19 February 2020

Before HM Assistant Coroner Simon Milburn
Huntingdon Town Hall, 53 High St, Huntingdon, PE29 3AE
Opens Monday 24 February 2020, expected to last seven days
Charlotte Nokes was 38 when she died at HMP Peterborough, a private prison run by Sodexo. In the morning of 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 24 February at Huntingdon Town Hall.
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 one of four women 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 left often 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.


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.

Last month, INQUEST 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. Read more.
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 Guardian about 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 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 that 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 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.