Fresh inquest into Stephen Port murders to examine police probe, court told

Families of the victims of serial killer Stephen Port have been told a fresh inquest into their deaths will focus on possible failings in the police investigation.

But the Old Bailey was told it would not be lawful to investigate the conduct of another coroner who previously failed to identify foul play in the deaths of two of the young men before Port was caught.

Port, now aged 44, drugged and raped four young men and dumped their bodies near his home in Barking, east London, between 2014 and 2015.

Following a trial at the Old Bailey, he was handed a whole-life sentence for the murders of fashion student Anthony Walgate, 23, Gabriel Kovari, 22, Kent chef Daniel Whitworth, 21, and Jack Taylor, 25, a forklift truck driver from Dagenham.

Since then, the victims’ families have question why he was not stopped sooner and the Independent Office for Police Conduct has investigated.

An earlier inquest into the deaths of Mr Whitworth and Mr Kovari which had reached an open conclusion was quashed.

During the trial it had transpired a suicide note purporting to be penned by Mr Whitworth admitting involvement in Mr Kovari’s death had been faked by Port to cover his tracks.

On Friday, Judge Sarah Munro QC, sitting as assistant coroner for east London, vowed to hold a “full, fair and fearless” inquest.

She offered her “sincere condolences” to the family of Mr Taylor and Mr Whitworth’s partner in court as well as bereaved relatives not present.

Andrew O’Connor QC, counsel for the coroner, told the court: “The main focus of these inquests should be the adequacy of the police investigation into Mr Port.”

He said it would not be necessary to call extensive evidence on the circumstances of the deaths because Port’s conviction was evidence in itself.

On the scope of the inquest, he said: “The starting point will be evidence of police involvement and knowledge of Stephen Port prior to the death of Anthony Walgate.

“It will then be necessary for you to examine the way the police responded to each of the four deaths, the response to earlier deaths being relevant.

“It will inform your investigation into whether steps should have been taken before the later deaths – even before the last death of Jack Taylor.”

Mr O’Connor argued that Ms Munro had no power to investigate any “insufficiency” by the original coroner in the inquest into the deaths of Mr Kovari and Mr Whitworth.

That included whether she properly scrutinised the fake suicide note and Mr Whitworth’s movements in the days before his death.

He said: “What this boils down to is evidence relating to these matters was not called at the inquest into Mr Kovari and Mr Whitworth’s deaths. When witnesses and a police officer were called they were not pressed.”

But he said: “The inquests happened. We will be hearing evidence of those inquests. The transcripts will be before you.

“Witnesses, police officers who took part in those inquests can and no doubt will be asked about what they said at those inquests, what they did before those inquests and what they did or did not do after those inquests.”

He stressed Ms Munro would not be able to look at whether the original coroner in some way “failed”.

Mr O’Connor said Port himself had the legal right to take part in the inquests but it was not yet known if he wanted to.

If he did, it was suggested he could hear evidence by video link from prison and it would not be necessary for him to give evidence.

Any involvement by Port in his victims’ inquests would cause “upset” to the families, the court heard.

During the hearing, Ms Munro said: “My priority this morning is to express my sincere condolences to the families both present and absent for the loss of their loved ones.

“You have my assurance that I will conduct full, fair and fearless inquests.”

“I recognise you will all feel frustration at the time it has taken to reach this point. I assure you work has been progressing as expeditiously as possible. There is a considerable amount of work to be done.

“I note that concerns have previously been raised about independence of the process. Those concerns can be allayed by my appointment.”

Afterwards, lawyer Andrew Petherbridge, acting for the families, said: “It’s clear from today’s hearing that there remains a long process ahead for the families.

“However, they remain committed to unearthing the truth and are grateful to the coroner for the careful consideration she is giving all matters.”

A further pre-inquest review will take place at the Old Bailey in November with a full inquest at the same venue as soon as possible in 2020.

A decision on whether to hold the inquest with a jury was put off until the next hearing.

A prisoner who died at HMP Nottingham had a history of self-harm

A prisoner who died at HMP Nottingham had a history of self-harm and had already attempted to take his own life in police custody, an inquest has heard.

Shane Stroughton, who was the first of five inmates to die at the jail in the space of a month, was found hanged in his cell in September 2017 despite having “frequent” contact with medical professionals.

The 29-year-old, who was originally jailed for assault at the age of 19, was recalled to prison for breaching a curfew after being released on licence three months before his death.

An inquest jury at Nottingham Coroner’s Court heard that an ambulance was called to the jail and CPR was administered but Mr Stroughton could not be resuscitated.

The category B prison, which has a capacity of 1,060, was found to be “fundamentally unsafe” following an inspection in January last year – prompting the first use of the “urgent notification” system.

Introducing the case to the jury, Assistant Coroner Ivan Cartwright said: “At prison, he was accommodated in a number of different cells.

“During his time in prison, Mr Stroughton had frequent contact with healthcare and medical staff.”

