December 18, 2025

Sundeep Ghuman: Prevention of future deaths report

State Custody related deaths

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Date of report: 15/12/2025

Ref: 2025-0625

Deceased name: Sundeep Ghuman

Coroner name: David Manknell

Coroner Area: London Inner South

Category: State Custody related deaths

This report is being sent to: Ministry of Justice | HMP Belmarsh

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: Secretary of State for Justice, Governor, HMP Belmarsh
1	CORONER I am David Manknell KC, Assistant Coroner for the coroner area of London Inner South
2	CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3	INVESTIGATION and INQUEST On 7 May 2020 an inquest was opened into the death of Mr Sundeep Ghuman and adjourned pending Police investigation. Following the Police investigation a criminal trial took place, and in 2022 one of Mr Ghuman’s cellmates, [“M”], was found guilty of murder. Following the resumption of the inquest, the final hearing took place from 20 October 2025 until 7 November 2025. The medical cause of death was 1a. Head injury. In section 3 of the Record of Inquest the jury recorded the following: “At the time of his death Sundeep Ghuman was a prisoner at HMP Belmarsh on House Block two. Sundeep was in a triple cell and on 7th February 2020 two prisoners were placed in the cell, ‘M’ and his cousin ‘T’. ‘M’ was a racist. On 18th February 2020 between 17:24 and 17:30 one of the prisoners , ‘M’ violently assaulted Sundeep with a table leg causing unsurvivable head injuries. Prison Officers attended the cell and called the emergency services at 17:32. Sundeep was taken to the Royal London Hospital, he arrived at 19:52 and was met by the Trauma Team. Sundeep died on 19th February 2020 at 18:10 in the Royal London Hospital. The cause of Sundeep’s death was from a head injury.” The jury’s conclusion at the inquest was a narrative conclusion. The conclusion in section 4 of the Record of Inquest was as follows: “(1) Sundeep Ghuman was unlawfully killed by a cell mate, ‘M’ while a prisoner at HMP Belmarsh. (2) (a) The cell sharing risk assessment, (C.S.R.A) of M at HMP Belmarsh was not carried out appropriately by the prison on 5-6 November 2019 due to the following reasons: The P.S.I 2015 [Prison Service Instruction (PSI) 20/2015] provided that if evidence is found of racially motivated offence of reports in community or custody that is a strong indicator the prisoner should be high risk but can share with own ethnicity. Racist alert was active and was evidence of racism and should lead to high risk can share with own ethnicity unless further sources checked, e.g. intelligence and the rationale should then be recorded in the CSRA. No evidence of this was undertaken by the prison officer completing the reception assessment. Previous CSRA from [HMP] Highdown stated, ‘standard risk but racist share with own ethnicity and corresponding NOMIS entry, confirmed this and this was not accurately reflected in Belmarsh CSRA reception assessment, which only references standard risk, transferred in from Highdown. (2)(b) If ‘M’s’ CSRA had been carried out appropriately on 5th November 2019 that would have avoided ‘M’ being placed in Sundeep’s cell and Sundeep’s death would have been avoided. (3)(a) In requiring Sundeep to share a cell with ‘M’ there were failings in the assessment by the prison service in their assessment of risk to Sundeep as a result of the risk presented by ‘M’s’ racism as the CSRA was not carried out appropriately and this materially contributed to his death as absent the failing it is likely that Sundeep would not have been in a cell with ‘M’ on 18th February 2020. (3)(c) In requiring Sundeep to share a cell with ‘M’, there were failings by the prison in their assessment of a result of any additional risk associated with the use of a triple rather than a double cell as additional potential risks such as a greater number of people means more scope for tension and any potential imbalance in relationships amongst the three prisoners was not considered. However the evidence does not support that prison officers were expected to consider such additional risks with the use of triple cells, the P.S.I did not cater for the use of triple cells. We cannot say that absent the failing, Sundeep would probably not have been in a cell with ‘M’ on 18th February 2020 or that it is reasonably possible that they would have not been in a cell together. (4)(a) There was a failing by the prison that made a material contribution to Sundeep’s death due to the lack of efficiency of the CSRA process, including the training of prison officers. The prison operated the ‘S1’ system which demonstrates CSRA PSI process not properly understood and applied. On balance, prison officers had not recorded adequate training on CSRA process other than through shadowing (main for of training) and those officers providing training through shadowing did not understand the requirements of the P.S.I. the risk was heightened as the CSRA process did not require the second day check or any other assurance of the reception assessment leading to a single point of failure.”
