3 March 2020

Before HM Assistant Coroner Simon Milburn
Huntingdon Town Hall
24 February – 3 March 2020

The inquest into the death of Charlotte Nokes has today concluded with the jury finding her death was by ‘natural causes’. Charlotte was 38 when she was found dead in her cell in HMP Peterborough on the morning of 23 July 2016. She was serving an indefinite Imprisonment for Public Protection (IPP) sentence and was over seven years over the minimum tariff when she died.

The jury concluded the medical cause of Charlotte’s death was “Sudden Arrhythmic Death Syndrome”. The coroner’s decision on whether to write a follow up report to Prevent Future Deaths is awaited. The family hope their concerns around the adequacy of cell observations, and the risk of suicide for IPP prisoners, will be highlighted.

Known to her family as Charlie or Lottie, they described her as funny, intelligent, charismatic and creative. She was an extremely talented artist whose work was exhibited by the Koestler Trust. She developed her passion for art whilst in prison and had been offered a scholarship to study at Central St Martins on release.

Charlotte was given an IPP sentence on 4 January 2008. She was to serve a minimum term of 15 months imprisonment. However, at the time of her death, she had served 8½ years in custody. The jury heard that the indefinite nature of Charlotte’s sentence, and her fear that she would never be released from prison, contributed to a sense of extreme hopelessness. She described her sentence to her family as a death sentence. The inquest heard that despite being seven years over tariff, Charlotte was only at the very early stages of being ready to engage with the therapeutic help she needed to begin the path to release.

The inquest heard that Charlotte had been diagnosed with a Personality Disorder and was prescribed a number of antipsychotic drugs to treat her symptoms. In the months leading up to her death, she often appeared over-sedated, drowsy and was slurring her speech. The jury heard that some of her depot medication was administered for unusually long periods.

At the time of her death, Charlotte was placed on suicide and self-harm monitoring procedures, known as Assessment, Care in Custody and Teamwork (ACCT) after she had attempted to take her life. Charlotte was on twice hourly observations as part of the ACCT process. Despite this, the inquest jury heard that she died a number of hours before she was found at 08:35, despite documented welfare checks throughout the night and concerns about her welfare.

On the morning of 23 July 2017, Charlotte was checked at 07:23, 07:53 and 08:12. She was noted to be asleep in an upright position. At 08:30 another officer looked through the observation panel to Charlotte’s cell. She noted that Charlotte appeared to have been in the same strange sleeping position as the night before – she was sitting upright and slumped forward. She unlocked Charlotte’s cell and called her name. There was no response. She called Charlotte’s name and again there was no response. She then shook Charlotte’s shoulder and noticed that she was cold to touch, her whole body was stiff and her face was “very red and dark purple, further than bruising”. She raised the alarm. Paramedics arrived but by that time Charlotte could not be resuscitated. She was pronounced dead at 08:55. The evidence of the pathologist was that Charlotte had died some time before she was discovered, possibly 3-4 hours earlier.

On behalf of her family, Charlotte’s father Steven Nokes said: “As a family, we remain concerned about the way Charlotte was treated in prison and do not believe the care she received was appropriate. She had many struggles in life, was beaten up for being ‘different’ and experienced mental ill health. Prison was never the best place for her. The indefinite sentence only made this worse. Charlotte lost hope and so did we. She told us the IPP sentence was really a life sentence, and despite her hopes and dreams of moving to London to study art, she knew she would die in prison. This cannot continue.”

Steven spoke in detail to The Guardian during the inquest.

Deborah Coles, Director of INQUEST, said: Charlotte was trapped in limbo, her ambitions and prospects indefinitely on pause. She was forced to wait for action to truly end IPP sentences, despite them having long been deemed unlawful and ‘abolished’. Had she not died it is likely she would have still been in prison waiting for that action, as many others are.

For far too many women, prison remains a disproportionate and inappropriate response to their behaviour and needs. Indefinite sentences continue to cause additional harm. To prevent further deaths and harm, Government must work across health, social care and justice departments to dismantle failing women’s prisons and invest in specialist community led women’s services.”

Tara Mulcair of Birnberg Peirce who represents Charlotte’s family said: “Charlotte’s inquest has shone a light on the injustice faced by IPP prisoners. Charlotte was caught in a vicious cycle of indefinite incarceration, which created a strong sense of hopelessness and exacerbated her poor mental health, which in turn led to her continued detention.  In Charlotte’s mind, there was no prospect of release, as is the case for many still serving IPP sentences. There should now be an urgent review of all IPP prisoners who are over tariff and were sentenced before the Courts recognised that these sentences are unlawful. It is time to put right this injustice.”


