Waleed Ali arrived at HMP Wandsworth at 3.46pm on 22 October 2022. He was 54 years old. Two days earlier he had attacked his ex-partner with a knife in a public place. He had also stabbed himself. He had told the hospital he wanted to die, and the police at Charing Cross, where he was held overnight, had placed him under constant supervision because he said he wanted to kill himself.
A prison’s first duty to a man arriving in that condition is not to judge him. A court will do that. Its duty is to keep him alive long enough for a court to hear his case. That is the most basic thing a prison does. On 22 October 2022, HMP Wandsworth failed in its job.
By 9.59pm that evening, Ali was dead. He had hanged himself in his first-night cell. The Prisons and Probation Ombudsman, publishing his independent investigation this week, finds that the death was “absolutely foreseeable and therefore possibly preventable.” It is the second time in eight months that Ombudsman Adrian Usher has said a prisoner at Wandsworth might not have died had he been elsewhere.
The escort record travelling with Ali from the police station made clear he was at risk of suicide. Every institution that held him before he arrived (the police, the hospital, the court) had read it. No-one at Wandsworth did.
Every system that handled him, except the one built to hold him
On 20 October, after stabbing himself and his ex-partner, Ali was taken to hospital. The psychiatric team there recorded that he “hated his life” and wanted to end it. His discharge paperwork stated “self-stabbing with intent to end life.” He arrived at Charing Cross police station that afternoon, placed under constant supervision, screaming that he wanted to die.
The police completed Ali’s Person Escort Record (the document that follows a prisoner through the custody system) the following evening. It recorded clearly that he was “at risk of suicide and self-harm” and had been “under constant supervision” due to the “high level of risk.” A mental health nurse at Westminster Magistrates’ Court also emailed HMP Wandsworth’s reception, mental health team and healthcare inbox that afternoon, warning that Ali was due the next day and had tried to take his own life. The reception inbox was not checked. That email was not read until 25 October; three days after Ali died.
When Ali appeared before magistrates on 22 October, charged with attempted murder and remanded in custody, he was sent to HMP Wandsworth.
Serco, the private company running the escort contract, collected Ali from court that afternoon. He removed all his clothes but his underwear. The escort officer had not been briefed on his risk. On the van to Wandsworth, audio captured Ali “often crying and wailing.”
The escort officer’s response, recorded by the van’s CCTV system and quoted in full in the PPO report, was: “Oh bloody hell, really? I don’t want to listen to that.” When another prisoner told Ali to “shut the fuck up,” she laughed.
During the journey, Ali banged on the floor, said he could not breathe, clutched his chest, and appeared to stop breathing. He slumped motionless for approximately sixty seconds. The officer did not react. She did not check on him.
He arrived at Wandsworth at 3.46pm. Sixteen minutes passed before a supervising officer opened the holding cell door. Ali was lying on his side on the floor and slumped into the doorway.
What happened inside the prison
In reception, a nurse assessed Ali. She recorded that he appeared “mentally stable” and “calm,” but also noted “strange behaviour” and referred him to the mental health team. She did not open an ACCT (the suicide and self-harm monitoring document that would have placed him under structured observation). The officer handling the cell-sharing risk assessment later told investigators he “could not remember seeing” the escort record and did not have access to the digital version.
The prison’s digital systems confirmed that no-one at Wandsworth accessed Ali’s escort record at any point during the six hours between his arrival and his death.
That evening, a GP made a note in Ali’s new medical record. A fresh record had been created because his date of birth had been entered incorrectly on his warrant. The note stated that Ali had “transferred to the wing.” Ali had not transferred to the wing. He was still in the first-night centre. Shortly afterwards, the GP walked past the room Ali was in, looked in, and left for the day.
