In the recent case of R (Scarfe & Ors) -v- Governor HMP Woodhill & SoS Justice [2017] EWHC 1194 (Admin) the court was asked to exercise public law powers by way of a judicial review, at the request of the families of the deceased prisoners.

Following numerous self-inflicted deaths at HMP Woodhill over a number of years, deceased prisoners’ families wanted to ensure that repeat failings would not occur and that the prevention of future deaths (PFD) reports would be appropriately actioned. They argued that the failure to prevent self-inflicted deaths constituted a serious breach of fundamental provisions within article 2 of the European Convention of Human Rights (ECHR), which imposes a positive duty to protect life.

The court gave guidance on the interpretation of article 2 ECHR and the difference between ‘systematic’ and ‘operational’ failings.


The court found that there had been a series of ‘distinct but separate operational mistakes in suicide prevention’ at HMP Woodhill. Whilst there was evidence of a series of individual failings of compliance, these did not amount to a systemic failing which could be characterised as a ‘failure of the system’.

Furthermore, the court noted that even if there had been a systematic failure the courts would be unlikely to be equipped to deal with it: ‘Suicides in prison raise complex societal issues. The solution to those problems, acute as they are, lies not with judges applying principles of public law but with those who have the unenviable task of managing prisons’.


Whilst the court found, in this case, that the identified failings were by individuals, rather than being caused by the system, it is important that organisations involved in the provision of care within the prison system are aware that similar cases may be brought in the future. Trends should therefore be identified as a matter of urgency within all prison organisations and appropriate action taken.