Open letter to prison governors, prison healthcare providers, and commissioners at HMP Pentonville, Wormwood Scrubs, Bronzefield, Peterborough, Bristol and New Hall, NHS England Health Justice, CQC, GMC, RCGP, RCP, and hospitals providing care for the hunger strikers.
We write to you, once again, as healthcare professionals who are shocked at this government’s continued neglect of the health and rights of eight individuals who are currently – or have recently been – on hunger strike: Qesser Zuhrah, Amu Gib and Jon Cink (HMP Bronzefield); Heba Muraisi (HMP New Hall); Teuta Hoxha (HMP Peterborough); Kamran Ahmed (HMP Pentonville); Muhammad Umer Khalid (HMP Wormwood Scrubs); and Lewie Chiaramello (HMP Bristol).
Two of the hunger strikers – Heba Muraisi and Kamran Ahmed – are now approaching their 9th week of hunger strike, and continue to face the real possibility of irreversible harm or death. Heba has now gone 69 days without food. At this stage during the Irish republican hunger strike in 1981, 80% of the hunger strikers had died. Kamran, who is on day 62, was transferred to A&E for a sixth time on Wednesday 7th January with bradycardia and an array of concerning symptoms. We reiterate several of the concerns raised in our earlier letter dated 17th December, while amplifying demands for improved medical care and oversight to mitigate the risk of even greater harm.
The need for continuous, specialist medical monitoring
It is our view that the hunger strikers must be admitted and kept in hospital for continuous monitoring and specialist investigations, not merely transferred to A&E and discharged after a number of hours. This view is shared by Dr David Nicholl and Dr John Kalk, who wrote in The Guardian on 23rd December: “Were we responsible for [the hunger strikers’] care, we would refuse to discharge them from hospital unless the patient wished to return to prison, a stance that emerged after the 1989 anti-apartheid hunger strikes and became known as the “Kalk refusal”.” In the case of Kamran, we are deeply concerned at the recent suggestion that his cardiac physiology may be changing, and yet that he has not been admitted for specialist investigations such as an echocardiogram, further cardiac monitoring, or review by a cardiologist.
Lewie Chiaramello, the third active hunger striker, requires 24/7 access to life-sustaining medication for his diabetes, which is recognised as a disability under the Equalities Act 2010. It is our understanding that his diabetes reader and insulin have been withheld during visits, and during movements to and from his cell. We are particularly concerned about reports of sub-standard treatment in hospital. The use of restraints, and the refusal of communication with next of kin, has prompted some of the hunger strikers to reconsider transfer to hospital despite recognising the importance of timely medical intervention. That certain conditions should be worse in hospital than in prison is an indictment of the care provided to the hunger strikers in such settings.
The excessive and unnecessary of restraints on remand prisoners in hospital
The inhumane treatment of the hunger strikers in hospitals has not gone unnoticed. In our earlier letter we highlighted BMA guidelines on the use of restraint in hospitals, and the international standards that are often referenced in UK practice, which state that restraints should never be used where more humane means suffice. The proportionality test fails for each of these patients, who are currently some of the most surveilled people in the country.
Despite being assessed as no security risk last week, Kamran Ahmed was still classed as a high escape risk during a recent hospital transfer. He has twice been subjected to double shackling: shackled to a prison guard, and simultaneously cuffed wrist-to-wrist.
While some healthcare professionals have requested removal of the shackles, all such requests have been denied, with prison guards referring to their prison protocols. In several instances, shackling has compromised timely care-giving. During Kamran’s most recent A&E presentation at UCLH, healthcare staff were unable to cannulate due to the shackles, and had to call a specialist to cannulate between the fingers. This cannula eventually tissued, and rather than re-cannulating, the responsible physician opted to discharge him back to the prison.
In other instances, we are concerned that healthcare workers have not advocated for removal of restraints, ultimately failing in their duty of care as advocates for their patients. Such treatment is degrading both for the patients and also for the healthcare workers, who are unable to meet their professional obligations.
The as-yet unknown long-term physical and psychological effects of the hunger strike
While recognising that Qesser Zuhrah, Amu Gib, Jon Cink and Teuta Hoxha have paused their hunger strike, we emphasise that death is not the only tragic and devastating outcome of a hunger strike.
