13 December 2018

Before HM Coroner Caroline Topping
HM Coroner’s Court Woking

5 – 29 November 2018

Neglect and systemic failures by prison and healthcare providers contributed to the death of Natasha Chin at Sodexo run HMP Bronzefield, an inquest jury has found. Natasha, a black woman from Islington in London, was found unresponsive in her cell on 19 July 2016, less than 36 hours after entering the prison. Her family describe her as a lovely person who enjoyed making people laugh.

Natasha, aged 39, had alcohol and drug dependencies, a history of depression and poor physical health. Her medical cause of death related to the effects of vomiting, alongside chronic alcohol and drug dependence. Natasha was found unresponsive in her cell on 19 July 2016.

Natasha told prison staff that she felt unwell upon arrival at HMP Bronzefield and was placed in the prison’s specialist drug and alcohol wing. On the morning of her death Natasha’s condition deteriorated, and she started to vomit profusely. She did not collect the essential medication prescribed to her. By the evening Natasha had been vomiting for at least nine hours.

Healthcare staff did not follow up to understand why she had not collected her medication and did not ensure that she got it. They also did not respond promptly or at all to a prison officer’s requests to attend Natasha’s cell or adequately observe Natasha and monitor her vomiting. Prison staff did not document or escalate their welfare concerns for Natasha. The inquest also heard that Natasha rung her cell bell, but there was no response as staff were not aware that the cell bells were faulty.

Experts told the inquest that had Natasha’s condition been properly monitored and responded to, her vomiting would have been less severe. If she continued to vomit after receiving medication, she would have then been transferred to hospital and it is likely that she would have survived. After hearing three weeks of evidence, the inquest jury concluded that Natasha’s death was caused “by a systemic failure through poor governance which led to a lack of basic care”, and that the death was “contributed to by Neglect”.

The inquest further concluded Natasha’s death was caused by the failure by the healthcare provider in Sodexo Justice Services to ensure there were appropriate systems in for prompt administration of prescribed medication, and to ensure that medical records were checked before medication was administered and observations were undertaken.

The jury further detailed failures of healthcare staff, including the failure to:

  • ensure Natasha had her prescribed medication when due.
  • escalate Natasha’s failure to have her medication in accordance with prison policies.
  • carry out adequate assessments or observations and record them, which would have enabled Natasha to receive and have her medication adjusted accordingly.
  • monitor her vomiting adequately or at all.
  • monitor the level of Natasha’s hydration.

They also found operational staff failed to follow the escalation protocol for welfare concerns, or to diligently record welfare concerns according to policy. The coroner in this inquest will be writing prevention of future deaths report, which is likely to be available in the coming few weeks.

The Prison and Probation Ombudsman failed to identify many of these failures in their investigation and clinical review.

Previous deaths and numerous inspection reports dating back to at least 2010 have documented longstanding concerns about poor aspects of healthcare services at Bronzefield, yet this inquest shows many recommendations made to improve this are outstanding. Since Natasha’s death in 2016 there have been three further deaths of women found unresponsive in cells at HMP Bronzefield.

Marsha Chin, Natasha’s sister said: On behalf of Natasha’s family I would like to thank the coroner and the jury for their thorough and careful consideration of all the evidence surrounding Natasha’s death and her treatment in HMP Bronzefield.  As a family we have been shocked to learn of the inadequacies of the care provided to her and the fact that prison staff and management could have prevented her untimely death.  We can only hope that changes are now made to try to ensure no other family has to lose a loved one in such circumstances.”

Deborah Coles, Director of INQUEST said: Sodexo and the Ministry of Justice must be held to account for their failure to act upon repeated warnings about unsafe healthcare practices in Bronzefield. Natasha’s death was a result of this indifference and neglect. It is shameful that women continue to die such needless deaths in prison.

HMP Bronzefield is the most expensive women’s prison in England. Run by private company Sodexo, it costs over £65k to house each prisoner. Despite this they failed to provide Natasha with even a basic duty of care. Urgent action is needed to dismantle failing women’s prisons and invest this money, not in private companies but in specialist women’s services to support women in the community.“

Megan Phillips of Bhatt Murphy Solicitors who represented the family said: “The jury’s conclusions are a damning indictment of the inadequate care provided to Natasha and the unsafe practices, poor governance and failures in the systems in place at the prison that allowed neglect to contribute to her death.

This inquest has revealed extremely concerning evidence around the lack of any action taken by those in charge of healthcare at Sodexo on well known dangerous practices continuing in the prison. Sodexo were aware that patients were at risk of missing essential medication or receiving it too late, and this practice was not corrected or reported to any regulator, as it should have been. We remain concerned that such practices continue to place other vulnerable women in HMP Bronzefield at risk today.“


For further information please contact Lucy McKay on 020 7263 1111 or email.   

INQUEST has been working with the family of Natasha Chin since her death. The family is represented by INQUEST Lawyers Group members Megan Phillips and Michela Carini of Bhatt Murphy Solicitors and Maria Roche of Doughty Street Chambers.

The inquest was heard before HM Assistant Coroner Caroline Topping at Woking Coroner’s Court from the 5 November to 4 December 2018.  Other interested persons represented at the inquest were Sodexo who run the prison, Cimarron who provide GP agency services, a GP and several nurses and prison officers, some of whom were separately represented.

Following the 
death of Sarah Higgins at Bronzefield in 2010, the Prisons and Probation Ombudsman’s investigation concluded that prisoners undergoing methadone maintenance programs should be checked regularly if they report as unwell. 

Less than a year before Natasha’s death, an inspection of HMP Bronzefield in November 2015 found that “some aspects of medication security and administration and controlled drug management remained poor”. Inspectors from HM Inspectorate of Prisons repeated recommendations from a previous inspection, asking that the prison make improvements to management and administration of medications.

Since Natasha’s death in 2016 there have been three further deaths of women found unresponsive in cells at HMP Bronzefield. The inquests into these deaths are awaited.

In November 2018, Parliament’s Health and Social Care committee reported on their inquiry on healthcare in prison which found healthcare standards inside England’s prisons have deteriorated in recent years.

Reports on costs per place and costs per prisoner by individual prison, in the HM Prison and Probation Service Annual Report and Accounts 2017/18, show that HMP Bronzefield is the most expensive women’s prison in England and Wales. The cost per prisoner is £66,294, over £10,000 more expensive than the next most expensive HMP New Hall and over £25,000 more expensive than HMP Styal.

In November the Health and Social Care committee published a report on Prison Health, echoing the concerns from both written and oral evidence given by INQUEST to the inquiry. See the INQUEST media release for more information.

In May 2018 INQUEST published Still Dying on the Inside: Examining Deaths in Women’s Prisons. The report highlights the lack of action from successive governments to prevent deaths and puts forward a series of recommendations to close women’s prisons by redirecting resources from criminal justice to community-based services.

In June 2018 the Ministry of Justice launched a long awaited ‘Female Offenders Strategy’. INQUEST responded, saying much of the strategy was unsubstantive, empty rhetoric.

Since the 2007 publication of Baroness Corston’s seminal review on women in the criminal justice system, which was hailed by many as the blueprint for change, there has been little long-term systemic change and many of the recommendations she made have yet again been ignored. In the period since her review was published there have been 101 deaths in women’s prisons.