Mr Cartwright told the jury that the inmate had a history of self-harm.

He said: “Mr Stroughton made an attempt to hang himself in police custody.

“He made a number of different attempts to harm himself.

“On September 13 2017, a prison officer was unlocking cell doors for prisoners to collect their evening meals. They found Mr Stroughton hanging.”

The inquest, expected to last seven days, continues.

Holme House Prison Damned By Inquest Jury


In a damning verdict returned late on Thursday 13 June, the jury in the inquest into the death of Andrew Hall on 27 March 2009 found that he took his own life whilst the balance of his mind was disturbed, contributed to by neglect.

This is the third short form neglect verdict returned following a self inflicted death at Holme House prison.

Following three full weeks of evidence, the lengthy jury verdict listed 21 separate failures of Andrew Hall’s care and treatment at HMP Holme House. These included failures in risk assessment and risk management, and serious failures in communication. 

Andrew served part of his sentence at HMP Kirklevington.  Whilst there, he had attempted suicide by cutting both wrists.  Following a period of hospitalisation he was transferred to Holme House prison on an open ACCT (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm), which was subsequently closed.  The jury concluded that this ACCT should not have been closed.  Following the (improper) closure of the ACCT, on 23 March, Andrew was further assessed by a psychiatrist who considered him to be psychotic and at significant risk of self harm. Despite this, no ACCT was re-opened, a clear failure identified by the jury.  The jury found that none of the nurses in the subsequent four days had read the psychiatrist’s documented assessment. As a consequence, he was not afforded the level of observations, interaction and care necessary.

As a result, despite being in a camera cell, he was not being properly observed when he first inflicted a wound to his neck four days later.  The jury concluded that the failure to observe and interact contributed to his death.  In a devastating criticism, the jury also found ‘there was an opportunity for the staff to intervene between the time when he inflicted a wound to the vein in his neck and the time when he inflicted a wound to the artery in his neck’.  This period lasted around 20 minutes, during which blood could be seen on CCTV on the floor of the cell.

The full verdict is available from INQUEST.

At the conclusion of the inquest, the deputy coroner indicated that he would be reviewing recommendations made following previous inquests into deaths at HMP Holme House before drafting his own, with specific reference to continuing failures of record keeping and communications between discipline staff, nursing staff and the mental health in-reach team.  Since Andrew Hall died, there have been five further self-inflicted deaths at HMP Holme House. 

Paula Davidson, Andrew’s partner said:

“The verdict today has proven Andrew’s death was unnecessary and if individuals had carried out their roles there would not have been failings in his care which resulted in Andrew’s death

“There have been a number of deaths before and after Andrew’s death and we hope that lessons have been learned from today’s verdict which the jury have returned.

“I would not have the truth for the family and also for our little girl today if it had not been for the support from INQUEST and I would like to thank them and Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and Sean Horstead from Garden Court Chambers for all their support throughout this four year experience.”

Deborah Coles, co-director of INQUEST said:

“Had greater care been taken been taken of Andrew this tragic and disturbing death might not have happened at all.

“The fact that this is the third neglect verdict since 2004 at HMP Holme House should be a wake up call to the prison service.  Moreover, that there have been five further self inflicted deaths there since Andrew Hall died in March 2009 suggests that little has been done to address the issues raised at this and previous inquests.

“It is crucial for the safety of all prisoners at Holme House that these failings are addressed as a matter of urgency.”

The family is represented by INQUEST Lawyers Group members Fiona Borrill and Imogen Hamblin from Lester Morrill solicitors and barrister Sean Horstead of Garden Court Chambers. The same team represented the families of the two other self-inflicted deaths at HMP Holme House where neglect verdicts were returned at inquest.


Notes to editors:

1.  Full background on Andrew Hall’s death can be accessed here

2.  The full jury verdict is available from INQUEST.  Please contact Hannah Ward.

For further information, please contact: Hannah Ward, Communications Manager at INQUEST on 020 7263 1111/07972 492 230 or

INQUEST provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth complex casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability. INQUEST’s policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths occurring.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.


The inquest into the death of Paul Murphy is due to commence on Monday 14th May 2012, at Lincoln Crown Court, The Castle, Castle Hill, Lincoln LN1 3GA, before HM Coroner for Lincoln, Stuart Fisher.

Paul was 39 years old when he died on 13 June 2008 after being found hanging in his cell at HMP Lincoln.  He had been moved to the Vulnerable Prisoners Wing as he had got into debt with other prisoners and feared reprisals. On 12 June he was made subject to his third ACCT document after expressing further fears of harm from others, displaying paranoid behaviour and threatening to cut his wrists. Overnight he was subject to minimal checks and not placed in a safer cell.

Paul’s family hope that the inquest will explore the quality of the care he received on 12/13 June, and any possible links with a prison officer suspended the following month, and ultimately dismissed, for trafficking drugs and mobile phones within the prison.

The inquest is scheduled to last for two weeks.