Deaths in custody: why are more prisoners dying from ‘natural causes’?

An independent investigation is needed to explain the sharp rise in the number of Australian prison deaths being attributed to “natural causes” and the young ages of those dying, according to a Fremantle-based PhD researcher and human rights campaigner.

Deaths from natural causes have become the most frequent cause of death in Australian prisons, consistently outnumbering hanging deaths — historically the most frequent cause of prison deaths, as Crikey reported last week — every year since 2001 (except in 2003, when the numbers were the same). Natural causes accounted for almost three in four prison custody deaths in 2008, the last year for which national statistics are available, while 2007 and 2008 logged the highest number of deaths from natural causes since record-keeping began, with 32 and 38 deaths, respectively.

Equally disturbing are the young ages at which many of these prisoners are dying. Indigenous prisoners are dying from natural causes around 20 years earlier than indigenous people in the general population, while non-indigenous prisoners are dying almost 30 years earlier than their counterparts in the community. According to the Australian Institute of Criminology, 13 or one-third of the 38 people who died from natural causes in 2008 were younger than 45 years. Natural causes are the most common cause of death for indigenous prisoners above the age of 26.

“You can’t have people dying in significant numbers at these young ages — in their 20s, 30s, and so on — and deem them as natural causes,” said Gerry Georgatos, a researcher and Human Rights Alliance convener. “We would not, and do not, accept this elsewhere. We seek the cause of death and whatever may have contributed to premature deaths and, where possible, lay charges in pursuit of culpability and liability.”

Georgatos rejects the AIC’s claim that the rise in natural cause deaths is “probably linked to an ageing prison population and a prison population with more health problems than the general population”, saying that these “assumptions” need to be validated.

“I have deep concerns about the attribution of manner and cause of death and therefore … [about] the classification of deaths in custody,” Georgatos said. “There is nothing natural about a person dying of causes that basic medical intervention could prevent. More than 50% of Aboriginal folk who die in prison are classified as natural cause deaths, [but] maybe what has occurred is that medical attention wasn’t flagged or their insulin dependency was not given proper care or they were maltreated or neglected.”

At the very least, he says, there should be an independent inquiry and a review of as many cases of natural cause deaths as possible: “We do have a culture of turning a blind eye, favour dispensation and an acceptance of stressed prison health services … underwritten by a culture where reporting mechanisms and investigations by certain authorities do not scrub up.”

The AIC told Crikey in an email statement that further investigation into the classification of deaths was not necessary, since “an independent body, the state/territory coroner, is the one who determines the cause of death … not the AIC or the custodial authority involved”.

However, as Crikey has previously reported, coroners in all but two Australian states and territories (the ACT and Victoria) have no legal obligation to look beyond the immediate cause and manner of death — a situation that has led to claims that underlying issues of prisoner care and treatment are not properly investigated. Crikey’s own analysis of NSW coroners’ reports from the past nine years has revealed at least 10 cases of natural cause deaths in which coroners criticised the actions of custodial or prison health staff in their written findings.

David Kentwell, a 42-year-old inmate at the privately run Junee Correctional Centre, died of a heart attack in 2008 after staff breached protocols requiring staff to transfer inmates with continuing chest pain to hospital. On the morning of his death, Kentwell visited the clinic three times complaining of chest pain, but staff did not call an ambulance until three hours after his second visit.

Delayed transfer to hospital was also an issue in the death of 43-year-old Cane Pejovski, who died of a heart attack while imprisoned at John Morony Correctional Centre in 2002. Deputy state coroner Carl Milovanovich found that staff did not examine the inmate’s medical files closely enough on the day of his death. Had this been done, Milovanovich commented, staff would have seen that Pejovski had already been hospitalised three months earlier for chest pains and required immediate transfer.

In two other cases of natural cause deaths investigated in 2003 and 2005, coroners criticised the failure of staff to follow the directives and recommendations of visiting medical practitioners in the ongoing care of the prisoner.

Coroners in other jurisdictions have made similar findings. In his 2000 report on deaths in prison custody, former Western Australian Ombudsman Murray Allen noted that coroners made recommendations and comments “involving health issues and the administrative practices of health services personnel” at 10 out of 18 inquests into deaths from natural causes. Issues included failure to transfer medical files, failure to consult medical files , poorly conducted medical assessments and inadequate record keeping — all issues identified by Crikey’s own investigation into NSW prison deaths of the past decade. All 18 deaths occurred in Western Australian jails between January 1991 and September 1999.

Michael Levy, director of Justice Health Services in the ACT, says allegations of professional negligence, incompetence or maliciousness in prison health services do not accord with his experiences in the field. “There’s enough deaths in custody for a lot of recommendations to start to demonstrate a pattern and if that pattern were negligence, that would be demonstrated,” he said. “But that’s not the experience as far as I know, not in recent history in Australia.”

A more likely explanation for the high rate of deaths from natural causes is the worsening health of people entering the prison system, he said: “Access to health services while in custody should actually improve health outcomes, especially of life critical events, so … if the death rate is higher [than in the past], even in a situation where people have virtually immediate access to health services, which most prisoners do just because it’s a geographic issue — there’s a health service in the prison, there’s prison officers all over the place who can alert the health service at a moment’s notice — then what’s possibly happening is that even that excellent access doesn’t remedy the health deficit.

“We’re creating even sicker underclass than we have in previous eras, such that … the health services we’re putting up to them as temporary remedies aren’t even catching up or aren’t even addressing appropriately [that deficit] … Maybe we have to revisit what models of care we actually deliver to prisoners.”

Australian Medical Association federal vice-president Steve Hambleton told Crikey it would support an investigation into natural cause deaths, adding that the AMA has previously campaigned on this issue: “The ages of Australian prisoners dying are alarming. The differentiation between Aboriginal and Torres Strait Islanders and other Australians makes it even more disturbing.”

Chris Cunneen, professor of Justice and Social Inclusion at James Cook University, agrees any explanation must take into account Australia’s soaring rates of incarceration. “As I’ve said time and time again, the issue is mass incarceration,” Cunneen said. “We know that prisoner health is poor compared to the general population and that people are also spending more time in prison. This, combined with increasing prisoner numbers, means the ability to provide services is becoming more and more stressed.”

Yet the rise in natural cause deaths has outpaced even the explosion in Australia’s prison population, which has doubled from 15,000 in 1991 to 30,000 today. Between 2000 and 2008, the number of prison custody deaths attributed to natural causes rose to an average of 24.6 per year nationwide, compared to 16.3 in the decade to 1999 and 10.6 in the decade to 1989.

Crikey asked the AIC for further statistics on natural cause deaths in prisons, but was told that “research ethics protocol” required the institute to secure the agreement of police and corrections departments in each state and territory before releasing “new data”. No further information has since been provided.

Nevertheless, the AIC has conceded that more research in the area could prove useful: “Of course, part of the reason for the ongoing monitoring of deaths in custody by the AIC is to identify emerging trends in the data, and to recommend to authorities changes in policy that address these trends. In light of recent rises in natural cause deaths in prison, this issue will be targeted for further research in the next NDICP [National Deaths in Custody Program] annual report, due out at the end of this year.”

* This is the 11th and final chapter in a series of case studies and investigative reports into prison deaths