In our report Voices From The Inside, to be published on 14 November 2024, we have testimony of life inside UK prisons given by current and former prisoners and by friends and relatives of prisoners. Amongst our evidence is that of Zack Griffiths who was interviewed by a BBC radio journalist while taking part in a protest outside HMP Parc. This prison was then in the news because nine of its prisoners had died during the ten weeks between February and May 2024.
On 27 May 2024 a BBC report included this:
Naomi Lewis’ brother, Justin, from Newport, was found dead in his cell at HMP Parc in March. Ms Lewis said her brother had a history of ‘seriously self-harming’.
‘Justin didn’t get checked on all day. He was self-harming. There should have been a duty of care. He’s been failed in my eyes.’
Those detained are not supposed to die in prison due to neglect. In fact, health care provision in secure environments is supposed to be of an ‘equivalent’ standard to that provided in the wider community.
The Coroner’s Report on Brandon Johnson who died in Wandsworth Prison on 12 September 2019 age 40 was published on 2 October 2024. The Report states:
Medical Cause of Death
I (a) Cardio-Respiratory Failure
1(b) Ischaemic Heart Disease
1(c) Coronary artery atheroma and left ventricular hypertrophy
1(d) Chronic cocaine misuse
2 Schizophrenia, chronic substance misuse
Below the heading MATTERS OF CONCERN the Coroner writes: ‘I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells.’
There is no mention of the care required by Mr Johnson nor the care actually provided to Mr Johnson for any of these serious health issues. The report does not contain one word about what care (or lack of care) Mr Johnson received in prison. It deals only with the checks which should have been made to ascertain if he was alive.
In a long list of cases of deaths in prison I have found that the Coroners’ Reports comment on the checking up system and are entirely silent on the care that should have been provided to those detained by the state and in need of medical care. The lack of care for those in prison is often shocking. I have written before about the imprisonment and death of Floyd Carruthers whose death after neglect in prison should have led to headlines, television coverage and questions in parliament: in fact there was silence. He had been diagnosed with schizophrenia in 2003.
In April 2021 he breached an Anti-Social Behaviour Injunction by banging twice on his neighbour’s door, first at 17.30 and again at 19.30. He was sent to prison for 66 days for breaching an Anti-Social Behaviour Injunction, although the judge stated ‘there is no evidence of any criminality’. Mr Carruthers had an infected heart valve; he did not eat in the prison for four days. No medical personnel were called. When prison officers entered his cell they found he had collapsed. He died in hospital on 14 June 2021.
Matthew Braben was 30 when he took his own life at HMP Wormwood Scrubs. The Coroner’s report states:
Matthew’s death was probably the result of systemic failures across multiple agencies including the Prison services. … [There was a] a failure to identify his deteriorating mental health and increasing suicide risk. … Despite concerns raised by a highly engaged, caring and supportive family, it is probable insufficient weight was given to their attempts to raise the alarm.
Yasmin Adams was 25 years old when she took her own life at HMP Foston Hall. The Coroner stated:
During Yasmin’s second prison term the majority of prison staff were not aware of her mental health and learning disability diagnoses but should have been informed of these by prison healthcare. There should have been consideration for Yasmin’s care to be managed as an enhanced or complex case under the ACCT arrangements. The duty governor should have considered whether to terminate cellular confinement having been updated about Yasmin on 12 November 2016.
Healthcare should have been informed of and attended all post self-harm incidents.
There should have been documented consideration for involvement of Yasmin’s family in the ACCT process.
All prison staff should have been provided with basic mental health awareness training. Basic first aid training to prison staff should have included instruction in CPR (Cardiopulmonary Resuscitation). Assessment of risk for prisoners who self-harmed should have included a clear documented environmental risk assessment of cells.
Connor Hoult was 24 years old when he entered HMP Wakefield. During the night of 10 June 2019 he took his own life in his prison cell. Prison officers were supposed to conduct ‘welfare checks’ on him during the night and in the morning.