4	CIRCUMSTANCES OF THE DEATH Mr Sundeep Ghuman was a prisoner at HMP Belmarsh where, at the material time, he was sharing a cell with two other prisoners, [“M”], and another prisoner who was a cousin of [“M”]. Mr Ghuman was a British Asian man [“M”] had a history of racist and violent behaviour. There were active NOMIS alerts (NOMIS being the National Offender Management Information System, an operational database used in prisons in England and Wales at the time to manage offenders) for [“M”] in respect of racism and violence. The alert for racism had been added some years before on the basis that [“M”] was a member of a racist gang, the Racist Army of Woolwich and that they carried out racist assaults in south London. There were further intelligence reports thereafter in respect of racist behaviour in custody by [“M”] and involvement in incidents and threats of violence. The evidence from HMPPS policy officials was that a prisoner who posed a risk by reason of racism should in fact be marked as “high risk” on a CSRA, but permitted to share with his own ethnicity. On arrival at HMP High Down on 8 October 2019, the CSRA for [“M”] had recorded that he was “standard risk” but that due to his racism, [“M”] was to share with prisoners of his own ethnicity only. [“M”] was then moved to HMP Belmarsh on 5 November 2019 where reception staff did not impose the same restriction, but marked him as “standard risk as per High Down” without any qualification. They did not apply the “S1” marker used at HMP Belmarsh to indicate a racist prisoner who is only suitable to share with his own ethnicity. On 7 February 2020, staff at HMP Belmarsh moved [“M”] and his cousin from the cell and houseblock where they had been residing due to their disruptive behaviour (including “self isolating” due to drug debt to other prisoners) and they were placed into Mr Ghuman’s cell. No consideration or assessment of their suitability to share together was made by officers in charge of the move. No consideration was given to the information on NOMIS or the intelligence reports in respect of [“M”], and staff involved were unaware of his alert for racism or apparent history of involvement in racist violence. On 18 February 2020, Mr Ghuman was violently assaulted in his cell with a table leg by [“M”]. Mr Ghuman was taken to the Royal London Hospital, where he died in hospital of a head injury on 19 February 2020. On 16 May 2022 [“M”] was found guilty of Mr Ghuman’s murder and later sentenced to life in prison.
5	CORONER’S CONCERNS During the course of the investigation and inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The following matters are addressed both to the Secretary of State for Justice, and the Governor of HMP Belmarsh. The MATTERS OF CONCERN are as follows. 1) The operation of the CSRA process, and application of the CSRA policy at HMP Belmarsh and more widely in the prison service HMPPS provided a witness who holds a senior position in the safety group for HMPPS and is responsible for various policies and processes including the CSRA policy (“the policy witness”). His evidence was that the CSRA policy is to the effect that if a prisoner poses a risk because of racism, that they should be categorised as “high risk”, but if appropriate that they could be permitted to share with a prisoner of their own ethnicity. He confirmed that this had been the policy position in 2019 and remains the position now. The policy witness was not aware of the “S1” system operated at HMP Belmarsh (where such prisoners would be categorised as “standard risk” with a note to say that they can share with their own ethnicity) until he was preparing for his evidence in this case. He also emphasised that the policy is intended to enshrine a cautious approach to risk. By contrast, none of the witnesses from HMP Belmarsh (or HMP High Down) were aware that a prisoner who posed a risk because of racism should be high-risk, and all were under the impression that such a prisoner should be standard risk, with an “S1” label indicating that they should only share with their own ethnicity. This was not only the view of the prison staff responsible for the CSRA process, but also the evidence of the former Head of Residence and Services (now Head of Business Assurance), and the Head of Security and Intelligence, whose evidence was that he was unaware of the correct position until shortly before giving his evidence. The evidence of those staff was that HMP Belmarsh had operated in this way for many years. Nor were staff at HMP Belmarsh aware of the policy position that the guiding principle is one of caution. Rather, they emphasised the need to maximise occupancy and the risk of prisoners causing occupancy to be lost by falsely claiming to be racist. The misunderstanding of the need for such prisoners to be categorised as high risk creates itself a significant risk of fatal events such as in this case, because a standard risk prisoner (whether noted as S1 or not) is not noted in the same way on the electronic system, and it is not obvious to staff who subsequently make decisions in respect of that prisoner that the individual indeed presents a high risk. In addition, the lack of understanding of the policy by all staff (including senior management) at HMP Belmarsh appears to reflect a systemic failing of training and operational understanding, and a disconnect between those responsible for