*UPDATE on 14 October: the inquest has now been adjourned. Expected to resume in February. 

10 October 2019

Before HM Assistant Coroner for Cambridgeshire and Peterborough, Simon Milburn
Huntingdon Town Hall, 53 High St, Huntingdon PE29 3AE* 
Opens 14 October 2019, expected to last one week
Charlotte Nokes was 38 when she died at HMP Peterborough, a private prison run by Sodexo. On 23 July 2016 she was found unresponsive in her cell and was pronounced dead at 8.55am. The inquest into her death opens on Monday 14 October at Huntingdon Law Courts.
Despite being sentenced to a minimum term of 15 months, Charlotte had been in prison for over eight and a half years at the time of her death on an indefinite Imprisonment for Public Protection (IPP) sentence. IPP sentences were abolished by the Government in 2012 for new prisoners but remain in place for those sentenced prior to this date. Her family say she felt she would never be released from prison and she described the IPP sentence as a death sentence. It is understood that Charlotte is the first person to have died in a women’s prison whilst serving an IPP sentence.
Charlotte was born in Hayling Island in Hampshire. Known to her family as Charlie or Lottie, they described her as funny, intelligent, charismatic and creative. Charlotte was also an incredibly talented artist. Her artwork was supported by charities such as the Michael Varah Memorial Fund and the charity Women in Prison. Her art was exhibited by the Koestler Trust, a charity which helps people who have spent time in prison, immigration detention and mental health settings to express themselves creatively. Charlotte’s dream was to live in London and study art.
Charlotte had mental and physical health diagnoses including Borderline Personality Disorder and Premenstrual Dysphoric Disorder (PMDD, a severe form of premenstrual syndrome). In the months leading up to her death, Charlotte was prescribed heavy doses of medication to treat her mental and physical health that often left her appearing heavily sedated. She was under suicide and self-harm monitoring procedures (known as ACCT) at the time of her death.
Her family hope the inquest will explore the following issues:

  • the cause of Charlotte’s death;
  • the treatment of Charlotte’s mental health in HMP Peterborough, including the monitoring of the impact of the drugs she was prescribed on her physical health;
  • the use of segregation in HMP Peterborough;
  • Charlotte’s cell observations on 22-23 July 2016;
  • the temperature of Charlotte’s cell on 22-23 July 2016.

Charlotte’s family are still crowdfunding for the preparation costs of her inquest. You can donate to the fundraising page here.


*Please note change of venue from Huntingdon Law Courts

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.
Other deaths of people on IPP sentences include:

  • Steven Trudghill, 23, who died at HMP Highpoint on 9 January 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”.
  • 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.

Since Charlotte’s death in July 2016, there have been four further deaths in Peterborough (women’s) 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 contributed to her death. Media Release.

IPP sentences

  • 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.
  • In November 2016 HM Inspectorate of Prisons completed a review of the ongoing challenges of managing and progressing the large number of prisoners still serving IPP sentences. They found IPP prisoners fell into three broad categories:
    • those who had not reduced their risk and remained dangerous,
    • those who could reduce their risk if the support provided by the system was delivered more efficiently,
    • those who might be deemed ready for release if delays and inefficiencies in the offender management and parole processes were resolved.
  • The Parole Board noted in October 2017 that more than half of those released had being sent back to jail for breaching licence conditions. There were suggestions in the 2016 HMIP review (above) that this could be linked to a lack of access for people on IPP sentences to temporary release (ROTL) to prepare for leaving prison.
  • On 20 July 2018, the Parole Board reported that around 2,800 people remain in prison on an IPP sentence. People on IPP sentences also have particularly high rates of being recalled to prison, according to reports.