31 October 2019

The Ministry of Justice has today (31 October 2019) released the latest statistics on deaths and self-harm in prison custody and deaths of people (‘offenders’) in the community after release from prison.  

Safety in custody statistics

The statistics highlight historically high levels of self-inflicted deaths as seen over the past six years. In the 12 months to June, self-harm reached a record high of 60,594 incidents, up 22% from the previous 12 months.

The key statistics on deaths in prison in the 12 months to September 2019 include:

  • 308 deaths in prison in total, which represents six deaths every week in prisons in England and Wales. Of these deaths, eight were of women in prison.
  • 90 self-inflicted deaths. This represents one self-inflicted death in prison every four days.
  • 158 deaths which the MOJ categorise as due to “natural causes”. INQUEST’s casework and monitoring show that many of these deaths are in fact premature, avoidable and far from ‘natural’.
  • 58 deaths recorded as ‘other’, 56 of which are awaiting classification.
  • 2 homicides.

Deborah Coles, Executive Director of INQUEST said: “These statistics are more than numbers. They represent real people in extreme distress, leading to preventable deaths and traumatic bereavement for families. As a society we should not accept this endless cycle of systemic neglect and political indifference. Bereaved families deserve more than repetitive platitudes that ‘lessons will be learned’, when they consistently are not. The lack of accountability for these deaths, and the abject failure of the system to prevent them, is a moral and political disgrace. 

The lack of any oversight body to monitor and follow up on actions taken after prison inspections, investigations and inquests into prison deaths reinforces this accountability gap. Any incoming government must radically transform sentencing policy, reduce the prison population and redirect resources to community services.”

Deaths of ‘offenders in the community’

The data on ‘Deaths of Offenders in the Community’ looks at deaths of people supervised by the probation service both on post-release supervision and serving court orders. The number of deaths of people under post-release supervision in the community increased drastically by 38%, from 374 in 2017/18 to 515 in 2018/19. Unlike deaths in prison, deaths in the community are not subject to independent investigation.

Deborah Coles, Executive Director of INQUEST said: “These figures are deeply disturbing and require urgent scrutiny due to the current lack of independent investigation. What is known is that people are being released into failing support systems, poverty and an absence of services for mental health and addictions. This is state abandonment. This is the violence of austerity.”  

The Justice Committee published its report into prison governance today. The report highlights concern about the lack of follow up of recommendations following a death in custody. INQUEST submitted evidence calling for the establishment of a ‘national oversight mechanism’ an independent, public body with the duty to collate, analyse and monitor recommendations and their implementation arising from post death investigations, inquiries and inquests.  

A joint report by the Prison Reform Trust, Pact (the Prison Advice and Care Trust) and INQUEST, released today, reveals that most prisons in England and Wales are failing in their duty to ensure that emergency phone lines are in place for families to share urgent concerns about self-harm and suicide risks of relatives in prison. This is in serious breach of government policy that families should be able to share concerns ‘without delay’.

This new report maps the provision of safer custody telephone lines across the prison estate - dedicated phone lines which enable family members and others to pass on urgent information when they have concerns. The report finds just one in ten safer custody departments in prisons answer phone calls from concerned family members.



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

INQUEST responded to the Prison and Probation Ombudsman’s annual report in October 2019 which highlighted a 23 percent increase on self-inflicted deaths in PPO report on the same period last year. Media release.
INQUEST submitted evidence to the Health and Social Care Committee Inquiry into Healthcare in Prisons in May 2018 which evidences the impact of poor prison healthcare on both physical and mental health, contributing to death.
Inquests held following deaths in prison that have concluded in the past year:

Jury found staff actions inadequate at inquest into death of Marc Maltby in HMP Nottingham. Media Release, October 2019.
Marc, 23, died after being found hanging in his cell. Prison officers used a table tennis table to block his cell door after he started throwing objects through the observation hatch after reporting to staff that he was under threat.

Inquest concluded into the self-inflicted death of Jamal Hussein after a series of threats. Media release, October 2019.
Jamal, 32, died 11 days after being found with a ligature in his cell. A total of three intelligence reports were submitted in relation to Jamal potentially being at risk or bullied, but only one report was analysed prior to his death.
Jury highlights series of failings at inquest into death of Anthony Solomon at Nottingham Prison. Media Release, September 2019.
Anthony, 38, died from the toxic effects of synthetic cannabinoids. The jury returned a narrative conclusion highlighting a failure to answer the cell bell sooner and the prevalence of drugs in Nottingham prison at the time of this death.
Jury finds failure to adequately assess risk of self harm and suicide contributed to death of Rocky Stenning at HMP ChelmsfordMedia Release, July 2019.
Rocky, 26, died a self-inflicted death on 19 July 2018, just nine days after entering prison. Despite a history of mental ill health and recommendations of a psychiatric report, ACCT processes were not opened.

