Inquest concludes into death of IPP prisoner Charlotte Nokes seven years over original tariff

Wednesday 4 March 2020

Stephen Clark of Garden Court Chambers' Civil Liberties Team represented members of Charlotte’s family and was instructed by Tara Mulcair and Harriet Wistrich of Birnberg Peirce.

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The inquest into the death of Charlotte Nokes has concluded with the jury finding her death was by ‘natural causes’. Charlotte was 38 when she was found dead in her cell in HMP Peterborough on the morning of 23 July 2016. She was serving an indefinite Imprisonment for Public Protection (IPP) sentence and was over seven years over the minimum tariff when she died.

The jury concluded the medical cause of Charlotte’s death was “Sudden Arrhythmic Death Syndrome”. The coroner’s decision on whether to write a follow up report to Prevent Future Deaths is awaited. The family hope their concerns around the adequacy of cell observations, and the risk of suicide for IPP prisoners, will be highlighted.

Known to her family as Charlie or Lottie, they described her as funny, intelligent, charismatic and creative. She was an extremely talented artist whose work was exhibited by the Koestler Trust. She developed her passion for art whilst in prison and had been offered a scholarship to study at Central St Martins on release.

Charlotte was given an IPP sentence on 4 January 2008. She was to serve a minimum term of 15 months imprisonment. However, at the time of her death, she had served 8½ years in custody. The jury heard that the indefinite nature of Charlotte’s sentence, and her fear that she would never be released from prison, contributed to a sense of extreme hopelessness. She described her sentence to her family as a death sentence. The inquest heard that despite being seven years over tariff, Charlotte was only at the very early stages of being ready to engage with the therapeutic help she needed to begin the path to release.

The inquest heard that Charlotte had been diagnosed with a Personality Disorder and was prescribed a number of antipsychotic drugs to treat her symptoms. In the months leading up to her death, she often appeared over-sedated, drowsy and was slurring her speech. The jury heard that some of her depot medication was administered for unusually long periods.

At the time of her death, Charlotte was placed on suicide and self-harm monitoring procedures, known as Assessment, Care in Custody and Teamwork (ACCT) after she had attempted to take her life. Charlotte was on twice hourly observations as part of the ACCT process. Despite this, the inquest jury heard that she died a number of hours before she was found at 08:35, despite documented welfare checks throughout the night and concerns about her welfare.

On the morning of 23 July 2017, Charlotte was checked at 07:23, 07:53 and 08:12. She was noted to be asleep in an upright position. At 08:30 another officer looked through the observation panel to Charlotte’s cell. She noted that Charlotte appeared to have been in the same strange sleeping position as the night before – she was sitting upright and slumped forward. She unlocked Charlotte’s cell and called her name. There was no response. She called Charlotte’s name and again there was no response. She then shook Charlotte’s shoulder and noticed that she was cold to touch, her whole body was stiff and her face was “very red and dark purple, further than bruising”. She raised the alarm. Paramedics arrived but by that time Charlotte could not be resuscitated. She was pronounced dead at 08:55. The evidence of the pathologist was that Charlotte had died some time before she was discovered, possibly 3-4 hours earlier.

On behalf of her family, Charlotte’s father Steven Nokes said: 

“As a family, we remain concerned about the way Charlotte was treated in prison and do not believe the care she received was appropriate. She had many struggles in life, was beaten up for being ‘different’ and experienced mental ill health. Prison was never the best place for her. The indefinite sentence only made this worse. Charlotte lost hope and so did we. She told us the IPP sentence was really a life sentence, and despite her hopes and dreams of moving to London to study art, she knew she would die in prison. This cannot continue.”

Steven Nokes spoke in detail to The Guardian during the inquest.

Deborah Coles, Director of INQUEST, said: 

“Charlotte was trapped in limbo, her ambitions and prospects indefinitely on pause. She was forced to wait for action to truly end IPP sentences, despite them having long been deemed unlawful and ‘abolished’. Had she not died it is likely she would have still been in prison waiting for that action, as many others are.

For far too many women, prison remains a disproportionate and inappropriate response to their behaviour and needs. Indefinite sentences continue to cause additional harm. To prevent further deaths and harm, Government must work across health, social care and justice departments to dismantle failing women’s prisons and invest in specialist community led women’s services.”

Tara Mulcair of Birnberg Peirce who represents Charlotte’s family said: 

“Charlotte’s inquest has shone a light on the injustice faced by IPP prisoners. Charlotte was caught in a vicious cycle of indefinite incarceration, which created a strong sense of hopelessness and exacerbated her poor mental health, which in turn led to her continued detention.  In Charlotte’s mind, there was no prospect of release, as is the case for many still serving IPP sentences. There should now be an urgent review of all IPP prisoners who are over tariff and were sentenced before the Courts recognised that these sentences are unlawful. It is time to put right this injustice.”


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