Ali was placed in a shared double cell that evening. His cellmate had not wanted to share and had to be returned to the cell with a physical hold. Over the next hour, Ali pressed the emergency bell five times.
| Time pressed | Response time | Visit duration | Officer action |
|---|---|---|---|
| 6.56pm | Not recorded | Not recorded | Not recorded |
| 7.00pm | 29 minutes | 25 seconds | Ali asked, crying, to be moved. Officer did not ask why. |
| 7.39pm | Not recorded | 5 seconds | Ali asked, crying, to be moved. Officer did not ask why. |
| 7.44pm | Not recorded | Not recorded | Not recorded |
| 7.57pm | Not recorded | Not recorded | Not recorded |
One bell was not answered for 29 minutes. An officer attended four times. Each visit lasted between five and 25 seconds. Ali asked, crying, to be moved. The officer never asked why.
The cellmate rang the emergency bell after finding Ali hanged. A nurse walked past the cell a minute later. She did not notice the emergency light or hear anything. No officer came for six minutes. Ali was pronounced dead at 9.59pm.
The coroner, following a three-week inquest concluding on 4 March this year, returned a verdict of suicide. She found “systemic failures to properly assess and communicate risk.”
The same prison. The same failures.
Ali is not the first prisoner to die at HMP Wandsworth after arriving with a clearly-flagged suicide risk that staff failed to act on. Sebastião Lucas died in May 2021 after arriving with similar documentation. Staff failed to read it. No monitoring was opened. Rajwinder Singh died in June 2023 after staff ignored cell bell alerts. Usher’s report into Singh’s death was so serious that Usher took the unusual step of finding the prisoner might not have died had he been held elsewhere.
He has now written that sentence twice. Both times about Wandsworth.
Usher’s foreword to today’s report names the pattern directly. Ali “was a man presenting with a clear risk of suicide, who was distressed, possibly mentally unwell and vulnerable. The police identified Mr Ali as at risk of suicide following his arrest two days earlier. Although this information was recorded in documentation, which was available to court staff, escorting staff and prison officers, no-one checked it.”
The report describes the prison’s failure as “symptomatic” of a prison in sustained crisis. Not an individual error, not a bad shift, but a condition that persisted over years.
Ali was the 15th prisoner to die at HMP Wandsworth since October 2019. Three more men died there within eight days last month. There have been nine further self-inflicted deaths at the prison since Ali’s.
What the prison has done since
The PPO made a single recommendation: that the governor, the head of healthcare and Serco’s head of operations should audit whether staff are actually following the rules on escort records.
HMPPS accepted the recommendation. The action plan records that the prison now prints escort records on arrival; that a reception audit process has been introduced; that staff have been trained; that monthly meetings between the prison and escort contract managers now take place. Oxleas NHS Foundation Trust, which provides healthcare at the prison, has given its healthcare staff direct access to the digital record. A multi-agency learning event took place in September 2024.
These things are real. They are also, in one sense, beside the point. The question the PPO’s report leaves behind is not whether the processes have been updated. It is how many times the same update can be made, accepted, completed and filed before the next man arrives at the gate with a document nobody reads.
“The failures make for depressing reading”
Wandsworth Prison holds people on behalf of every borough in London and beyond. The state puts people there because society has decided that some people, sometimes, have to be removed from it. Sometimes because they have done terrible things. That decision is legitimate. It comes with a condition: the state assumes responsibility for keeping those people alive.
Waleed Ali had done something terrible. The state had a duty to him anyway. On 22 October 2022, it did not discharge that duty.
The Ombudsman finds that the failures “make for depressing reading.” It is the only emotive word in his entire 24-page report and he uses it once.
Nineteen stories. Twenty-four deaths investigated since 2019. Nine more self-inflicted deaths since Ali’s. One recommendation per case. Action plans completed. And the next man arrives.
If you are affected by anything in this article, Samaritans are available 24 hours a day, 365 days a year. Call free on 116 123, email jo@samaritans.org, or visit samaritans.org.
INQUEST provides specialist, independent and confidential support for families bereaved following a death in state detention. Visit inquest.org.uk or call 020 7263 1111.
The Wandsworth Prison Improvement Campaign works to improve conditions at the jail and supports prisoners on release through its Leavers Lounge programme. Visit wpic.org.uk.
The Prisons and Probation Ombudsman publishes all fatal incident investigations at ppo.gov.uk/establishment/hmp-wandsworth.
