Revealed: The inmates dying needlessly in Britain’s prisons
Prisoners are dying needlessly in British prisons due to a series of failures in healthcare. Independent can reveal.
A damning review commissioned by the Prisons and Probation Ombudsman (PPO) has revealed that prisoners with epilepsy were found dead after being locked in single cells despite suffering uncontrolled seizures.
The shocking research also revealed prisoners were four times more likely to die from sudden and unexpected death from epilepsy (SUDEP) than those on the outside.
And nearly a quarter of prisoners who died from epilepsy in the last decade did not receive the care they deserved.
PPO Adrian Usher, who has published a newsletter calling for better care for epilepsy in custody, said grieving families would be tormented by the question “whether their loved one would still be here if they had received equivalent care”.
The heartbroken family of Trevor Monerville, whose care was deemed “unacceptable” after he was found unresponsive in his cell at HMP Lewes in 2021, are campaigning for prison staff to be properly trained about the risks to people with epilepsy.
His sister, Nadine Smith, said it was “incredibly frustrating” and “painful” to learn that epileptic prisoners continued to die in custody without proper intervention for their conditions.
Mr Monerville, 33, a handyman and handyman from Hackney, east London, was suffering from frequent seizures and taking daily medication when he was sent to a category B men’s prison to be recalled over allegations of criminal damage.
Although his seizures got worse in prison, he spent most of his time alone in a single cell.
He was found face down in his cell at 9:47 a.m. on April 18, 2021, having suffered a fatal seizure. The staff had failed to complete the morning roll call as required.
Miss Smith said Independent: “When I went to get his belongings, they showed me the cell where he was staying alone, and I told him how to use the call bell on his own when he had a seizure.
“This shows a lack of understanding of how seizures work. If the proper things had been in place he would certainly be here today.”
A coroner found Mr Monerville’s care was “inadequate and inadequate” and noted a lack of training for prison staff in dealing with long-term conditions such as epilepsy.
Later that year, Amarjit Singh, 41, died in his cell at HMP Pentonville in north London.
Mr Singh’s cellmate pressed the emergency call bell at 11.30pm on November 20, 2021, when he heard signs of a seizure in the bunk above him. However, this question remained unanswered for 40 minutes, apparently due to tampering with the control panel.
When a prison officer finally responded, he asked his cellmate to check on Mr. Singh, who appeared to be sleeping. In his statement to the police, his cellmate said the officer told him that if Mr Singh had an epileptic seizure it would “go away by morning”.
At around 7am, Mr Singh was found unresponsive and stiff. A coroner found negligence contributed to his death, which was recorded as being related to epilepsy.
Of the 25 cases in which epilepsy was recorded as the primary cause of death, only six received care equivalent to the epilepsy care they would receive in the community.
At least seven did not receive adequate care; In the other 12 cases, the standard of epilepsy care was not even evaluated.
Mr Usher, who was appointed prison ombudsman in 2023, launched the investigation after noticing a number of epilepsy cases. He said the investigation, which examined 125 deaths, “transformed gut feelings into concrete data.”
It found that only 10 per cent of epileptic prisoners who had been seizure-free for a year were in remission, compared to the NHS target of 70 per cent remission in the community.
In the cases they examined, only 38 per cent of prisoners had a documented care plan, which is required under National Institute for Health and Care Excellence (NICE) guidelines.
The report stated that there was evidence that seizures were not taken seriously when the individual had a history of illicit drug use and the frequency of seizures was not well monitored.
The researchers found 11 instances where an inmate’s seizure frequency increased and action could be taken to address the situation. Some of these prisoners died.
Mr Usher said the bulletin, which will be published on Monday, was a “starting gun” to raise awareness of this extremely dangerous condition and raise standards of care.
“The court’s sentence is the loss of your freedom, not the loss of other services,” he said. Independent.
“You have the right to the same health care that you would receive in the community. We found that in a quarter of cases this was not true and people who died did not receive the care they would have received in the community.”
He called for changes, including ensuring all epileptic inmates receive a care plan, are kept in shared cells and do not sleep on top bunk beds. He also warned that inmates in the early stages of a diagnosis of epilepsy should not be transferred to prisons as this could impact continuity of care.
The report also found that 22 percent of inmates with epilepsy recorded as a primary or secondary cause of death died within days or weeks of entering a new prison, highlighting the risks of prison transfers.
Andrew Neilson, campaign director at the Howard League for Sentencing Reform, said a health condition such as epilepsy should not become “a disability or a death sentence”.
“We hope that the information gained from this report will go some way towards better understanding and treating health problems such as epilepsy in custody and preventing further deaths in the future,” he added.
A government spokesman said: “People in custody should receive the same standard of care as in the community. This includes appropriate epilepsy diagnosis, clear care plans, safe medication management, effective mental health and substance abuse support, and continuity of care during prison transfers.
“We will take these recommendations into account and work with the prison service to ensure standards of care are met at all times.”
