28 May 2024

Before HM Senior Coroner Maria Voisin
Avon Coroner’s Court, Bristol
Hearing: 19-27 February 2024

Ann-Marie Roberts, 51, died of a serious complication of diabetes only two weeks after arriving at HMP Eastwood Park. She was remanded to custody during a mental health crisis. Now an inquest has found that her death was due to natural causes (diabetic ketoacidosis). 

Ann-Marie’s death is one of 16 deaths at the women’s prison in Gloucestershire since 2016. The average age of the women who died was just 42. 

Ann-Marie enjoyed going on walks and was a talented artist. Her family describe her as a sociable person who loved going out, meeting and talking to new people.  

Ann-Marie’s mental health declined while she training to be a nurse. She had bipolar disorder and a history of mental ill health. She also had Type 2 Diabetes which she managed well in the community. 

She went from being supported in the community to living alone without support, and her mental health deteriorated. Ann-Marie became increasingly unwell, lost a lot of weight and was vomiting regularly. 

On 12 July 2021, Ann-Marie was remanded to HMP Eastwood Park due to an incident that occurred during an acute mental health crisis. She was remanded despite concerns raised regarding her mental health, capacity and the fact that she had never been in contact with the police before. 

The inquest did not explore whether her remand to custody was appropriate and whether Ann-Marie would have been better placed in a mental health hospital rather than a prison cell. 

At an initial health screen, a prison nurse noted that Ann-Marie had Type 2 Diabetes. No care plan was put in place for the management of Ann-Marie’s diabetes. Ann-Marie also disclosed that she felt depressed and suicidal. A safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place.

On 14 July, a prison GP reviewed Ann-Marie’s blood test results which showed high blood glucose levels. The GP arranged for a healthcare review on 27 July. 

During Ann-Marie’s early days in custody, numerous members of staff including mental health key workers and substance misuse assessors noted that it was difficult to hold a conversation with Ann-Marie. They noted that she struggled to give an accurate picture of her mental and physical health. 

As a result, it was decided that Ann-Marie required additional mental health support. However, evidence at the inquest suggested that Ann-Marie had no meaningful engagement with the mental health team prior to her death.

On 19 July, Ann-Marie told a prison officer that she was unable to keep her medication down. Three days later, Ann-Marie complained to prison officers of stomach pain. She was simply offered paracetamol. 

The next day, on 23 July, Ann-Marie again told staff that she was not feeling well, felt hot and had a headache. 

Giving evidence at the inquest, the wing orderly said that she saw Ann-Marie that day and that she “had always seemed unwell and confused about where she was and why.” None of this information had been passed on to the prison healthcare team. 

The expert endocrinologist instructed by the coroner observed that feelings of tiredness and generalised weakness, shortness of breath, abdominal pain, confusion and drowsiness and vomiting are all symptoms of worsening diabetic ketoacidosis. 

They also gave evidence that the mortality rate from diabetic ketoacidosis is less than 2% and that early treatment is highly effective.

Despite this, the inquest heard evidence that prison officers had failed to share any information relating to Ann-Marie’s presentation with the healthcare staff at the prison. 

During the night of 24 July, prison staff gave evidence that they checked on Ann-Marie as part of ACCT monitoring. According to the CCTV evidence, the majority of these checks consisted of a cursory glance through the ‘hatch’ of Ann-Marie’s cell door, some of which were as short as a second. 

At approximately 2.30am, a prison officer attempted to speak with Ann-Marie as she noticed that her curtain rod had fallen to the floor. Ann-Marie did not respond, and it was noted that she was ‘staring into space’. No steps were taken by the prison officer following this interaction.

At approximately 7am, a prison officer noted that Ann-Marie was in a strange position and raised this with the two other prison officers who had been conducting checks throughout the night. 

The same officer returned to Ann-Marie’s cell on four further occasions within 13 minutes. In his witness statement, he stated that he was not quite sure whether or not Ann-Marie was breathing. 

Despite his concerns, no one entered Ann-Marie’s cell until another prisoner raised concerns with staff about her welfare at 9.13am. Officers unlocked her cell and found Ann-Marie unresponsive. 