creating and maintaining the policy and those who take operational decisions within prisons. The fact that the comprehensive misunderstanding of the policy by HMP Belmarsh over a period of many years was entirely unknown to those responsible for the policy, even in circumstances where HMP Belmarsh operated its own system (complete with bespoke “S1” stickers) and not picked up by any audit or monitoring procedure also indicates a failure in policy implementation. The overall widespread and longstanding failure in policy implementation by HMP Belmarsh creates a risk of future deaths as a result of racist violence. If policies designed to prevent these events are fundamentally misunderstood and are incorrectly implemented to this extent, there is a real risk of departure from the minimum standards set in policy and specifically designed to reduce this very risk. 2) A lack of either guidance or operational understanding of how NOMIS alerts for racism should be treated by staff. The evidence of staff at HMP Belmarsh (and HMP High Down) was highly inconsistent as to how an active alert for racism would be treated. Evidence of some officers was that if an alert was currently marked as “active” then they should assume that there was a real risk of danger posed by racism, or require further investigation and have the active status removed if no longer appropriate. This appeared to be the approach endorsed by the policy witness, on that basis that an officer seeing an alert will not have the benefit of the underlying intelligence, or knowing what led to the alert being made and maintained as active. The majority of officers from HMP Belmarsh who gave evidence on this issue however, expressed the view that it was a matter for them as to what weight they should give an active alert for racism. Their evidence was that a racist alert might be old, that the alert was only part of the picture, and that they would give at least equal weight to what was said by the prisoner upon arrival at the prison. In the case of [“M”], the evidence of the relevant officer (who carried out the secondary CSRA in reception) was that he was aware of the alert, but because it was old, and because there was no concern apparent when he spoke to [“M”], that the alert could be disregarded. No officer recalled any specific training as to how an active alert for racism should be approached when conducting a CSRA. The lack of understanding of how an active alert for racism should be approached when assessing suitability cell sharing creates a risk of future fatal events. An unstructured approach and lack of training creates a risk that, as in this case, staff may inappropriately disregard an active alert for racism, leading to potentially fatal racist violence. 3) The lack of consideration of risks, beyond the minimum requirements of the CSRA, when allocating prisoners to share a cell a) As to the risk of violence: The evidence of HMPPS staff and officials was that the threshold for making someone High Risk on a CSRA as a result of the risk of them being violent is a very high threshold. The Head of Security and Intelligence’s evidence was that, in general, a prisoner would only be made high risk for violence on the CSRA if they had either previously killed a cellmate or they had previously inflicted life-threatening injuries on a cellmate. Lesser violence, even against other prisoners and cellmates would not lead to them being High Risk. The finding of weapons in cells was not regarded as relevant unless there was evidence that they had been used. Similarly, the threshold for someone being regarded as “vulnerable” for the purposes of the CSRA was said to be very high. The evidence of the Head of Security and Intelligence was that this was in effect limited to prisoners with significant disabilities including serious learning difficulties. The policy witness’s evidence was that the CSRA policy only provides a “baseline” and he would expect measures to be in place to allow judgements to be made beyond this that minimise any problems caused by cell sharing. His evidence was that he would expect staff to be exercising judgement beyond what is stated on the formal CSRA, although the extent to which they are able to do that will be dependent on a range of things, including what information they have got about the individuals, what the circumstances are for the move, what the capacity pressures may be. The evidence of staff at HMP Belmarsh (including from the Head of Security and Intelligence) was by contrast to the effect that moves into a cell are simply a daily occurrence and that as long as a CSRA says the individuals concerned can share then they can be moved in, and that no further consideration is necessary or appropriate. Consistently with this, the evidence of officers was that when arranging a cell move they would not look at the NOMIS notes of a prisoner, or other records, but solely at the CSRA to check that they were not High Risk (or “S1”). In this case, the officers confirmed that when deciding to move [“M”] and his cousin into Mr Ghuman’s cell, no consideration was given to the appropriateness of the move save for checking that the CSRA permitted sharing. This approach creates a substantial risk that a prisoner who is prone to violence against