Diabetic prisoner died after ‘truly shocking’ treatment report says


A diabetic prisoner who died after being restrained and left on a cell floor in isolation for 21 hours was subjected to “truly shocking” treatment, a report has found.

Staff at the privately-run HMP Peterborough believed Annabella Landsberg was “play-acting” and that they spent “far too long” before carrying out proper examinations despite her being critically ill, the Prisons and Probation Ombudsman said.

An inquest jury on Thursday also found there were “failings” by the Sodexo-operated prison in Cambridgeshire, as well as by custody officers, healthcare staff and doctors.

The mother-of-three, who was 45 and lived in Worthing, West Sussex, was restrained by prison staff on September 2 2017 and left without examination by healthcare staff for 21 hours.

When she was finally examined the following day, she was found to be “extremely ill” and sent to hospital where she died on September 6, the report found.

“The events leading up to Ms Landsberg’s death are truly shocking,” it said.

“Both discipline and nursing staff assumed initially that Ms Landsberg was play-acting and it took them far too long to seek managerial intervention and to carry out appropriate clinical examinations.”

The inquest in Huntingdon heard that duty nurse Lesley Watts said Ms Landsberg was “wasting staff’s time” and was “clearly faking medical issues”.

She was suffering from multiple organ failure when she was taken to hospital as a result of her diabetes.

After the hearing, sister Sandra Landsberg said: “It was very distressing to learn that my sister was left on her cell floor for so long when she was so unwell, repeatedly considered to be ‘faking it’.

“My sister will not come back, but no other family should have to go through this. Prisoners should be properly supported and looked after.”

Deborah Coles, the director of the Inquest charity, which represented the Landsbergs, said she “suffered dehumanising, ill treatment”.

“Annabella was a black woman with multiple vulnerabilities,” she said.

“That she came to die a preventable death in such appalling circumstances is shameful.

“Distress of black women in prison is too often disbelieved and viewed as a discipline and control problem.”

Damian Evans, director at HMP Peterborough, said: “It is clear that the care Annabella Landsberg received whilst she was at HMP Peterborough fell short of the standard we expect and we are very sorry for this.

“Our thoughts continue to be with Annabella’s family and friends.

“Since Annabella’s death we have undertaken a thorough review of the delivery of healthcare services at HMP Peterborough and accepted all the recommendations from the initial Prison and Probation Ombudsman’s report into her death.

“This has led to many changes and improvements being made.

“We will consider the jury’s extensive findings and conclusions with great care and continue to make improvements.”

Read the Report

HMP Peterborough (Male): Many strengths but serious problems with drugs and violence

Peterborough men’s prison has much good practice to share with the wider service but was found by inspectors to have become less safe over the last three years because of the ravages of drugs and violence.

The jail, holding 800 prisoners and run by Sodexo, is on the same site as a female prison and the two establishments share a management team. Peter Clarke, HM Chief Inspector of Prisons, said there was much to commend in the men’s jail when inspectors visited in July 2018.

“However, the simple fact was that while Peterborough was a safe prison in 2015 (the previous inspection), our judgement on this occasion was that safety had declined to such an extent that we had no choice other than to reduce our assessment in this area by two levels, to ‘not sufficiently good’.” That is the second lowest assessment in HMI Prisons’ “healthy prison tests.”

“In common with many other prisons, Peterborough has suffered the ravages of the epidemic of drugs – especially new psychoactive substances (NPS) – that have flowed into them in recent years and the debt, bullying and violence they cause,” Mr Clarke said.

Over 50% of prisoners told inspectors it was easy to get hold of illicit drugs, and more than one in five had acquired a drug habit since entering the jail. “As a result, levels of violence had doubled since the last inspection. Unsurprisingly, 55% of prisoners had felt unsafe since coming into the prison and 20% felt unsafe at the time of the inspection.”

Inspectors noted, however, a determined attempt by the jail to get to grips with the drugs and violence. Encouragingly, in the three months leading up to the inspection, there had been a reduction in levels of violence.

Aside from the violence, and the need to strengthen the governance and clinical oversight of health care, most of the functions that a prison must perform were being delivered well. Dedicated staff, many new and inexperienced, worked hard in very difficult circumstances.

