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.”