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‘When I found out how the prison had treated her, it was heartbreaking’

<span>Photograph: Martin Godwin/The Guardian</span>
Photograph: Martin Godwin/The Guardian

In September 2017, diabetic Annabella Landsberg was restrained in her cell by four officers after refusing to take her medication. Afterwards, she lay on the floor of her cell in the segregation unit at HMP Peterborough and refused to get up. Although staff checked on Landsberg, 45, later that evening and night, none entered her cell. All recorded her as still lying on the floor.

The following day, subsequent checks by the nurse, prison officers and the duty manager found that Landsberg remained immobile – yet no concerns were raised. In fact, prison records showed that a nurse had thrown a cup of cold water over Landsberg to “receive a response”. There was none, but the nurse recorded Landsberg was “seeking attention and faking medical issues”.

It wasn’t until 2.45pm that prison staff became concerned – and on checking her blood, oxygen and sugar levels, realised that she was seriously ill. An ambulance was called and Landsberg was taken to hospital, where she remained in intensive care until her death three days later from multi-organ failure. Although her death was recorded as from natural causes, the prison and probation ombudsman (PPO) called the events leading to it “truly shocking”. The PPO said staff took far too long to carry out clinical observations that “might have been able to prevent her death”.

The next day, checks by the nurse and officers found that Landsberg remained immobile – yet no concerns were raised

At her inquest last April, the jury heard that nursing staff at the private prison, run by Sodexo, were not aware of Landsberg’s diabetes and therefore missed visible warning signs. In their narrative verdict, they concluded there were “failings on the part of the prison, healthcare staff and custody officers that contributed to the death”. These included a lack of medical or welfare checks after the use of force left Landsberg on the floor of her cell, repeated failure to recognise the severity of the situation, inadequate staffing and training, as well as poor systems for handling prisoners with chronic conditions.

Landsberg moved to the UK from Zimbabwe in 2002 and settled in Worthing, West Sussex, where she became a senior care worker. Her younger sister Sandra, who also works in care, says all was well until Annabella was diagnosed HIV positive in 2007. “It changed her personality and behaviour,” says Sandra. “She started acting childishly, drinking and mixing with people living on the streets.”

In 2016, Landsberg was sentenced to four and a half years in prison for robbery and assault.

For Sandra, who saw her sister in hospital before she died, realising her death could have been prevented has been traumatic. “When I saw the state she was in and later learned of how she had been treated, it was heartbreaking. The staff failed in their professional duty of care: no one deserves treatment like that,” she said.

Damian Evans, director at HMP Peterborough, says: “It is clear that the care Annabella Landsberg received while she was at HMP Peterborough fell short of the standard we expect and we are very sorry for this. Our thoughts continue to be with Annabella’s family and friends. Since Annabella’s death we have undertaken a thorough review of the delivery of healthcare services at HMP Peterborough and accepted all the recommendations from the initial prisons and probation ombudsman’s report into her death. This has led to many changes and improvements being made.

• In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.