The Prisons and Probation Ombudsman, Adrian Usher, has found that the death of Waleed Ali at HMP Wandsworth was “absolutely foreseeable and possibly preventable”. In a highly critical report, he found that staff ignored repeated warnings that Mr Ali was at risk of suicide.
Mr Ali, 54, was a remand prisoner. He died within hours of arriving at Wandsworth on 22 October 2022.
Before he reached the prison, Mr Ali spent time in hospital. There he said he hated his life and wanted to end it. His discharge paperwork recorded an attempt to end his life.
Later that day he moved to Charing Cross police station in central London. He told officers again and again that he wanted to die. He remained under constant supervision. A digital person escort record (dPER) flagged the risk that he might harm himself or attempt suicide.
Police and liaison nurses recorded his agitation and self-harm again on 21 October. They sent an email warning Wandsworth’s reception and mental health teams of his attempt to end his life. The prison did not check that inbox until three days after his death.
After his remand to Wandsworth on 22 October, escort officers again failed to check or update the dPER. During the van journey Mr Ali cried and shouted that he could not breathe. A record shows one officer responding: “Oh bloody hell, really? I don’t want to listen to that”.
Arrival at Wandsworth
Mr Ali reached the prison at 3.55pm. He had a brief meeting with reception staff, and a nurse there completed an initial health screen. Nobody could find his medical records, because his warrant gave the wrong date of birth. The nurse referred him to the mental health team because he was behaving strangely.
According to the Ombudsman, Wandsworth staff never accessed the dPER and mislaid key clinical information. Instead they relied on the short reception screen, where Mr Ali denied having suicidal thoughts. They did so despite his odd behaviour and recent suicide attempt. The Ombudsman found this fell well below the care he would have received in the community.
Mr Ali went into a shared cell at around 6.30pm. Within an hour he pressed his cell bell five times and asked repeatedly to move. On one occasion an officer took 29 minutes to respond. That officer did not ask why he wanted to move, and reported seeing and hearing nothing to suggest he was unsafe. A routine check took place at 8.03pm. By 9.06pm his cellmate had raised the alarm.
Failures across agencies
The Ombudsman pointed to clear and repeated signs of distress, and to suicide warnings that nobody checked. He found that multiple agencies “failed in their duty of care”. His report identified systemic failures in risk assessment, information-sharing and basic checks. These spanned the police, the transport contractor Serco and HMP Wandsworth.
An inquest recorded that Mr Ali died by suicide. The coroner found that he intended to take his own life. However, the coroner also found systemic failures to assess and communicate the risk properly.
Inspectors and monitors have repeatedly described Wandsworth as a prison in crisis, citing chronic staff shortages and rising self-harm. They say work on action plans to improve safety is now under way.
HMP Wandsworth is a category B reception prison for men in London. At its last full inspection before this report, in August 2024, inspectors rated safety, respect and purposeful activity as poor. They judged preparation for release not sufficiently good.