Teenager Jordon Hullock whose meningitis and heart condition was overlooked was failed by HMP Doncaster healthcare staff, inquest finds. Media Release, July 2019.
Jordan, 19, died on 30 June 2015. The inquest jury concluded Jordan’s death was by natural causes, and that there were serious failures and shortcomings in his care in the days leading up to his death. 

Inquest concludes a series of failings contributed to death of Shane Stroughton in HMP Nottingham. Media Release, June 2019.
Shane, 29, died a self-inflicted death on 13 September 2017. The jury unanimously agreed that there was inadequate mental health care, a lack of trained ACCT assessors and a failure of prison staff to communicate with Shane’s family regarding incidents involving him at HMP Nottingham. 

Jury returns damning conclusion at inquest of Andrew Brown at HMP Nottingham. Media Release, June 2019.
Andrew, 42, died a self-inflicted death on 17 September 2017. The inquest concluded that there were numerous failings which contributed to his death, including a failure to follow procedures, an unsuitable environment which did not meet his basic needs, failure to respond to the emergency bell and a failure to investigate an earlier assault on Andrew. 

Inquest in to the death of Marcus McGuire highlights failings at HMP BirminghamMedia Release, June 2019. Marcus, 35, died on April 2018. The jury found a lack of mental health assessment and issues with ACCT procedures were possible causative of his self-inflicted death. He was recalled to prison in November 2017, shortly after being discharged from a psychiatric hospital where he had been detained after making threats to his life.

Inquest finds serious failures at Sodexo run HMP Peterborough contributed to death of Annabella Landsberg. Media Release, April 2019.
Annabella, 45, died from complications relating to her Type 2 diabetes on 6 September 2017. The inquest jury found failings on the part of the prison, healthcare staff, GPs and custody officers contributed to the death of Annabella Landsberg. 

Father of four, Sean Mccann, died after a catalogue of errors and neglect by prison staff. Media Release, 15 February 2019.Sean, 32, died in March 2016 at Peterborough prison. The jury concluded staff failed to properly assess his mental health, officers were not sufficiently trained and staff failed to take the cell with the ‘ligature point’ out of use. They ruled that his death was an ‘accident’ contributed to by neglect.
Jury conclusion highlights numerous failings contributed to the death of Michael Judge at HMP SwalesideMedia Release, 1 February 2019.
Michael, 32, died a self-inflicted death at HMP Swaleside. The jury highlighted numerous failings at the prison which contributed to his death.
Critical inquest finds systemic failures and missed opportunities contributed to death of Tyrone Givans at HMP Pentonville. Media Release, January 2019.
Tyrone, 32, died a self-inflicted death on 26 February 2018. The jury found that his substance abuse and profound deafness were insufficiently processed and addressed, staff communication was unsatisfactory, prison record IT systems were unfit for purpose and the inadequate recording of prison patient records. 

Inquest concludes that systematic failures and consistently missed opportunities caused death of Ryan Harvey at Woodhill prison, Media Release, January 2019.
Ryan died aged 23 on 8 May 2015. The jury found a failure by healthcare staff to undertake an adequate assessment of Ryan’s learning disability, and to conduct an assessment of his mental health, may have contributed to his death. 

Critical inquest highlights Home Office failures following death of immigration detainee, Michal Netyks, in prison. Media Release, December 2018.
Michal died aged 35. The inquest jury concluded that his death was the result of suicide, which was in part contributed to by the immigration deportation process. 

Neglect and serious medical failures in Sodexo run prison contributed to death of Natasha Chin. Media Release, December 2018.
Natasha, 39, died less than 36 hours after entering Sodexo run HMP Bronzefield on 19 July 2016. The inquest jury concluded her death was caused by healthcare failures and contributed to by neglect. 

Inquest finds death of Wayne Moore in HMP Nottingham was preventable. Media Release, November 2018.
Wayne, 46, was found collapsed in HMP Nottingham and later died in hospital on 16 December 2013. The inquest jury found inadequacies in ensuring Wayne’s health records were transferred from the hospital to prison staff, and in the communication of potential warning signs between prison staff and healthcare when his condition was deteriorating.
Inquest concludes into death of Tommy Nicol who ‘lost hope’ on IPP sentence. Media Release, November 2018.
Tommy, 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”.
“Deeply inadequate” prison procedures contributed to death of Jessica Whitchurch. Media Release, November 2018. Jess, 31, died two days after being found with a ligature in her cell in Eastwood Park prison in May 2016. The jury returning a damning conclusion identifying multiple failures that contributed to her death.