This article is more than 6 months old

This article is more than 6 months old

An artist caught in a “perfect storm” of deteriorating mental health and a prison term she feared would never end suffered an extremely rare sudden death alone in her cell, an inquest has concluded.

Charlotte Nokes, 38, was on suicide watch when she died in her cell in Peterborough prison, run by the outsourcing company Sodexo, on 23 July 2016, the inquest was told.

Nokes, who had been offered a scholarship at Central Saint Martins art school in London, was struggling with the indeterminate term of her sentence, known as an imprisonment for public protection (IPP).

Charlotte Nokes's father: 'They might as well have thrown the key away' Read more

IPP sentences, which were abolished in 2012 after their use spiralled out of control and the European court of human rights deemed them unlawful, gave offenders a minimum jail tariff but no maximum.

Nokes, who was diagnosed with a personality disorder, was given a minimum term of 15 months for attempted robbery and possession of a bladed weapon, but at the time of her death had been in prison for eight and a half years, jurors were told.

Her family were concerned the medication she was receiving to treat her worsening mental health, which had been exacerbated by the IPP sentence, contributed to her death.

But the inquest heard a postmortem examination was unable to establish a cause of death and appropriate checks to monitor the side effects of medication had taken place.

On Tuesday, jurors at an inquest in Huntingdon, Cambridgeshire, concluded Nokes died of natural causes, namely sudden arrhythmic death syndrome (Sads), also known as sudden unexpected death syndrome.

After the inquest, Charlotte’s father, Steven Nokes, said the family were disappointed by the conclusions of the inquest.

He said: “Natural causes is too ambiguous. There were so many other things to consider in Charlotte’s death. After a three-and-a-half-year wait since she died, this felt like an anti-climax.

“We’ve been grieving all this time. The grief won’t go away. But we have an answer now. A line can be drawn under it. It’s not quite the answer we wanted. Charlotte died and it doesn’t seem that much is happening to stop something like this from happening again.”

Tara Mulcair, a solicitor at Birnberg Peirce, who represents Nokes’s family, said: “Charlotte’s inquest has shone a light on the injustice faced by IPP prisoners … 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.”

Charlotte’s father; a psychologist who treated her; and a forensic psychiatrist with expert knowledge of mental heath in prisons, told the jurors Nokes’s IPP sentence had had a significant impact on her mental health.

Dr Dinesh Maganty, a consultant forensic psychiatrist, said Nokes was caught in a “perfect storm”.

“[When] individuals with a personality disorder and depression and anxiety, [are] incarcerated the sense of hope is gone; and for treatment of a personality disorder, for psychological treatment, the provision for a sense of hope is key,” he said.

“That’s very difficult, almost impossible when you’re on an IPP sentence as there’s a sense of injustice over-hanging you and no sense of hope.”

Maganty said the death rate of those serving IPP sentences was disproportionately high “because of this loss of this sense of hope”.

Nicky Asplin, the principal counselling psychologist who worked with Nokes in the months before she died, told the jury that during a therapy session shortly before her death, Nokes expressed “a lot of frustration at the never-ending sentence of an IPP prison sentence”.

The psychologist said she had raised concerns with the National Offender Management Service (Noms) – now called Her Majesty’s Prison and Probation Service – about the impact of the sentence on Nokes.

“I expressed my concern that she was significantly over tariff and could we move this forward,” Asplin said.

Steven Nokes told the inquest his daughter “almost always” mentioned her IPP sentence. “It was a source of great distress for her,” he said. “She would say things like: ‘Dad, I don’t think you understand the sentence, it’s like a death sentence’, and: ‘I could be in here for the rest of my life.’”

Nokes, from Hayling Island, Hampshire, was subject to ACCT (assessment, care in custody and teamwork), a care plan for prisoners identified as being at risk of suicide or self-harm.

She was on a mix of drugs, including medication used to treat anxiety, anti-depressants, a hypnotic to treat insomnia, a treatment for acute mania and another to control tremors caused by anti-psychotic medication, the inquest heard.

She was observed on more than one occasion to be “over-sedated” with slurred speech, the inquest heard.

She was found unresponsive in her cell at 8.55am on 23 July 2016 and was pronounced dead at the scene, the jury was told.

Dr Martin Goddard, who conducted the postmortem examination, told the inquest he was unable to record a cause of death, ruling out third-party involvement, or a toxic cause of death, such as a drug overdose. He also said there were no obvious underlying natural causes.

Goddard told the jury it was possible she had suffered from Sads, which is only recorded in 1% to 5% of deaths at inquests.

“I apologise to the family that I’ve been unable to give them peace of mind, but I’m afraid that is the way it is,” he said. “There is nothing to suggest it was an unnatural death.”

Deborah Coles, the director of Inquest, which has worked with Nokes’s family since her death, and supported other families bereaved by the deaths of people on IPP sentences, said if Nokes had not died, she would probably still have been in prison.

“Charlotte was trapped in limbo, her ambitions and prospects indefinitely on pause,” Coles said. “She was being 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.”