22 January 2020

Every four days a person takes their life in prison, and rising numbers of ‘natural’ and unclassified deaths are too often found to relate to serious failures in healthcare. The lack of government action on official recommendations is leading to preventable deaths.

Deaths in prison: a national scandal exposes dangerous, longstanding failures across the prison estate and historically high levels of deaths in custody and offers unique insight and analysis into findings from 61 prison inquests in England and Wales in 2018 and 2019.

The report details repeated safety failures including mental and physical healthcare, communication systems, emergency responses, and drugs and medication. It also looks at the wider statistics and historic context, showing the repetitive and persistent nature of such failings.

With case studies of deaths and inquest findings, it tells the harrowing human stories behind the statistics (see page 9). INQUEST also details the experiences of bereaved families who struggle to access minimal legal aid for inquests, while prisons automatically receive millions in public funding.


The report sets out the following recommendations to improve safety and prevent future deaths:

1. Halt prison building, commit to an immediate reduction in the prison population and divert people away from the criminal justice system.

2. Prison staff, including healthcare staff, require improved training to meet minimum human rights standards to ensure the health, well-being and safety of prisoners.

3. Ensure access to justice for bereaved families through the provision of automatic non-means tested legal aid funding for specialist legal representation to cover preparation and representation at the inquest and other legal processes. Funding should be equivalent to that enjoyed by state bodies/public authorities and corporate bodies represented.

4. Establish a ‘National Oversight Mechanism’ – a new and independent body tasked with the duty to collate, analyse and monitor learning and implementation arising out of post death investigations, inquiries and inquests. This body must be accountable to parliament to ensure the advantage of parliamentary oversight and debate. It should provide a role for bereaved families and community groups to voice concerns and provide a mandate for its work.

5. Ensure accountability for institutional failings that lead to deaths in prison. For example, full consideration should be given to prosecutions under the Corporate Manslaughter and Corporate Homicide Act, where ongoing failures are identified and the prison service and health providers have been forewarned. The reintroduction of The Public Authority (Accountability) Bill would also establish a statutory duty of candour on state authorities and officers and private entities.


Deborah Coles, Director of INQUEST, said: “This report exposes indefensible levels of neglect and despair in prison. Officials and Ministers repeat the empty words that ‘lessons will be learned’. Yet the recommendations of coroners, the prison ombudsman and inspectorate are being systematically ignored. This is a national scandal.
 
The personal stories of those who died show prisons failing in their duty of care towards people long failed by struggling health, education, welfare and social services. The system is also failing their families whose trauma over deaths is compounded by the struggle for truth, justice and change. In the long term, protecting both prisoners and the public from more harm will require investment in our communities, not ineffective punitive policies.” 

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