INQUEST into death of IPP sentenced prisoner Lewis Powter
The below media release is reshared from Bhatt Murphy solicitors. The
inquest concluded with critical findings, see media coverage.
18 July 2022
The inquest into the death of Lewis Powter is to be heard before HM
Assistant Coroner Lorna Skinner at Cambridge and Peterborough Coroner’s Court
in Huntingdon on 18 – 19 July 2022. Lewis Powter was 36 years old when he died
on 10 May 2020 at his home in Sawston.
Background
When he was 23 years old Lewis was given an indefinite sentence for public
protection for GBH; his minimum term was set at just two years. Despite his
tariff expiring in 2009 Lewis was not released until 2011. He was released and
then recalled five times prior to his death.
In prison he was assessed as high risk of death . On 18 January 2017 Lewis was assaulted by three Sodexo
officers at HMP Peterborough. Those officers were subject to disciplinary
proceedings leading to the dismissal of one officer, another officer receiving
a final warning and a third officer receiving a warning. Since the assault
Lewis experienced PTSD symptoms including hypervigilance.
In June 2019 Lewis was recalled after being out in the community for
four days following being late back for his curfew due to cancelled public
transport. The National Probation Service in a report stated that the recall
was “inappropriate” but despite this Lewis was not released until November
2019. Upon his release he experienced extreme anxiety and fear about being
recalled to prison.
In 2008 HM Prisons published a thematic report into IPP sentences which
highlighted the impact of serving an IPP sentence on prisoners’ emotional and
mental health, including self-harm. In 2008 the Sainsbury Centre for Mental
Health also published a report which highlighted the negative impact that
serving an indeterminate sentence had on prisoners’ mental health and
wellbeing. In 2012 the IPP sentence was abolished; but for those IPP prisoner
like Lewis there was no change to their sentence.
Leah Biamonti, Lewis's mother, said: "The IPP sentence my son
was serving at the time of his death was insufferable both for him but also the
family who supported him, taking a great toll. His two children, growing up
without him, were confused by his multiple recalls to prison.
Although released from prison for the first time in 2011, it felt as if
it was just the beginning , never given the opportunity to adjust to anything
that could be recognised as a semblance of a ‘normal’ life, before being
recalled for a rule break, to start the protracted cycle again of working
towards another potential release. Each release characterised by a lack of
practical support and , in my view, especially with early release’s, a lack of
understanding of the extent to which the IPP sentence impacted on the mental
and emotional health of individuals, extreme feelings of uncertainty,
hopelessness, depression , and as we know now high rates of suicide in the IPP
population, and in my sons case extreme and immobilising anxiety.
In our experience there are insufficient support systems in place to
support those with complex needs as a result of, or exacerbated by an IPP
sentence, relying heavily on family to help rebuild a future in the community.
Although it no longer exists , the IPP sentence remains in place for many who
are utterly stuck within a sick and broken system.
Release from prison is not the end, it is a time when knowledge and
understanding of the impact of this inhumane sentence matters, and when the
most intensive support is needed to aid both practical and psychological
readjustment to life outside prison, and to support the prevention of what is
currently an almost inevitable recall to prison."
Lucy McKay, spokesperson for the charity INQUEST, said: “The evidence on
the harmful impacts of unlawful indefinite prison sentences is clear and well
founded. Yet thousands of people are still languishing in prison with IPP
sentences, or living in the community with the endless threat of recall for the
most minor slip ups. IPP sentences were rightly abolished in 2012, so why in
2020 was Lewis still forced to live with this unjust sentence on his shoulders?
We hope this inquest offers necessary scrutiny of the circumstances of his
death, and considers ongoing issues for those in a similar position”
IPP As at 30 September 2021, there were 9,254 (8,306 male; 326 female)
indeterminate sentenced prisoners (those serving Imprisonment for Public
Protection (IPP) sentences and life sentences). Although this represents a
slight overall decrease (-2%), there was a 24% increase in the number of
prisoners serving indeterminate sentences in the 18-20 years age bracket when
compared with 30 September 2020.
The number of unreleased prisoners (6,971) serving life sentences is
broadly unchanged from one year ago but there was a small (5%) decrease in the
number of prisoners still held beyond their tariff expiry date. The number of
unreleased IPP prisoners fell by 12% to 1,661. At point of sentencing,
offenders are given a minimum time period (“tariff”) that they need to serve in
prison before they can apply to the Parole Board for release. The majority of
the unreleased IPP prisoners have been held for more than eight years beyond
the end of their tariff.