When healthcare staff arrived, they called an ambulance and began CPR. Ann-Marie was pronounced dead at the scene. The inquest heard evidence it was likely Ann-Marie had been dead since the 7-8am observations. 

Giving evidence, the expert endocrinologist noted that if Ann-Marie had been admitted to hospital between midnight and 3am, she likely would have survived.  

The jury concluded that Ann-Marie died of diabetic ketoacidosis. To the family’s disappointment, they returned a short form natural causes conclusion without any criticism of the prison or healthcare.

Tracey Greig, Ann-Marie’s sister, said: “My sister, Ann-Marie passed unexpectedly and undoubtedly in very traumatic circumstances. I had felt things weren’t right, and I had many questions surrounding her death. 

Throughout the inquest I was shown just how much the system had failed Ann-Marie. Excuses were made, backs covered, no responsibility taken for lack of actions that could have saved her. 

I believe things could have been done by the prison officers and healthcare team that would have been done had it been a family member of their own. To treat another human being the way she was treated is beyond appalling. 

She was in a cell on her own, very poorly, without being monitored correctly all night until she eventually went into a coma and tragically died. 

As a person who struggled with her mental health long term, she needed to be in hospital or at the very least monitored as a patient. There was a massive lack of empathy and care towards my sister and then lack of responsibility and accountability. 

Grieving for a loved one is hard enough but to have to accept such actions towards your family member is beyond pain. These kinds of actions and lack of the compassion, care and respect that one human being should have towards another has to change.”

Erica San, at Bhatt Murphy Solicitors, said: “The evidence heard at the inquest demonstrated that the prison complex is an entirely inappropriate environment for a vulnerable woman like Ann-Marie, who had complex physical and mental health needs. 

The HM Chief Inspector of Prisons had recently found that not enough was being done at HMP Eastwood Park to implement the PPO’s numerous recommendations regarding their officers’ failures to enter a cell without undue delay when there was a risk to life: Ann-Marie’s death is another sad example of this. 

Despite multiple prison officers having clear concerns regarding Ann-Marie’s wellbeing, it was only when another prisoner raised concerns about Ann-Marie’s unresponsiveness that a prison officer finally entered her cell to find that she was not breathing.”

Jodie Anderson, Senior Caseworker at INQUEST, said: “Over seventeen years on from the Corston Review into the deaths of vulnerable women in the criminal justice system and we are no closer towards the radical alternatives and women-centred approaches to crime and punishment. 

The recommendations made then are needed now more than ever, with many women feeling the devastating effects of austerity, decimated public services and the criminalisation of mental health and substance misuse. 

Ann-Marie entered Eastwood Park and just weeks later died from a very treatable condition. The lack of empathy and care shown by staff over that time points to a prison estate devoid of humanity.

We must turn our efforts to ensuring more sustainable alternatives are created for women, than these existing broken structures.”

ENDS

NOTES TO EDITORS

For further information, please contact [email protected]  

A photo of Ann-Marie for media use is available here

The family is represented by INQUEST Lawyers Group members Megan Phillips and Erica San of Bhatt Murphy Solicitors and Christopher Johnson of Doughty Street Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.

Other Interested persons represented are HMP Eastwood Park and Avon and Wiltshire Mental Health Partnership NHS Trust.

In 2023, HMIP published an inspection report following a visit to Eastwood Park prison in 2022. Charlie Taylor, Chief Inspector of Prisons, 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.” 

Eastwood Park held 348 women at the time of the inspection, 83% of whom reported having mental health problems. Self-harm was very high, but case management documents to support those at risk of self-harm and suicide were poor. The prison received the lowest grade for safety, which is unusual in the women’s estate.

Other similar cases

• Annabella Landsberg, 45, had Type 2 diabetes and died from related complications in hospital on 6 September 2017 after being found unresponsive in her cell at HMP Peterborough. The inquest into her death found a catalogue of serious failures in HMP Peterborough, a private prison run by Sodexo. 
• Serena Maria Nicolle, 52, died at HMP Bronzefield on 3 September 2018. The inquest into her death heard concerning evidence about Serena’s treatment at the prison. The coroner concluded that Serena “died suddenly due to Hypersensitive Heart Disease, contributed to by chronic conditions of Diabetes, Sleep Apnoea and Obesity.”