The physical toll taken on the body during the course of a prolonged hunger strike can be severe. The long-term harm and permanent complications can be difficult to identify, and may not become apparent for many years or decades. Deficiencies invital vitamins and electrolytes can lead to long term irreversible neuro-cognitive impairments and damage (this holds true for both those in a state of ongoing starvation and for those who are in refeeding phase). Neurological damage can lead to coordination difficulties, somatosensory issues, and cognitive impairment. Cognitive and neurological damage may be permanent, even when given thiamine supplements. To this end, we are aware that the hunger strikers were given oral thiamine supplementation (after some initial delay), despite evidence that oral absorption is inadequate in the starvation phase.
Severe muscle loss may take months or years to reverse, leading to sustained physical weakness and joint problems that may never fully resolve. Metabolic instability can lead to increased diabetes risk due to problems regulating blood sugar, reproductive hormone suppression, thyroid dysfunction, and other hormonal disruptions. Gastrointestinal problems such as chronic nausea, early satiety and abdominal pain can persist. Damage to the heart, liver, kidneys and cardiovascular system may be irreversible.
We note that the survivors of the 1981 Irish republican hunger strike experienced significant health problems later in life, such as digestive, visual and neurological complications.
The deep psychological trauma that results from a wilful neglect and lack of respect for life must be recognised, and may have long term implications for psychological wellbeing. Through the ongoing medical, institutional and systematic neglect endured by the hunger strikers, places them at heightened risk of severe and resistant complex PTSD, severe anxiety disorders, and severe depressive disorders. In combination with the above, cognitive fatigue, trauma and enforced isolation will significantly increase the likelihood of the development of long term disability and early death.
We also wish to emphasise the psychological harm that can result from prolonged remand (pre-trial detention). Official statistics and reports indicate severe psychological harm can occur from the chronic uncertainty and stress of indefinite detention. The deprivation of autonomy and inability to plan a future, is associated with profound anxiety and helplessness, which can lead to depression, anxiety, and PTSD. Remand prisoners – who are legally innocent – exhibit worse mental health than sentenced prisoners, with markedly higher rates of self-harm and suicidal ideation. After release there may also be enduring functional impairment, and increased long-term psychological morbidity.
A failure to ensure safe refeeding
As several of the hunger strikers have entered into the late stage of acute starvation, they are at extreme risk of refeeding syndrome and as such, any prisoners who end or pause their hunger strike must be taken to hospital without delay to manage the refeeding process.
We note that since Teuta Hoxha paused her hunger strike on 3rd January, it took several days before she was transferred to hospital. Despite requests that she could not safely manage refeeding in prison without the care of clinicians with the appropriate expertise, these delays persisted.
It has taken significant public pressure to ensure the transfer of Teuta and other hunger strikers to hospital. Additionally, Amu Gib and Qesser Zuhrah were discharged from hospital prematurely, despite medical advice that this was unsafe. This contradicts the Department of Health’s policy on refeeding, which directs that those at very high risk of refeeding syndrome should be managed in hospital to monitor fluid balance, electrolytes, micronutrients and vitamins and vital signs including ECG monitoring.
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To our colleagues working in healthcare settings in the prisons, we remind you that your primary obligation is to your patient. We further remind you of Rule 21(1) of the Prison Rules 1999, which states that “a medical practitioner working within the prison shall report to the governor on the case of any prisoner whose health is likely to be injuriously affected by continued imprisonment or any conditions of imprisonment. The governor shall send the report to the Secretary of State without delay, together with his own recommendations.”
To our colleagues in managerial, clinical governance, and commissioning roles within NHS Health and Justice in prisons, we ask that you recognise that healthcare services in prisons lack the expertise and resources to provide appropriate care to the hunger strikers, and that any delay in transfer to hospital may be catastrophic.
To our colleagues working in the hospitals receiving the hunger strikers, we remind you of the Department of Health policies on the clinical management of people refusing food, and for those undergoing refeeding. These documents exist to ensure the safety of critically unwell patients. The scope for mistakes in continuous clinical monitoring and care is exceptionally narrow; minor errors or omissions at this stage could lead to serious – and potentially fatal – outcomes for the hunger strikers. The heightened clinical needs of the hunger strikers, and the complex moral, legal, and political factors at play, should prompt healthcare providers in receiving emergency departments to advocate for admission under a specialty service.
We, the undersigned, call on all parties in positions of responsibility and authority, to act immediately to resolve this inherently dangerous and fragile situation, and safeguard the health and lives of the hunger strikers. In the words of their lawyers, “We are concerned that, should this situation be allowed to continue without resolution, there is the real and increasingly likely potential that young British citizens will die in prison, having never even been convicted of an offence.”
