Four in ten prisoners who took their own lives in custody were denied adequate healthcare before their deaths, according to damning new figures exposing the scale of neglect inside Britain’s overcrowded prisons.
Inmates are legally entitled to receive the same standard of healthcare as someone living in the community. However, official findings uncovered by The Independent show in 101 out of 233 self-inflicted deaths investigated by the prisons watchdog between 2020 and 2023, the mental or physical healthcare did not meet this requirement.
In each case a clinical reviewer assessed whether the care was equivalent to what they would expect outside of jail as part of investigations into the deaths by the Prison and Probation Ombudsman (PPO). In many of the self-inflicted deaths, failings related to mental healthcare.
The chairman of the justice committee, Andy Slaughter, said “we are failing people in custody” after the figures came to light, while the chief inspector of prisons, Charlie Taylor, warned “without any doubt” there will be more potentially preventable deaths if action is not taken to drive up standards.
“We see it frequently in prisons that we inspect that there are people who just aren’t getting the support that they need,” he told The Independent. “If someone needs treatment, they need treatment.”
One grieving family described the treatment of prisoners as “medieval” after father-of-two Jason Lee McQuoid, 37, did not eat or sleep for three days as he begged for help after being segregated at HMP Risley, Cheshire. Despite repeatedly warning he was going to take his life, he was not seen by a mental-health clinician in the 72 hours before his death.
“I can’t believe that human beings could watch another human being in such a desperate state – pleading for help – and not intervene,” his heartbroken aunt Joyce McQuoid told The Independent.
“He was just left. There was no mental-health intervention, there was no medication. He hadn’t eaten for three days.
“It was just utterly devastating to find out that he had suffered so much torment before his death and that had been going on unnecessarily for at least 72 hours.”
She said she was “not surprised” such a high proportion of prisoners are not getting the right care, adding: “The way we treat prisoners here is medieval, we shove them in a concrete cell and they are forgotten about. Prison is a terrifying place to be. You put them in a cell and they are left to rot.”
Last October, a jury concluded Jason, who was inside for shoplifting in Winsford, Cheshire, had been failed before his death in March 2021.
In December, another inquest jury found neglect and a failure to procure basic medical attention contributed to the death of publican Haydar Jefferies, who took his own life inside HMP Coldingley in Surrey in February 2023.
The 50-year-old’s mental health rapidly deteriorated after he was recalled to prison after nine years rebuilding his life on the outside over an unproven allegation under the terms of his indefinite jail term.
Shortly before his death, he was observed naked on all fours in his cell barking like a dog, in the throes of severe depression and suffering acute psychosis. Staff did not provide him with any medical attention.
In a strongly worded intervention this week, a third coroner called for action after identifying multiple prison and healthcare failures in the self-inflicted deaths of three prisoners within 19 days of each other at HMP Lowdham Grange, Nottinghamshire.
“I am troubled that unless there is a radical change in culture, and reflective learning from deaths is prioritised, prisoners will continue to die in custody,” Nottinghamshire coroner Laurinda Bower said.
Prisons inspector Mr Taylor said he was “not surprised” but “very disappointed” by the findings of clinical reviewers for the PPO, adding that all too often prisons are failing to get the basics right when it comes to preventing suicides.
This includes paying particular attention to new arrivals, those cut off from family, sent to prisons far from home or detoxing from alcohol misuse.
In a thematic review last year, he found that even in cases where a prisoner is referred for a hospital transfer under the Mental Health Act, only 15 per cent are moved within 28 days.
“Unfortunately, what it meant was people who were a great risk to themselves, as well as the people around them and the people working in the prison, were spending long periods of time locked in segregation units,” he said, adding such units are often dark, dingy and wholly inadequate places for severely unwell prisoners.
Mr Slaughter, whose justice committee is holding two inquiries into prisons, said the overcrowding crisis Labour inherited has created a “vicious spiral downwards” in terms of prison services.
“We are failing people in custody because their punishment is being deprived of their liberty,” he added. “They should not be having additional punishments because of the poor services or poor circumstances at the prison.”
Leila Hagmann, media and communications coordinator at INQUEST, who supported the McQuoid family, said: "Every human being deserves access to the healthcare they need. So why are we failing those locked behind prison walls?
“These figures reaffirm what bereaved families and INQUEST have long been saying: prisons are inherently harmful institutions where you are more likely to die than in the community.”
Andrew Neilson, of the Howard League for Penal Reform, said too often prisoners who ought to be in hospital beds are left in squalid conditions.
“These figures show the tragic results of a prison system stretched too far,” he added. “Our overcrowded prison system that has been asked to do much, with too little, for too long, is ill-equipped to help people who require intensive support for their mental health.”
A Ministry of Justice spokesperson said: “These shocking statistics, covering the period between 2020 and 2023, clearly illustrate the crisis this government inherited in our prisons, with deeply concerning levels of self-harm.
“The new Mental Health Bill will rightly end the use of prison cells for people facing acute crisis as a so-called ‘place of safety’ and ensure they get the urgent specialist help they need instead.”
An NHS spokesperson said: “These figures are shocking and we know that healthcare in prisons is under increasing pressure due to growing prison populations.“Mental health services are provided in all prisons in England and there has been increased investment to improve capacity as well as a new mental health pathway developed to strengthen the care and support individuals receive pre, during and post custody.”
If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch.
If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week. If you are in another country, you can go to www.befrienders.org to find a helpline near you