his cell mate will be placed with a prisoner who is at risk of such violence. The fact that the violent prisoner may not have previously killed a cellmate or inflicted life-threatening injuries on a cellmate in the past is not a sufficient safeguard against a future cellmate being subject to a level of violence that may result in death. This risk is heightened if the other prisoner has a level of vulnerability, or some other feature that makes violence against them more likely, including any relevant prejudice. A more nuanced approach appears to be required in respect of individual cell sharing decisions, and this appears to be the intention of the policy, but not reflected in implementation at HMP Belmarsh. b) Drug use The evidence from all witnesses was that use of illicit drugs in prison (including Spice) had no bearing on cell sharing suitability either in the CSRA or otherwise. Although the effect of the drug Spice was not a factor in Mr Ghuman’s death, the evidence that emerged during the inquest on this issue as it relates to cell sharing is an issue that gives rise to a concern of future deaths. The evidence of multiple witnesses from staff was that Spice use is widespread in the Prison, and that officers are well aware of prisoners that use it in their cells. It was also apparent that the secondhand or passive effects of Spice can be dramatic and seriously harmful. One of the witnesses, an Officer at HMP Belmarsh, described how having been exposed to secondhand inhalation from outside a cell for a very short period, he was unable to stand, and remained unwell and disoriented, requiring rest and supervision overnight as a result. The evidence was that Spice use can make prisoners very unwell, and can also make them act irrationally and in a way that has no regard for their own safety. There was evidence in this case that prisoners who were Spice dealers would persuade young and easily exploited prisoners to try Spice, including by falsely claiming that it was a regular roll-up cigarette, in order to “test” a batch of the drug or simply to take pleasure in seeing them suffer the effects. There appears to be no consideration in HMPPS of the risks to prisoners from inhalation of Spice when a cellmate is a user or supplier, or of the risks of more easily exploited prisoners being led into Spice use by cellmates who use the drug, and no assessment of whether it is safe to place a prisoner in a cell with a user or supplier of Spice. I am aware that deaths have been directly linked to Spice use. In the absence of any assessment of the risks in individual cases, there appears to be a risk of death of a prisoner through being placed into a cell with a known user or supplier of Spice. 4) In respect of HMP Belmarsh more generally, a concern for the safety of prisoners given the evidence of such widespread and seemingly ubiquitous violence and drug use in the prison. There was evidence of concern in respect of the widespread levels of prisoner-on- prisoner violence at HMP Belmarsh, and the widespread use of drugs, especially Spice, and the evidence of staff that this was unavoidable. The evidence was clear and consistent about both of these issues, with a number of witnesses effectively giving evidence that “lots of prisoners here” or “most prisoners at Belmarsh” are violent or have a violent history, and that it was therefore accepted that there will be regular incidents of violence by prisoners against other prisoners. Similarly, the evidence about Spice use was that it is known to be widespread in the Prison, and that a very significant proportion of prisoners are Spice users. However, that evidence on these topics did not correspond to recorded findings in Adjudications or criminal proceedings. In [“M”]’s case there were multiple instances of violence (and indeed racism) being identified in intelligence reports and in some cases on NOMIS, but without matters proceeding to an adjudication. Similarly, although it was apparently well-known that [“M”] and his cousin were regular Spice users, no formal proceedings for drug possession were taken against them. The evidence overall was that HMP Belmarsh has widespread levels of violence by prisoners against other prisoners, and seemingly ubiquitous levels of Spice use in the prison. This seems to be at a level where staff do not consider that they can always take robust action and formal measures when this occurs. In those circumstances, I have a concern that the Prison may not currently be capable of providing a safe and secure environment for prisoners accommodated there, and that there is a risk of future deaths from drug use or violence.
6	ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.
7	YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 February 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
8	COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Sundeep Ghuman Oxleas NHS Foundation Trust Practice Plus Group CGL (‘Change Grow Live’) The Prison and Probation Ombudsman I have also sent a copy to the following individuals for their information: [REDACTED] HMPPS, [REDACTED] HMP Belmarsh [REDACTED] HMP Belmarsh I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9	15 December 2025 [REDACTED]

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