conduct.”
Investigations into how prison staff behave, including the use of force, are carried out by colleagues inside the same prison. Parliament decided that arrangement was not good enough for the police nearly 25 years ago and created what is now the Independent Office for Police Conduct. Usher wants prison staff to get the same.
A prisoner in England and Wales takes their own life roughly every five days. Eleven per cent of those deaths happen within 48 hours of arriving in the system, in reception prisons alone. Wandsworth is a reception prison.
Recommendations from the Ombudsman get accepted almost every time, 99% this year, none rejected outright. So why does a watchdog need to exist at all, if the system already listens? Three deaths at Wandsworth, four years apart, give the answer.
Three deaths, one pattern
HMP Wandsworth sits a mile from Putney Bridge.
Sebastião Lucas died two days after arriving at Wandsworth in May 2021. He had told a prison nurse he was going to kill himself; she opened a suicide-watch procedure and referred him to the mental health team. Staff failed to complete the observation checks his own file required in the two hours before he was found. The Ombudsman made six recommendations. Wandsworth accepted all six.
Two years later, Rajwinder Singh arrived at Wandsworth showing an established history of self-harm, a case this newspaper first reported in August 2025. Over 12 days his condition worsened; he set fire to his own hair, then his cell. On the night of 20 June 2023 he pressed his emergency cell bell at 8.36pm. Nobody came. Half an hour later, an officer found him hanging.
The Ombudsman’s investigators pulled the CCTV and compared it against the paper record: officers had written down that they had checked on him at times when the footage showed they had not. “I do not make the following statement lightly,” Usher wrote in the published report, “but I consider that had Mr Singh been sent to a different prison in 2023, not in such a state of crisis, he would almost certainly still be alive today.”
The falsification was referred to the police. Two officers faced a gross misconduct hearing in March 2024. Both were given an 18-month written warning. A third officer implicated in the same falsified entries had already resigned from the Prison Service by then, so no disciplinary process ever reached him. The Ombudsman’s own report says it has seen no evidence the prison investigated whether the falsifying of records went further than the three men it could identify, noting that two different officers apparently falsifying the same man’s records “might be part of a wider cultural issue.”
Waleed Ali arrived at Wandsworth in October 2022 carrying a document that said, in writing, that he was at risk of suicide. The police had written it. The hospital had acted on it. The court’s own mental health nurse had emailed a warning about him the day before he arrived. Nobody at Wandsworth read any of it.
The reception officer who processed him later told investigators he “did not see why he should check” the record, on the assumption that if there had been a risk, someone would have told him directly. He was placed in a shared cell. He was dead within six hours of walking through the gate. The Ombudsman’s verdict: “absolutely foreseeable and therefore possibly preventable.” Wandsworth and the escort contractor Serco both told investigators afterwards that they had opened internal inquiries into the staff involved. Neither could tell the Ombudsman what those inquiries found. Wandsworth said it could not locate the paperwork.
What the numbers actually show
Set against that, one fact cuts the other way: Wandsworth’s overall death rate is below the national average, not above it. But look only at the cases the Ombudsman has finished investigating and the picture flips.
Of 18 concluded so far, ten found a man had taken his own life. That is 56% of finished cases, against just under a fifth of deaths nationally over the same period. The two figures do not span quite the same stretch of time, but the gap survives the caveat. Wandsworth is a reception prison, and the Ombudsman’s own research shows reception prisons carry the highest rate of self-inflicted death of any part of the system, without a matching increase in training, staffing, or repair to the buildings themselves.
The two officers
Bobby Cunningham was Wandsworth’s head of security between 2021 and 2023. The Sunday Times reported that he had a garden landscaped by a firm later shown to be a front for a cocaine-dealing operation, met an associate of the convicted dealer, and authorised a prisoner’s transfer to open conditions in a way prison rules did not permit. He was connected to organised crime operating inside the prison he was meant to secure. He was allowed to resign on medical grounds with a package reported to be worth around £160,000. He was later, retrospectively, dismissed for gross misconduct and required to repay the sum. He was never referred to the police and has not been charged with any offence.
Linda De Sousa Abreu was a prison officer at the same jail. In June 2024 another prisoner filmed her having sex with an inmate in his cell. The footage went viral. She pleaded guilty to misconduct in a public office and was sentenced to 15 months in prison, of which she served five.
The fair objection
Usher is not describing a workforce of villains. Giving evidence to MPs last year, he described what his investigators hear from staff, especially those promoted without proper training, after someone in their care has died: “I did not know what I was doing and I have been complaining that I did not know what I was doing and I haven’t had any help.” A third of Wandsworth’s officers were absent on any given day as of last autumn, according to independent monitors, with fewer than 85 covering more than 1,400 men.
The wait for answers is part of the same failure. The median time between a death at Wandsworth and the Ombudsman’s published report is 2.6 years. One report took 5.2 years. Morgan Sullivan died at 20 in November 2022; his inquest has still not been held. The Ombudsman says giving families answers faster is one of the reasons timeliness matters.
Has it got better?
From a low base, yes. Wandsworth recorded seven deaths in 2023/24, five the following year, and four so far this year. Violence recorded by monitors fell by 70 incidents over the past year. The prison’s own reform wing is understood to be working. And in one case last year, the Ombudsman examined a man’s care at Wandsworth in full and cleared the prison of any fault at all.
Against that: the prison holds roughly 1,444 men in space certified for around 894. Three men died within eight days of each other in March. The governor who drove the recent reforms is understood to be leaving.
The Ombudsman has made his case publicly, on the record, in a report laid before Parliament. Whether the government acts on it is now a question for the Ministry of Justice, which sponsors his office.
What a reader can do
Every Prisons and Probation Ombudsman fatal incident report is published at ppo.gov.uk. Prisoners and people on probation can complain to the Ombudsman once they have exhausted the prison’s own complaints process: mail@ppo.gov.uk, 020 7633 4100.
Coroners’ Prevention of Future Deaths reports for anyone who dies in custody are searchable at judiciary.uk. The House of Commons Justice Committee has taken evidence from Usher twice in the past year and can be written to directly. If you are affected by anything in this article, Samaritans are available 24 hours a day, 365 days a year: 116 123, free, or jo@samaritans.org.