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

Charlotte’s family are represented by Inquest Lawyers Group members Tara Mulcair and Harriet Wistrich of Birnberg Peirce and Stephen Clark of Garden Court Chambers. The INQUEST caseworker is Selen Cavcav. 

The other Interested Persons represented at the inquest are Sodexo Justice Services, Cambridgeshire and Peterborough NHS Foundation Trust and the prison GP.

INQUEST recently published a new report exposing the national scandal of deaths in prison, many caused by neglect and repeated failures. The evidence is gathered from our casework with bereaved families and our monitoring of inquests - illustrating the repeated failings and providing a unique insight into the harms and dangers of imprisonment. Learn more.

Women’s Prisons

INQUEST is calling for urgent action to save lives by ending the inappropriate use of imprisonment for women, closing women's prisons and redirecting resources from criminal justice into community-based services. Learn more about our recent reports and campaigns on women’s prisons.

IPP sentences

It is understood that Charlotte is one of four women to have died whilst serving an IPP sentence. There has been significant public concern over the use of IPP sentences which have been described as the most controversial sentences in the history of British prison sentences. They were found to be unlawful by the House of Lords and were abolished in 2012. However, those who were sentenced before 2012 have languished in prison for many years after the end of the tariff with no release date. 

  • IPP sentences came into use on 4 April 2005, as part of section 225 of the Criminal Justice Act 2003, introduced by then Home Secretary, David Blunkett.
  • In 2007 the Queen's Bench Division of the High Court ruled that the continued incarceration of prisoners serving IPPs after tariff expiry where the prisons lack the facilities and courses required to assess their suitability for release was unlawful.
  • In 2010 a joint report by the chief inspectors of prisons and probation concluded that IPP sentences were unsustainable for prisons in the UK.
  • On 3 December 2012 the IPP sentence for new cases was abolished by the Legal Aid, Sentencing and Punishment of Offenders Act.
  • In November 2019 it was reported that there are still 2,223 people serving IPP sentences who have yet to be released (93% over the original tariff) and a further 1,206 serving an IPP sentence who are back in prison having been recalled while on licence. Of those, 93% are still in prison having passed their tariff expiry date.
  • Women in Prison report that on 30 June 2019 there were 42 women remaining in prison on an IPP sentence. Nearly 80% of IPP sentences for women were for offences of arson, which is often an indicator of serious mental illness or self-harm.

Other deaths of people on IPP sentences include:

  • David Dunnings, 35, died a self-inflicted death whilst at HMP Coldingley in 2017. He was on an IPP sentence and significantly over tariff. In their investigation the Prisons and Probation Ombudsman found that ‘the uncertainty about how long he might have to remain in prison were significant sources of anxiety to him’. Media release.
  • Shane Stroughton, 29, died a self-inflicted death on 13 September 2017, whilst a prisoner at HMP Nottingham. Aged 19 he was given an IPP sentence for a minimum two and a half years but had remained in prison for nearly ten before being released in June 2017. He was recalled to prison shortly after release. The jury found serious failures in the suicide and self-harm monitoring procedures and in communication with Shane’s family. Media Release.
  • Kelvin Speakman, 30, died of self-inflicted injuries at HMP Hewell on 9 May 2016. He had a history of mental ill health and drug and alcohol dependence. Kelvin had been sentenced in 2007 for a minimum of two years but had been in prison for nine when he died. His family spoke to the Guardianabout his experiences.
  • Tommy Nicol, 37, was found with a ligature in his cell at HMP The Mount and died four days later in hospital in September 2015. Tommy made a complaint to the prison six months prior, in which he described his inability to progress in his IPP sentence towards release as “psychological torture”. Media Release.
  • Steven Trudghill, 23, was found hanging in his cell at HMP Highpoint in 2014. The coroner at the conclusion of the inquest wrote a Prevention of Future Deaths report addressed to the Ministry of Justice, which raised concerns about other prisoners on IPP sentences who were at continued risk. He said, it is the “case that there are complex mental health needs which might actually be the reason for the continuing risk that keeps them in custody, as with Steven, yet the specific treatments are not available within the prison system”.

Since Charlotte’s death in July 2016, there have been four further deaths of women in Peterborough prison, of which one was self-inflicted, one is awaiting classification and two were non-self-inflicted.

  • Annabella Landsberg, 45, died at HMP Peterborough in September 2017. Her death was non self-inflicted and the jury found “failings on the part of the prison, healthcare staff, GPs and custody officers that contributed to her death. Media Release.