Severe staff shortages and extreme confinement
A recurring feature of recent inspections is the chronic shortage of staff across many prisons. This affects every aspect of daily life. At HMP Woodhill, inspectors reported that prisoners were routinely confined to their cells for more than 21 hours a day because there were not enough staff to unlock them safely.
Being locked up for this long means:
- Very little time to exercise
- Almost no meaningful activity
- Limited access to education or rehabilitation
- Minimal opportunities for human contact
- Delays in accessing healthcare or medication
For prisoners with mental health problems, prolonged isolation can rapidly worsen their condition. Even prisoners entering custody without any history of mental ill-health can deteriorate quickly under these conditions.
Prison staff themselves consistently report that there simply are not enough officers to monitor, support or protect the people in their care. This creates an environment where risks go unnoticed and emergencies are not responded to quickly enough.
A growing drugs crisis making prisons unsafe
Another factor repeatedly highlighted in official reports is the widespread availability of illicit substances. Drones delivering drugs into prisons have increased dramatically, making it easier for synthetic cannabinoids and other harmful drugs to enter the prison system.
Substances such as synthetic cannabis (“spice”) are known to cause:
- Hallucinations
- Erratic or violent behaviour
- Paranoia
- Extreme anxiety
- Psychosis
Prisoners under the influence can lose control of their actions, endanger themselves, and be vulnerable to exploitation, violence, and debt. Staff shortages make it even harder to manage these risks or intervene early when someone shows signs of distress or drug-related mental health episodes.
This environment fuels violence, bullying, and fear. For people already struggling with addiction or trauma, it can be overwhelming, and in some cases, fatal.
Deep failings in mental health care and dangerous delays in hospital transfers
Mental health treatment inside prisons is inconsistent and, in some cases, dangerously inadequate. Oversight bodies have documented repeated failures to identify mental health needs, delays in providing medication, and long waits for specialist care.
At HMP Downview, the Independent Monitoring Board reported a 90% increase in acutely mentally unwell women facing long delays in being transferred to psychiatric hospitals. These are women deemed too unwell to remain in prison, yet they are often left waiting for months because of shortages in secure hospital beds or delays in assessments.
During these delays, many continue to deteriorate, often without getting the urgent care they need.
Poor coordination between prison staff, healthcare teams and community mental health services also contributes to risk. Information does not always flow correctly, and warning signs are sometimes missed.
Breakdowns in risk assessment, monitoring, and basic safeguard procedures
Many inquests following deaths in custody highlight similar themes:
- Risk assessments not properly completed
- Warnings not shared between prison and healthcare staff
- Prisoners not placed on appropriate monitoring procedures
- Failures to provide medication or follow-up care
- Neglect of vulnerable prisoners in segregation units
These failings create situations where people at high risk of suicide or self-harm do not receive the protection or support they are entitled to.
Families are often left with devastating questions:
How did the prison fail to notice the warning signs? Why were they not properly monitored? Why was their healthcare delayed? Why did no one intervene?
Why deaths in custody raise serious human rights concerns
Every person held in custody is entirely under the care and control of the state. This places clear and strict obligations on public authorities.
Under Article 2 of the European Convention on Human Rights, the right to life, the state has a legal duty to:
- Protect life
- Take reasonable steps to reduce the risk of suicide or harm
- Provide adequate medical and mental health care
- Investigate every death fully and independently
These obligations apply from the moment a person enters custody, through their time in prison, and after their death.
Where the state fails to meet this duty, through inadequate staffing, poor monitoring, failures in healthcare or delayed transfers, families may have grounds to pursue a claim for breach of human rights.
The vital role of inquests in uncovering the truth
When someone dies in custody, a full coroner’s inquest must take place. This investigation is essential for several reasons:
- It examines how the person died and whether any failings contributed.
- It reviews evidence from prison officers, healthcare staff, and external specialists.
- It considers whether appropriate safeguards, such as ACCT monitoring, were in place.
- It allows families to access information that would otherwise remain undisclosed.
- It can lead to Prevention of Future Deaths (PFD) reports, which require the prison or NHS to address identified failings.
In many cases, inquests are the only way families have been able to uncover systemic issues that contributed to their loved one’s death.
These findings have wider public value. They inform the public, reveal shortcomings in the prison system, and push for necessary reforms that may save lives in the future.
Can families get legal representation at an inquest?
Yes. Many families are eligible for Legal Aid, particularly for deaths occurring in custody or detention. Legal representation is crucial because public bodies involved in a death in custody, such as the prison service, healthcare providers commissioned by NHS England, and other agencies, often have their own legal teams. A family should not be left to deal with a complex legal process on their own, especially whilst grieving.
How Simpson Millar supports families after a death in custody
At Simpson Millar, our Public Law and Human Rights team has extensive experience representing families who have lost loved ones in:
- Prisons
- Police custody
- Immigration detention
- Mental health hospitals
- Secure children’s homes
We help families by:
- Advising on their rights
- Preparing them for the inquest process
- Gathering expert evidence
- Challenging unsafe or unlawful practices
- Pursuing civil claims where appropriate
- Ensuring accountability from public authorities
We take a compassionate, straightforward approach, explaining every step clearly and ensuring that families feel supported and heard.
If you have concerns about a death in custody, we might be able to help
If you have lost a loved one in custody or are worried about how someone is being treated while detained, our specialist solicitors can offer clear, practical advice.
We can help you understand your options, prepare for an inquest, and take steps to hold public bodies accountable where failings may have contributed to the death.
For confidential legal advice, call our expert team on 0808 149 9561 or request a callback today.