The number of recalled prisoners serving life
sentences increased by 10% to 658 when compared to September 2020 whilst the
number of recalled Imprisonment for Public Protection (IPP) prisoners was
unchanged from one year ago.
45% served more than 10 years longer than the tariff they were
given. Since December 2022, 98% of people serving an IPP sentence who had
never been released from prison, were past their tariff expiry date. Numbers
originally given a tariff of less than two years.
INQUEST into death of IPP prisoner Lewis Powter
The below media release is reshared from Bhatt Murphy solicitors. The
inquest concluded with critical findings, see media coverage.
18 July 2022
The inquest into the death of Lewis Powter is to be heard before HM
Assistant Coroner Lorna Skinner at Cambridge and Peterborough Coroner’s Court
in Huntingdon on 18 – 19 July 2022. Lewis Powter was 36 years old when he died
on 10 May 2020 at his home in Sawston.
Background
When he was 23 years old Lewis was given an indefinite sentence for public
protection for GBH; his minimum term was set at just two years. Despite his
tariff expiring in 2009 Lewis was not released until 2011. He was released and
then recalled five times prior to his death.
Lewis had epilepsy and complex mental health needs including EUPD, PTSD,
substance misuse and anxiety. In prison he was assessed as high risk of death
by misadventure. On 18 January 2017 Lewis was assaulted by three Sodexo
officers at HMP Peterborough. Those officers were subject to disciplinary
proceedings leading to the dismissal of one officer, another officer receiving
a final warning and a third officer receiving a warning. Since the assault
Lewis experienced PTSD symptoms including hypervigilance.
In June 2019 Lewis was recalled after being out in the community for
four days following being late back for his curfew due to cancelled public
transport. The National Probation Service in a report stated that the recall
was “inappropriate” but despite this Lewis was not released until November
2019. Upon his release he experienced extreme anxiety and fear about being
recalled to prison.
In 2008 HM Prisons published a thematic report into IPP sentences which
highlighted the impact of serving an IPP sentence on prisoners’ emotional and
mental health, including self-harm. In 2008 the Sainsbury Centre for Mental
Health also published a report which highlighted the negative impact that
serving an indeterminate sentence had on prisoners’ mental health and
wellbeing. In 2012 the IPP sentence was abolished; but for those IPP prisoner
like Lewis there was no change to their sentence.
Leah Biamonti, Lewis's mother, said: "The IPP sentence my son
was serving at the time of his death was insufferable both for him but also the
family who supported him, taking a great toll. His two children, growing up
without him, were confused by his multiple recalls to prison.
Although released from prison for the first time in 2011, it felt as if
it was just the beginning , never given the opportunity to adjust to anything
that could be recognised as a semblance of a ‘normal’ life, before being
recalled for rule breaking, to start the protracted cycle again of working
towards another potential release. Each release characterised by a lack of
practical support and , in my view, especially with early release’s, a lack of
understanding of the extent to which the IPP sentence impacted on the mental
and emotional health of individuals, extreme feelings of uncertainty,
hopelessness, depression , and as we know now high rates of suicide in the IPP
population, and in my sons case extreme and immobilising anxiety.
In our experience there are insufficient support systems in place to
support those with complex needs as a result of, or exacerbated by an IPP
sentence, relying heavily on family to help rebuild a future in the community.
Although it no longer exists , the IPP sentence remains in place for many who
are utterly stuck within a sick and broken system.
Release from prison is not the end, it is a time when knowledge and
understanding of the impact of this inhumane sentence matters, and when the
most intensive support is needed to aid both practical and psychological
readjustment to life outside prison, and to support the prevention of what is
currently an almost inevitable recall to prison."
Lucy McKay, spokesperson for the charity INQUEST, said: “The evidence on
the harmful impacts of unlawful indefinite prison sentences is clear and well
founded. Yet thousands of people are still languishing in prison with IPP
sentences, or living in the community with the endless threat of recall for the
most minor slip ups. IPP sentences were rightly abolished in 2012, so why in
2020 was Lewis still forced to live with this unjust sentence on his shoulders?