Naznin Mirza Doctor
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Lauren Grunwell Teacher
Zahra Hussain Plastic Surgery Resident / PhD student
Katherine Anthony GP
Meg Graham Clinical psychologist
Miriam Al-Kashi GP
Serajdin Ajnin Hospital consultant
Nic Lee
Gill Moreton Senior Principal Psychological Therapist
Dr Sonia Allam Physician
Arabella Scott National Lead Nurse for Substance Misuse
Sukaina Hirji Doctor
Ann San Retired nurse
Zoe Timimi PhD student
Sabina Hafesji
Lynn Cochrane Optometrist
Jane Macaskill Retired Surgeon
Shida Khan Midw
Hayley Pinto Doctor
Jonathan Miller Associate
Hilary Neve Dr
Sobbia Gull GP
Omar Al-Falahi GZP
Hilary Neve Dr
Maryam Rehman Pharmacist
Sahar Awadallah GP
M Hewitt GP
Qaiys Abu Qaoud Doctor
Qais Nazari Medical doctor
Jehad Aldeghather GP
Caroline Lenoury Healthcare assistant
andrea needham registered nurseHilary Klonin Doctor
Julia N lki Child psychiatrist
Azhar Malik Retired GP
Monique Keersmaekers GP
Morgan McMonagle Consultant surgeon
Jack Czauderna Retired Family Doctor
Maureen O’Leary Retired Consultant Psychiatrist
Gerry Oncology Nurse
Mehroz Ahsen GP Registrar
Mazin Karem Doctor
Moyra Mcallister GP
Maya Sacre Nurse
Joanna Penning Speech therapist between 1989 and 1997
Nimrah Ali Optometrist
Wendy McMullen Consultant
Tracy Ogilvie Retired nurse
Gerry McCartney Honorary Consultant
Eilidh Cameron Nicol Consultant
Asad Khan Retired Consultant Physician
Rachel Blackman Retired GP
Ranjeet Brar Consultant Vascular Surgeon
Jon Dale Retired occupational physician
Jane Darougar Psychotherapist
Helen Mitchell Nurse
Sue Wedlock
Bernadette Wren Emerita Consultant Clinical Psychologist
Reiner Tegtmeyer
Anna Livingstone Doctor – retired
Alec Phillips Doctor
Awais Anwar Doctor
Maggie Palmer Family Therapist NHS
Tammie Cook-Duncan Lead Nurse
Jill Stoner Retired
Kristen Wagg TNA
Judith Alison Summers Consultant psychiatrist
Teresa Bailey Child Psychotherapist
Jo Hammond Retired
Stephanie Foster Clinical Nurse Specialist
Nils Rickardsson Olsson Clinical Psychologist
Kelly Burgess
Charlie Ataliotis Nurse
Joanne Miller GP
Cathy Troupp Child psychotherapist
Graham Ogden Professor EmeritusZulaiga abrahams physiotherapist
Sacha Brown Specialist Physiotherapist
Adam Glover Clinical Engineer
Nicoletta Dentico Director
Howard Worgan Operational Services Manager
Sonya Dabydeen Dr
Dr Marion Neffgen NHS Consultant
Simon MacLardie Community Nurse
Janet Braybrook Support (retired)
Busra Nalbant GP
Maria Cass Pain Specialist Physiotherapist
Juliana Woode Registered Nurse
Jim Fagan Community Nurse (retired)
Sarah Dunne GP
Mogdad Alrawi Consultant- NHS
Justyna Lenczewska Pharmacist
Abi Deivanayagam Public health Doctor
Nadeem Ashraf Consultant Colorectal Surgeon
Mubashir Cheema Doctor
Polly Brandon GP
Mary Todd Dr
james wilson RMN
Aara Essajee Nurse
Alice Jefferson-Perry Nurse
Jill Austin Dr, Consultant
Melody Parmar Speech and language therapist
Leila Khosravi Paediatrician
Ian Mckendrick Registered Mental Nurse
Steven Haigh Retired
Margaret O’Connor Health Visitor
Imran Shafi Orthodontist
Dave Croucher Staff Nurse
Mohamed Emara General practitioner
S Dar Dr
Muhammad Hanif Consultant
Victoria Holt GP
Shahab Siddiqi Consultant
Jacob Laing Medical registrar, UHS Sussex NHS Foundation Trust
Jonathan Fluxman GP – retired
Michael Foulkes Consultant Psychotherapist (retired)
