Four lives, four deaths. Neglect in our prisons

In fact, health care provision in secure environments is supposed to be of an ‘equivalent’ standard to that provided in the wider community. So let us consider four men and their deaths.

I have written before about Floyd Carruthers. There should have been anger and demand for change after he died in hospital having been found collapsed in his prison cell. In fact, there was silence.

He had not committed any crime, the judge at Birmingham County Court who ordered him to prison for 66 days stated ‘there is no evidence of any criminality’. He had breached an Anti-social Behaviour Injunction only once. He had been living with mental illness for 20 years and had also had a heart valve replacement. The Coroner’s report states:

The staff on Lima Wing and the HMP Birmingham Healthcare staff took insufficient steps to safeguard Mr Carruthers throughout the period 10.5.2021 to 29.5.21. This includes insufficient record keeping, handover and escalation of events, such as missed meals and not leaving his cell… death was contributed to by neglect.

Connor Hoult was only 24 years old when he entered HMP Wakefield. During the night of 10 June 2019 he took his own life in his prison cell. The 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 at risk of suicide.

On 25 March 2024, the Coroner’s Report on Alan Davies was published. Mr Davies 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’ vocalised requests 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 stating that they would not return to assist Mr Davies in healthcare, and felt unable to challenge this.

The Coroner stated: ‘Mr Davies died from an equal combination of misadventure, self neglect and neglect’.

Martin Willis: Prevention of future deaths report was published on 1 April 2024.

Yet 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.

On 26 October 2023 the Ministry of Justice released the latest quarterly statistics on deaths and self-harm in prison in England and Wales. Those 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.

Context

The context is the appalling state of our prisons, a shameful blot on our society. There have been two recent reports by the Prison Inspectorate which have been truly shocking.

The Inspectorate found conditions in HMP Wandsworth ‘degrading and inhumane’, (thus violating the European Convention on Human Rights, Article 3). Their report details vermin and rodents running live throughout the prison, including in the kitchen, broken windows and tiles, toilets in cells overflowing sewage on to the floor. This was the topic of a powerful Channel 4 news report.

In the women’s prison HMP Eastwood Park the Inspectorate found mentally ill women held in cells with blood spattered walls – the blood having been left uncleaned after self-harm incidents by previous prisoners. Charlie Taylor, Chief Inspector, said:

Some of the most vulnerable women across the prison estate were held in an environment wholly unsuitable for their therapeutic needs. The levels of distress we observed were appalling. No prisoner should be held in such terrible conditions.

Looking ahead

As Rosanna Ellul, quoted above, points out we need a reformed criminal justice system, with a dramatic reduction in the numbers sent to prison, and very extensive investment in the alternatives to custody. They exist, they are effective and they should be available to all sentencers in every criminal court.

Rona Epstein is an Honorary Research Fellow at Coventry Law School, Coventry University and Honorary Visiting Research Fellow at York Law School, University of York.