We hope this inquest offers necessary scrutiny of the circumstances of his
death, and considers ongoing issues for those in a similar position”
Leah Biamonti is represented in the forthcoming inquest by Jane Ryan of Bhatt
Murphy solicitors and Stephen Clark of Garden Court chambers. For further
information please contact: j.ryan@bhattmurphy.co.uk
INQUEST
has supported 27 bereaved families of IPP prisoners who died between 2008 to 2021. In what follows, we outline the circumstances of the deaths of six IPP prisoners. Their deaths highlight key issues in the IPP sentence.
Introduction, Written evidence from INQUEST
INQUEST on related deaths
and their investigation. For four decades, The inqesat has provided expertise to
bereaved people, lawyers, advice and support agencies, the media and
parliamentarians. Our specialist casework includes deaths in prison and police
custody, immigration detention, mental health settings and deaths involving
multi-agency failings or where wider issues of state and corporate
accountability are in question. INQUEST’s Executive Director, Deborah Coles,
sits on the cross-government Ministerial Board on Deaths in Custody a member of the Independent Advisory Panel on Deaths in Custody.
IPP Prisoners
The inquest welcomes the Justice Committee’s new inquiry into Imprisonment of (IPP) sentences in prison. In this submission, we provide
an overview of the detrimental consequences of IPP sentences
for prisoners informed by our casework and expertise on investigations and
inquests into deaths.
Prisons, by their very nature, are dehumanising places which create and
intensify vulnerability. This is further heightened for
the 1,661 people who remain on indeterminate sentences, not knowing
when they will be released. INQUEST has worked on a number of deaths
in prison which have been linked to the harms of IPP sentences. In
this submission, we draw attention to the way in which the IPP
sentence has a severely harmful impact on the mental and physical health of
prisoners. We highlight the deaths
of three men, one woman and two anonymous
people whose experiences reflect the damaging and fatal effects of the IPP
sentence. We make recommendations to bring an end to the harm caused to
prisoners and their families by IPP sentences.
Overview
According to the most current statistics[1] released
by the Ministry of Justice, there were a total of 1,661 people imprisoned
under IPP sentences as of 30 September 2021. The percentage of post-tariff
IPP prisoners continues to rise: 96% of IPP prisoners were
post-tariff in June 2021 compared to 94% in June 2020[2] and
91% in March 2019[3]. As
of 30 September 2021, the majority of unreleased IPP prisoners had been held
for more than eight years beyond the end of their tariff[4]. Furthermore,
the number of recalled IPP prisoners grew by 184% from 477 to 1,357
from 30 September 2015 to 30 September 2020[5].
As of 30 September 2021, 1,357 IPP prisoners had been recalled to custody[6] [7]. Bereaved
families that INQUEST has worked with have also said that IPP prisoners
often struggle to gain placement on rehabilitation courses that are required by
the Parole Board for release[8].
The Independent Advisory Panel on Deaths in Custody stated in their 2019
briefing paper[9] that,
“the close links between hopelessness, self-harm and
suicide … suggests that IPP prisoners are a particularly vulnerable
group in custody and – as the number over-tariff grows – the risk is thought to
be increasing”. IPP prisoners have been shown[10] to
suffer disproportionately high rates of self-harm, with a self-harm rate of 550
per 1000 prisoners compared to 324 per 1000 prisoners for determinate-sentenced
prisoners. The self-harm rate of IPP prisoners is more than twice as much as
that of prisoners serving life sentences. Since the IPP sentence was introduced
in 2005, UNGRIPP state that 70 people serving IPP sentences have
taken their own lives[11].
Case Studies
In what follows, we outline the circumstances
of the deaths of six IPP prisoners. Their deaths highlight
key issues in the IPP sentence.
Tommy Nicol[12] [13]
Tommy Nicol was a 37-year-old mixed-race White and Middle Eastern man
who died at Watford General Hospital on 25 September 2015 after being
found with a ligature around his neck in his cell at HMP The Mount three days
earlier. In November 2009, Tommy received an IPP sentence with a minimum term
of four years, but at the time of his death he had served six years
with no immediate hope of being released. In January 2015, Tommy made a
complaint to the prison in which he described his inability to progress in his
IPP sentence towards release as “psychological torture of a person who is
doing 99 years”. In June 2015, the Parole Board’s review of Tommy’s
sentence concluded that Tommy should do further “motivational and
psychological” work before release, recommending that he complete a course
of therapy, but Tommy was unable to secure a place. Tommy
expressed frustration about not being able to do the required therapy
course ahead of the review, with his next Parole Board review not due until
February 2017. After the Parole Board review, Tommy’s mental health
deteriorated until the time of his death, as he seriously self-harmed and when
moved to segregation, began displaying psychotic symptoms. Tommy received
no mental health support in the four days he spent in segregation, despite
spending over 24 hours in an unfurnished cell.