Raven Nielsen
Coral Jones Doctor
Ryan Weir NHS Dentist
Lindsey Mitchell Programme ManagerRebecca Nada-Rajah Staff Nurse
Muhammad Tholudin Doctor (Consultant)
Elizabeth Foster Retired General Practitioner
Mussadiq Master Pharmacist
Jane Kevern Retired GP
John Puntis Retired
Kathleen Cruise Nurse
Faiza Malik Doctor
M Hewitt Retired GP
Barrak Almoosawi Paediatrician
Jean Brant Senior Lecturer
Ahmet Kaya Healthcare management
Janet Heslip BMS
Mehboob Datoo Pharmacist
RANA HAMMAD Registered Nurse
Georgia Musson Registered Nurse
Kamil McClelland GP Registrar
Ramy Aly Consultant
Neda Hasan Specialist Registrar
Anna Nicholson-Lailey Doctor
Bianca Gill Nurse
Ilhame Atherfold
Danuta Orlowska Psychologist
Izzy Clennell Trainee Clinical Scientist
Fareed Bashir Consultant Psychiatrist
Oliver Spear GP trainee
Darine Ayoub Midwife
ZAINAB ARGHANDAWI Pharmacist
Winona Martell-Brown Doctor
Kavian Kulasabanathan GP registrar
Roshni Patel GP registrar
Terence Matthews Retired consultant
David Drake Doctor
Faieq Ali General Practitioner
Lyvia Dabydeen Retired Consultant
Carley Moore Nurse practitioner
Nadhya Qureshi Anaesthetist
Chris Fisher Internal medical trainee
Ali Bokhari Consultant Paediatrician
Ashal Uyanak SAS & MLR Doctor
jane Calvert Support worker
Ruth Speare Consultant
Shakira Akther Registered Nurse
Iraide Beascoechea – Artaraz NurseKhalid Aziz Doctor
Robert Mitchell Nurse
Rabiya Mansoor Pharmacist
Hecate Diaz Consultant paediatrician
Joanne Early Clinical Psychologist
Maira Vega-Poblete Doctor
Mary Kumarendran Doctor
Rita Fenning Health Vistor
Dr Nadia Dabbagh Doctor
Richard Moyse Fenning Physicist
Sahar Awadallah GP
Alba Bajrami Doctor
Peter Lillie GP
Sian Falder Consultant
Ximena Poblete Doctor
Karen Rock RMN
Ben Bouquet Doctor
Javed Iqbal Pharmacist
Gwen Keenan Clinical psychologist
Juliette Brown Consultant
Francesca Lennon Children’s nurse
Zahra Youssef GP
Shaheen Said Clinical pharmacist
Nosheen Chaouad CNS
Frances Bell Davies Specialty Trainee doctor
Alistair Wardrope Consultant
Khalida Huq Pharmacist
Irene Costanzo Senior Staff nurse
Rizwan Sarwar Doctor
Azelea Rushd Doctor – GP
Alice Clack Consultant
Megan Charles Psychotherapist
Daniel Hadley SpR
Andrew Schuman Doctor and teacher
Mr Abbas Esmail Manager
Navara Anjum
Saiqa Batool GP
Eman Alkizwini Doctor
Neema Jabbar Doctor
Paul W Registered Nurse
Mohammed Mohammed Doctor
hannah campling psychiatrist
Reem Shafiq Psychologist
Megan Lawton Occupational TherapistJordan Rivera Occupational Therapist
Farhana Rahman Doctor
Nabiha Essaji Doctor
Nida Aslam Pharmacist
Katherine Mahony Children’s nurse
Hannah Caller Doctor
Caroline Chan Gp
Alice Blewitt Resident doctor
Leila Cass-Darweish Psychotherapist
Leigh Evans Registered Nurse
Samantha Perera Consultant
BENJAMIN EDER GP Registrar
Faizal Musa Pharmacist
Lucy Adam Specialty doctor
Helen Green Midwife
Mhoira Leng Medical Director
Zoe Brandon Doctor
Jo Markham Mental health nurse
Sameenah Din Paramedic
Khaled Dawas Surgeon
Natalie Kirkhope Advanced clinical practitioner
Rhiannon Osborne Resident Doctor
Silas Webb registrar
Sian Thomas Retired
Charlie Whale Nurse
Julia Smith Health Promotion Manager
Mina Naguib Senior Clinical Fellow
Tim Flynn Psychotherapist
James Smith Emergency Physician
Olivia Brandon Doctor
Linnea Freear Clinical Scientist