It was refreshing, Mr Clarke said, to see a local prison where time out of cell was good for most prisoners and where there were activity places for 80% of the population. In rehabilitation and release planning, the prison was judged to be ‘good’, the highest assessment.

Overall, Mr Clarke said:

“HMP Peterborough still had much work to do to reduce the violence that had flowed from the influx of drugs into the establishment. Nevertheless, at the time of this inspection the signs were promising that further progress could be made. It is essential that the prison is restored to being a safe place, so that all the good work that was being delivered in so many areas is not put in jeopardy.”

Michael Spurr, Chief Executive of Her Majesty’s Prison and Probation Service, said:

“HMP Peterborough continues to provide a positive regime with good levels of purposeful activity and an effective resettlement scheme to reduce reoffending. As with other prisons across the estate, Peterborough has faced a rise in the illicit supply of drugs and a population more prone to violence – tackling this is a priority and progress is being made. The prison’s Director will use the report’s recommendations to support further improvement.”

A copy of the full report, published on 27 November 2018, can be found on the HM Inspectorate of Prisons website at: www.justiceinspectorates.gov.uk/hmiprisons

HMP Forest Bank – A well-led local prison

forestbankHMP Forest Bank continues to manage the challenges it faces well and had improved further, said Peter Clarke, Chief Inspector of Prisons. However, the needs of some marginalised groups of prisoners merited further attention, he added. Today he published the report of an unannounced inspection of the local prison in Greater Manchester.

Forest Bank holds just under 1,500 prisoners, a small number of whom are young adults aged between 18 and 21. It experienced a significant throughput of prisoners with over 100 new arrivals each week, many with complex personal needs. At its last inspection in 2012, inspectors reported positively on a well-run prison. This more recent inspection found that Forest Bank had continued to maintain some very good outcomes for prisoners and had introduced improvements, despite the challenges that it faced in common with other establishments.

Inspectors were pleased to find that:

  • reception and induction arrangements were fit for purpose and reasonable;
  • initiatives were in place to address violence, although the prison’s own analysis indicated that over 40% of such incidents were linked to the growing problem of new psychoactive substances (NPS);
  • use of segregation had reduced and force was not used excessively;
  • the environment was bright and clean and relationships between staff and prisoners were respectful;
  • most prisoners received a good amount of time out of cell and there were sufficient activity places for most of the population to be employed at least part-time;
  • there was good leadership of learning and skills and some excellent partnerships had led to some very good work opportunities;
  • the quality of offender supervision was effective and public protection arrangements were sound; and
  • the resettlement strategy was good across a range of pathways, although more needed to be done to strengthen links with the new community rehabilitation company (CRC).

However, inspectors were concerned to find that:

  • despite the prison’s proactive approach to improving safety, some prisoners were too frightened to come out of their cells and levels of self-harm were high;
  • prisoners in crisis held on normal location said they received good support but too many were isolated, held in segregation or subject to other restrictions;
  • there had been two self-inflicted deaths since the last inspection, although the prison was seeking to learn from those tragedies;
  • mental health services were poor; and
  • the incentives and earned privileges scheme was punitive and ineffective.

Peter Clarke said:

“Forest Bank manages big challenges and risks. It has a large population and turnover of prisoners, an inner city profile with high levels of need among its prisoners, and the destabilising influence of NPS. The experience most prisoners had of Forest Bank was reasonable. However, those who were more marginalised due to poor behaviour, self-harm or mental health issues had a much less positive experience and this required attention. This inspection found that the prison was well led, competent and confident in its approach and it coped well. A focus on continuing improvement suggests our concerns will be addressed and the effectiveness of the prison will be sustained.”

Michael Spurr, Chief Executive of the National Offender Management Service, said:
“As the inspectorate notes, Forest Bank continues to be a well-run prison which has a strong focus on resettlement. I am particularly pleased that the hard work of the Director and staff has been recognised as their efforts have impacted on the prisoners’ motivation to learn and find employment.

“The prison holds a number of vulnerable prisoners and will use the recommendations in this report to improve the support they receive.”

A copy of the full report can be found on the HM Inspectorate of Prisons website at: justiceinspectorates.gov.uk/hmiprisons