The inquest heard evidence from consultant forensic psychiatrist Dr
Dinesh Maganty, who said that the IPP sentence had contributed to Tommy’s death
“more than anything else” as it made him “lose hope”. Dr Dinesh
Maganty described Tommy’s risk level on the day of his death as
the highest it could have been, referring to the “perfect storm of
risk factors” including his IPP sentence. Tommy’s sister, Donna
Mooney, said “My brother was jailed for a minimum term of four years, yet two
years after he had completed his tariff, he was still in jail. Tommy became
more and more desperate, but nobody would listen to him. The prison authorities
didn’t even carry out a mental health assessment despite his very high risk
of self-harm and suicide.”
Charlotte Nokes[14]
Charlotte Nokes was a 38-year-old woman who was found dead in her cell
at HMP Peterborough on the morning of 23 July 2016. The inquest jury concluded
the medical cause of Charlotte’s death was Sudden Arrhythmic Death Syndrome. In
2008, Charlotte was sentenced to an IPP sentence with a minimum term of 15
months, but at the time of her death, Charlotte had been in prison for over
eight and a half years. Charlotte had mental and physical health diagnoses
including borderline personality disorder and premenstrual dysphoric disorder.
In the months leading up to her death, Charlotte was prescribed heavy doses of
medication to treat her mental and physical health that left her appearing
heavily sedated. At the time of her death, she was placed
on an ACCT (Assessment, Care in Custody and Teamwork - the care
planning process for prisoners identified as being at risk of suicide or
self-harm) after she had attempted to take her life.
The inquest jury heard that despite being seven years over tariff,
Charlotte was only at the early stages of being ready to engage with the
therapeutic help she needed to begin the path to release. Furthermore, the
inquest heard that the indefinite nature of Charlotte’s sentence, and her fear
that she would never be released from prison, contributed to a sense of extreme
hopelessness. Charlotte described the IPP sentence as a death sentence to her family.
Nicky Asplin, the principal counselling psychologist who worked with Charlotte
in the months before she died, told the inquest jury that during a therapy
session shortly before her death, Charlotte expressed “a lot
of frustration at the never-ending sentence of an IPP prison sentence”[15].
Tara Mulclair of Birnberg Peirce who represented Charlotte’s family at the
inquest, said that Charlotte’s indefinite incarceration “created a strong
sense of hopelessness and exacerbated her poor mental health”.
Charlotte’s father, Steven Nokes, said, “She had many struggles in
life, was beaten up for being ‘different’ and experienced mental ill health.
Prison was never the best place for her. The indefinite sentence only made this
worse.”
Shane Stroughton[16]
Shane was a 29-year-old man who died shortly after he was found hanging
at HMP Nottingham on 13 September 2017. Shane had a well-documented
history of depression and anxiety. At the age of 19, Shane received an IPP
sentence with a minimum tariff of two and a half years. However, he remained in
prison for close to ten years, and was released on 13 June 2017 having
served in excess of six years over his original tariff. In July
2017, Shane was recalled to prison and placed at HMP Nottingham, where he was
immediately identified as a high risk of suicide having used a ligature in
police custody. A few days after arriving at HMP Nottingham, Shane set fire to
his cell and used another ligature, making himself unconscious. In August 2017,
Shane was placed on an ACCT. Despite this measure and the fact that
his family had called the prison to say that he appeared to have lost two stone
in weight, records suggest that the prison interacted little with
Shane after that.
The jury at Shane’s inquest heard evidence that Shane had lost 20% of
his body weight in six weeks and that by the time of his death, he had a Body
Mass Index that meant he was underweight and malnourished – but the prison
did not pick this up. On 11 September, Shane was told he was to be re-released,
but his probation officer was working with four or five times the appropriate
caseload and could not spend any time with him. Following the inquest,
Shane’s mother, Deborah, said, “So much went wrong in Shane’s case. The IPP was
vicious. He had a two-and-a-half-year term but did ten, and it made his mental
health problems worse and also institutionalised him. He could
not cope with freedom and so was recalled quickly.”
