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‘Natural Causes’ deaths in prisons – are changes happening fast enough?
7 Jul 2021
Following the recent ‘File on Four’ broadcast ‘A Death Sentence?’ which features the death of Tariq Dalton at HMP Highdown in November 2018, Imogen Mellor considers the issue of ‘natural causes’ deaths in prisons more widely, and looks at how the inquest process seeks to bring about change.
Imogen is currently in her first six specialising in family and immigration, with a keen interest in inquests and inquiries. She will be commencing second six in October 2021.
It is easy to take for granted the fact that in a medical emergency, it is possible to call an ambulance or visit A & E. It is also easy to take for granted that if we had a medical query, we would be able to see a GP or even a specialist. We take it for granted that a medical complaint that we might have would be taken seriously and treated with the appropriate medication and care. However, the likely case is that most of the readers of this article are not detained in prison. In that situation, prisoners are completely dependent on prison staff and medical teams to meet their needs, leaving them in a particularly vulnerable position. Despite this vulnerability, statistics have shown that prisoners do not receive the same level of care as those in the community. This can expose prisoners to serious harm and, in the worst cases, death.
Year on year many of the ‘natural causes’ deaths occurring in prisons have been found to have been avoidable and premature. Far from being ‘natural’, many of these deaths may have been brought about in circumstances that are in breach of Article 2 ECHR that protects the right to life, or through negligence. Indeed, in a report by INQUEST it was concluded that the state has failed on numerous occasions to provide basic medical care. The data sample related to 61 inquests of deaths which occurred between December 2013 and January 2019. The Prisons and Probation Ombudsman (PPO) in its annual report (2019/2020) corroborated that there have been systemic failures in medical care, stating that “just over half of all the recommendations we made as a result of our fatal incident investigations into deaths from natural causes were about the need for improvements in healthcare.”
Such shortcomings include poor communication between healthcare, mental health and prison staff and the inadequate recording and sharing of important medical and mental health related information. These issues clearly existed before the above reports by INQUEST and the PPO in 2019/2020. As an example, an investigation by the PPO into the circumstances surrounding the death of a man in HMP Winchester in 2006 made recommendations that “Clinical records should always accompany prisoners who are transferred directly from one healthcare inpatient unit to another.” In that case, the deceased had been transferred from Bullingdon to Winchester so that he would be provided with better care. However, his medical notes were not transferred for approximately one week, which impacted Winchester’s ability to care for him. Although the delay in the transfer of records could be likened to someone in the community registering with a new doctor, in this case it was concluded that since he was transferred for the purposes of receiving better care, it followed that his records should have been transferred with him.
The 2019/2020 INQUEST report raised concerns regarding insufficient medical screenings and action of staff during medical emergencies. Further, failure to recognise and review existing health conditions has been a recuring issue. For example, Annabella Landsberg, 45, died in HMP Peterborough in 2017, following severe dehydration and organ failure relating to Type 2 diabetes. She had been lying unresponsive on the floor of her cell for 21 hours with staff failing to recognise her condition. A nurse threw a cup of water over her, believing her to be faking her illness, rather than conduct any physical observation, as she was called upon to do. The inquest jury concluded that there had been several serious failures in the management and healthcare systems at the prison.
These issues are not new either. In a PPO report (2011), in which data was collected from 402 PPO investigations into natural causes deaths conducted between 1 January 2007 and 31 December 2010, weaknesses and areas of improvement were identified, including the “quality of prisons’ emergency responses to those in serious clinical need”. In terms of emergency responses, failures included a lack of access to emergency equipment and staff with first aid training, as well as delays in entering cells and trained professionals attending the scene. Learning was deemed necessary in 34% of the cases where an emergency response was required. Similar to the most recent INQUEST and PPO reports, the 2011 PPO report identified failures in monitoring long-term health conditions and in making referrals to appropriate medical staff. In as many as 40% of investigations into the deaths of prisoners under the age of 45 years, it was found that a proper and timely investigation of symptoms did not happen.
The same themes were also highlighted in PPO 2016/2017 report, where it was noted that there were “instances of healthcare staff failing to make urgent referrals to specialists when they had concerns that a prisoner might have cancer. Delays can prevent early diagnosis, early treatment and even result in unnecessary deaths. Similar problems arose when healthcare staff failed to review and treat abnormal blood test results”
It is deeply concerning that lessons are not being learned despite the same recommendations being made year after year. This is evidenced by the fact that the numbers of death by natural causes are increasing rather than decreasing. In 2009, 2010 and 2011, the number of deaths due to natural causes was 101, 123 and 127 respectively. Between 2015 and 2016 natural causes deaths rose by 39%. And though there was a 10% fall between 2016 to 2017, the number of deaths in 2017 was still incredibly high at 184. In 2020 there were 207 deaths due to natural causes (a rate of 2.6 per 1,000 prisoners), which is an 18% increase from 175 deaths in 2019. Of course, covid-19 probably contributed to this number, although it should be remembered that even if the cause of death was the virus, some of these deaths might have been preventable if appropriate measures were taken.
When a person dies in prison or detention an inquest will follow. Inquests can be a vital means of assessing what mistakes, if any, have been made. Moreover, paragraph 5 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to organisations or agencies, where the coroner believes that action should be taken to prevent future deaths. Analysing data from inquests can help shed light on whether lessons have been learned or whether similar mistakes and errors continue to occur.
However, the type of inquest held will vary depending on whether the case is held to engage Article 2 ECHR or not. Where a natural causes death engages Article 2, the jury or coroner can comment on ‘how and in what circumstances’ the deceased came to their death, as opposed to just answering ‘how’ the deceased came to their death in non-Article 2 cases. In Tyrell v HM Senior Coroner County Durham and Darlington and MOJ  EWHC 1892 (Admin) it was held that Article 2 “would not arise in any case where it is established that the death arose from natural causes and there is no reason to believe that the state failed to protect the life of a prisoner in question…” This includes providing timely and appropriate medical care which is equivocal to that which would have been obtained by the deceased if they were in the community. The conduct of the State, and any preliminary assessments as to the care given are therefore incredibly important tools to assess whether Article 2 ECHR is engaged. Such a decision can be influenced by clinical reviewers prior to the inquest when they categorise deaths as either “foreseeable” or “unforeseeable”.
The full involvement of the deceased’s loved ones can be a vital driving force behind an inquest appropriately scrutinising the state’s involvement in their death. This in turn can expose systemic weaknesses in the prison system and hopefully influence positive change. However, seeking the truth is no easy feat. The families are up fighting against Goliath: the prison service and public bodies. As INQUEST noted:
“There are unlimited public funds available to the Prison Service, and other public bodies whose conduct may be brought into question. NHS commissioning of prison healthcare and other services and the increasing involvement of the private sector has added to the number of legal teams defending the interests and reputations of state and corporate bodies. These teams too often work together to shut down or narrow lines of enquiry and argue against critical conclusions and recommendations.”
Moreover, there is an inequality in arms as between the families and the public bodies. Families often do not benefit from legal aid which could at least to some small extent balance the inequality. In 2017, only £92,000 of the MoJ’s £4.2million budget for Prison and Probation Service legal representation at prison inquests was given in legal aid to bereaved families through the Exceptional Case Funding scheme. This is a devastatingly low figure, which might have prevented families engaging with the process and pushing for much needed answers.Back to News