The Coroner’s Report states:
No response is required … from prisoners who appear to be asleep in bed.
At 9.50 am an officer entered the cell to ‘seize some unauthorised footwear’ and found that Connor had been dead for some hours. The Coroner’s Report makes no mention of what support or therapy is or should be available in the prison for men, such as this young man, at risk of suicide.
Alan Davies died in HMP Cardiff having been refusing food. On 25 March 2024, the Coroner’s Report stated that he was transferred to HMP Cardiff from Caswell Clinic on 2 September 2021. Caswell Clinic is a medium secure, forensic mental health unit for men and women. So the prison knew it was receiving an ill man. Ten days later he was found collapsed in his cell; he died in hospital. He had been refusing food but had not intended to end his life. The Coroner’s Report states:
There were missed opportunities regarding the transfer of Mr Davies to hospital. The management, coordination and planning of Mr D’s care … was unsatisfactory.
On camera call on the Healthcare wing, Mr Davies’ calls for ‘help’ while lying on the floor of his cell were not recognised or heeded from 00.19 on 12th September 2021 until it was identified that he was in a collapsed state at about 02.54.
Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP Cardiff.
No clear plan to promote Mr Davies’ engagement with prison medical services, or the assessment of his mental or physical condition was devised or implemented at HMP Cardiff.
The Health Care assistant caring for Mr Davies overnight overheard more senior prison staff saying that they would not return to assist Mr Davies in healthcare, and but the Health Care assistant felt unable to challenge this.
The Coroner stated:
Mr Davies died from an equal combination of misadventure, self-neglect and neglect.
Martin Willis took his own life at HMP Stoke Heath. The Coroner’s report was published on 1 April 2024.
Once again, the Coroner reports a suicide in prison where there were no observations and no care. The conclusion of the inquest was that Mr Willis died from hanging while a prisoner at HMP Stoke Heath. The narrative conclusion was that:
Mr Martin Willis took his own life, in part because the risk of him doing so was not reported, communicated and the precautions in place were insufficient to prevent him doing so whilst the balance of his mind was disturbed. The ACCT procedure was not properly implemented, complied with or supervised. A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.
Appalling statistics
On 26 October 2023 the Ministry of Justice released the latest quarterly statistics on deaths and self-harm in prison in England and Wales. They show the number of self-inflicted deaths in prisons rose by 24% in the 12 months to from September 2022 to September 2023.
There were a total of 304 deaths of people in prison during this period, 92 of which were self-inflicted. Every four days someone takes their own life in a UK prison. The statistics also show that self-harm is once again rising across prisons, with the starkest rise of 63% in the women’s estate.
Rosanna Ellul, Policy and Parliamentary Manager at INQUEST, said:
These appalling statistics are yet another indictment of our unsafe prison system. Yet while these figures should be a sobering reminder of the inherent harms of prison, the government are determined to expand the prison estate by 20,000 places. As the prison population grows, we know the number of preventable deaths in prison will too. Successive governments have failed to properly consider measures to reduce reliance on prisons and, in the process, save lives. In the short-term, urgent action is needed to ensure people in prison have access to healthcare and adequate support. In the long term, we need a dramatic reduction of the prison population and more investment in alternatives which prevent harms in our society, rather than cause more harm.
As Rosanna Ellul, quoted above, points out we need a reformed criminal justice system, with a dramatic reduction in the numbers sent to prison. At the recent Labour Party conference the Prisons Minister Lord Timpson said that the government is moving quickly to review how courts sentence offenders. He suggested that community sentences should be ‘trusted more by the courts.’ This will require investment in all the community support services that are needed to provide convincing and effective alternatives to imprisonment. This investment will most probably be considerably lower than the anticipated cost of building a number of new prisons and the £50K per prisoner per year ‘maintenance’ cost of imprisonment acknowledged by Alex Chalk, former Conservative Prisons Minister.
We can only hope that money will speak, if ethics and principles do not, and that James Timpson’s words will be matched by action. Delays will cost lives.