Kelvin Speakman[17]
Kelvin was a 30-year-old man who died after being found with a ligature
at HMP Hewell on 9 May 2016. In 2007, Kelvin received an IPP sentence with a
minimum term of two years, but at the time of his death, he had been in
prison for nine years. Despite repeated self-harm incidents and suicide
attempts, Kelvin was never transferred to a secure mental health unit, even
though consultant psychiatrists had twice recommended it. The inquest
found multiple failings, especially in the assessment and care of
prisoners at risk of self-harm and suicide. The PPO report[18] into
Kelvin’s death echoed these findings, stating that Kelvin did not have the
required mental health assessments to safeguard against his continued
segregation. Kelvin’s older brother, Lee Dobson, told the Guardian “We
knew he was frustrated at his lack of progress, but he always put on a
brave face for us., If we had known, we could have at least tried to talk him
through his hard times. Instead, he died without help from us, or the system.”
Two other INQUEST cases: Case A and Case B[19]
Case A concerns the self-inflicted death of an IPP
prisoner. The Prisons and Probation Ombudsman found that the indeterminate
nature of the IPP sentence caused great anxiety for the prisoner, and that
it was not difficult to come to the conclusion that the IPP sentence
and its associated uncertainty played a significant role in
the prisoners’ decision to take their own life.
Case B concerns the self-inflicted death of an IPP
prisoner. The coroner informed the Prison’s Minister that they
must act to prevent other IPP prisoners dying in a similar way. The
coroner also stressed that the prison system is inadequate to meet the needs of
IPP prisoners who have a heightened risk of self-harm compared to other
prisoners. In particular, the coroner cited the infrequent nature
of Parole Board hearings and the lack of support for complex
mental health issues.
Key issues
The circumstances of the six deaths
outlined above highlight the following key issues:
The indeterminate nature of IPP sentences creates a sense of hopelessness
and despair for prisoners. This is worsened by the high probability
that such prisoners will remain in prison well beyond completion
of their minimum tariff and that many will
be recalled owing to the indefinite nature of the license. Consequently,
IPP sentences often exacerbate pre-existing mental ill health and induce mental
ill health for those who did not previously have it.
The sense of hopelessness and despair experienced by IPP prisoners
combined with the adverse mental health consequences of the IPP sentence
mean that IPP prisoners are especially vulnerable and are at a
disproportionately high risk of self-harm and self-inflicted death.[20] For
example, in all four of the non-anonymous cases
listed above, the individuals had self-harmed and/or previously attempted
to take their own life before their death. In five out of six of
the cases, the individuals died self-inflicted deaths.
Despite their vulnerability, IPP prisoners are not always
accurately assessed as needing mental health support and sometimes receive
inadequate care or none whatsoever.[21]
IPP prisoners sometimes struggle to gain a place on rehabilitation
courses which are a requirement by the Parole Board for release,
which prolongs their stay in prison. This, coupled with
irregular Parole Board hearings, exacerbates their sense of
hopelessness and despair which has an adverse impact on their mental
health.
The sense of hopelessness and despair experienced by IPP prisoners
combined with the adverse mental health consequences of the IPP sentence can
worsen pre-existing physical health issues and result in new
physical health issues, which can go unnoticed.
Recommendations. The Justice Committee must:
Take full account of the inherent risk posed by the IPP sentence to
prisoners mental and physical health and the evidence of increased self-harm
and suicide in its identification of “possible legislative and policy
solutions” to the IPP sentence.
Recommend concrete steps to prevent future harm and deaths of IPP
prisoners, including consideration of abolishing the IPP sentence
retroactively.
HMPPS must:
Prioritise IPP prisoners for engagement in programmes that assist their
case at Parole Board hearings. Given their lack of confidence in the
system, consideration should be given to the provision of independent advocacy
to support their appropriate engagement.
Convey clear information regularly to IPP prisoners about their
sentences, including upcoming Parole Board hearings.
Allocate a substantial budget for enhanced mental health screening and
support, substance abuse, housing, employment, and community reintegration to
holistically support all IPP prisoners.
INQUEST is aware of some inquest hearings where the IPP
sentence itself was not regarded as relevant to the death and was not allowed
to be discussed. Therefore, we believe that investigatory bodies and the
coroner service must:
Ensure that the nature and impact of the IPP sentence are fully examined
in any investigation or inquest into the death of an IPP prisoner. Independent
investigation and scrutiny of deaths can play an important role in drawing
attention to failing systems and processes as well as to actions needed to
prevent future deaths.
