The conduct of staff at HMP Peterborough probably contributed to the death of a diabetic prisoner who was restrained by four prison officers, an inquest has concluded.

After the restraint Annabella Landsberg, 45, was left on a concrete floor for 21 hours before being rushed to hospital where she died three days later on 6 September 2017. In the period she was on the floor, she did not take medicine or eat any of the food that was placed in her cell and she was not seen to drink any fluids.

Her sister, Sandra Landsberg, said the family were “happy and relieved” at the conclusion, but said that the prison and healthcare staff involved should “never be allowed” to practise again.

“They failed their job as professionals. The treatment she got was awful. No one deserves treatment like that.”

The jury had heard that staff thought her sister, who had been left lying in her own urine mumbling incoherently, was “pretending” to be ill. Sandra Landsberg said: “[Now] they will know to take every person seriously in the future … In the end, my sister had to lose a life. Her kids don’t have a mother now. That’s very traumatising.”



Recording a narrative verdict, the jury said: “We conclude that there were failings on the part of the prison, healthcare staff, GPs and custody officers that contributed to the death of Annabella Landsberg. HMP Peterborough prison management and systems in place failed to provide healthcare for chronic illnesses equivalent to that in the community, specifically the absence of a diabetic pathway and dedicated diabetic nurse.”

The jury concluded that a lack of awareness about Landsberg’s diabetic status “very probably” contributed to her death.

They recorded that “repeated failings” to recognise the severity of Landsberg’s situation after she presented with diabetic symptoms – such as oral thrush, dizziness, and saying that her legs were not working before she was restrained – probably contributed to her death.

They concluded that “unsatisfactory” staffing levels and an over-reliance on agency staff, inadequate training, and unsatisfactory observations also possibly contributed to her death.

During the inquest, the jury were told that a number of staff at the prison, including a nurse and a senior nurse, were not aware of Landsberg’s type 2 diabetes.

Representing the family, Megan Phillips of Bhatt Murphy said the case revealed “shocking” failures on the part of prison and healthcare staff at Peterborough, a private prison run by Sodexo.

“This case has revealed shocking failures by both discipline and healthcare staff at HMP Peterborough. Annabella had been at HMP Peterborough for over three months, and there were clear flags in her medical records, including with respect to her diabetes.

“Yet numerous members of the healthcare team failed to read her notes, and key healthcare staff were unaware that she even had diabetes.”

The prisons and probation ombudsman (PPO) published a report on an investigation into the death on Wednesday, which lambasted prison staff for assuming Landsberg was pretending and leaving her on the floor for so long.

“The events leading up to Ms Landsberg’s death are truly shocking … 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 …Whatever happened, it is unacceptable that she was left lying on the cell floor for 21 hours,” the report said.

The report raised concerns that a body-worn camera was removed by prison staff before restraining Landsberg, leading to the loss of vital evidence.

HMP Peterborough is the only mixed-gender prison in the country, and came under fire from HM Inspectorate of Prisons last year for excessive use of force and insufficient safety. In the past decade, 10 inmates have died in the prison.

Deborah Coles, the director of the charity Inquest, said the case was symptomatic of the way that black women are treated in institutional settings: “The image that sticks is of Bella lying on the floor of her cell and someone walking over her to put her food tray on the desk, or giving her a kick to see if she is responding.

“Inquest has seen too many stories of black women treated in an inhuman way [by police and prisons]. Black women consistently die in contentious circumstances where there are serious concerns about their dehumanising treatment.”

A nurse, Lesley Watts, who has since received a suspension from the Royal College of Nursing, admitted early in the inquest to throwing water on Landsberg in the hours before she was rushed to hospital. In the PPO report published on Wednesday, a recommendation was made that Watts’ fitness to practise should be examined by the Nursing and Midwifery Council. Watts has been served an interim suspension order since the incident.

Landsberg died on 6 September after arriving at the hospital with multi-organ failure. It was concluded that a hyperosmolar hyperglycaemic state (HSS) and rhabdomyolysis – a breakdown of skeletal muscle – caused Landsberg’s death, with her type 2 diabetes being an underlying cause of death.

Landsberg fled her native Zimbabwe following a gang rape around 2002 and was diagnosed with HIV in 2007. She had three children. Landsberg’s body was repatriated to Zimbabwe and her funeral was held in Harare, after her three children were denied access to the UK for her funeral.