[1] Ministry of Justice “Offender management statistics quarterly: April to June 2021” https://www.gov.uk/government/statistics/offender-management-statistics-quarterly-april-to-june-2021/offender-management-statistics-quarterly-april-to-june-2021
[2] Ministry of Justice “Offender management statistics quarterly: January to March 2021” https://www.gov.uk/government/statistics/offender-management-statistics-quarterly-january-to-march-2021/offender-management-statistics-quarterly-january-to-march-2021
[3] Ministry of Justice “Offender Management Statistics Bulletin, England and Wales: Quarterly: October to December 2019” https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/882163/Offender_Management_Statistics_Quarterly_Q4_2019.pdf
[4] Ministry of Justice “Offender management statistics quarterly: April to June 2021” https://www.gov.uk/government/statistics/offender-management-statistics-quarterly-april-to-june-2021/offender-management-statistics-quarterly-april-to-june-2021
[5] Prison Reform Trust’s report “No life, no freedom, no future: The experiences of prisoners recalled under the sentence of Imprisonment for Public Protection” (2020) http://www.prisonreformtrust.org.uk/PressPolicy/News/vw/1/ItemID/954
[6] Ministry of Justice “Offender management statistics quarterly: April to June 2021” https://www.gov.uk/government/statistics/offender-management-statistics-quarterly-april-to-june-2021/offender-management-statistics-quarterly-april-to-june-2021
[7] Ministry of Justice “Offender management statistics quarterly: April to June 2020” https://www.gov.uk/government/statistics/offender-management-statistics-quarterly-april-to-june-2020/offender-management-statistics-quarterly-april-to-june-2020
[8] See the Guardian article (2021) with Donna Mooney’s comments about IPP prisoners struggling to access rehabilitation courses https://www.theguardian.com/society/2021/may/17/england-and-wales-prisoners-taking-fewer-rehabilitation-courses
[9] The Independent Advisory Panel on Deaths in Custody briefing paper “Indeterminate sentences for public protection (IPPs): preventing self-harm and deaths in custody” https://static1.squarespace.com/static/5c5ae65ed86cc93b6c1e19a3/t/5f59bfe535e751014cbeb04f/1599717352035/IPP+briefing+paper+for+Ministers+FINAL.pdf
[10] Prison Reform Trust press release for their report “Prison: the facts 2016” http://www.prisonreformtrust.org.uk/PressPolicy/News/vw/1/ItemID/335
[11] UNGRIPP https://www.ungripp.com/statistics
[12] See INQUEST’s press release on the opening of the inquest into the death of Tommy Nicol https://www.inquest.org.uk/tommy-nicol-opening
[13] See INQUEST’s press release on the conclusion of the inquest into the death of Tommy Nicol https://www.inquest.org.uk/tommy-nicol-conclusion
[14] See INQUEST’s press release on the conclusion of the inquest into the death of Charlotte Nokes https://www.inquest.org.uk/charlotte-nokes-conclusion
[15] See the Guardian article (2020) into the inquest of Charlotte Nokes https://www.theguardian.com/uk-news/2020/feb/25/artists-never-ending-jail-term-led-to-sense-of-hopelessness-inquest-told
[16] See INQUEST’s press release on the conclusion of the inquest into the death of Shane Stroughton https://www.inquest.org.uk/shane-stroughton-inquest-closed
[17] See the Guardian article (2020) on the death of Kelvin Speakman https://www.theguardian.com/society/2020/jan/22/prison-deaths-kelvin-speakman-hmp-hewell-worcestershire?CMP=Share_iOSApp_Other
[18] See the Prisons and Probation Ombudsman independent investigation into the death of Kelvin Speakman https://s3-eu-west-2.amazonaws.com/ppo-prod-storage-1g9rkhjhkjmgw/uploads/2018/12/M042-16-Death-of-Mr-Kelvin-Speakman-in-hospital-Hewell-09-05-2016-SI-22-30-30.pdf
[19] We have anonymised these cases as the prisoners’ families have not consented to INQUEST referencing their names
[20] See the IAP on Deaths in Custody report on “Indeterminate sentences for Public Protection (IPPs): preventing self-harm and deaths in custody (2019)“ https://static1.squarespace.com/static/5c5ae65ed86cc93b6c1e19a3/t/5f59bfe535e751014cbeb04f/1599717352035/IPP+briefing+paper+for+Ministers+FINAL.pdf
[21] See the 2008 Sainsbury Centre for Mental Health report “In the Dark: the mental health implications of Imprisonment for Public Protection”
