Dying in the Margins: A Literature Review on End of Life in English Prisons

: This paper explores dying in English prisons. Whilst often conﬂated, death and dying are conceptually different. While there is increased attention given to the investigation of deaths in custody, and the impact of prison deaths on healthcare staff and custodial staff, little attention has been paid to the experience of dying people themselves. Post-death investigations tell us little about dying experiences of the dying. This paper reviewed the literature on dying in English prisons and highlights this clear gap in knowledge. Four types of dying will be discussed in this paper: (1) suicide, (2) dying in older age, (3) deaths post-release, and (4) COVID-19 deaths. The importance of providing good end-of-life care and palliative care in prison is acknowledged in the literature, but this only shows awareness of the needs of a particular part of the prison population. To understand the complexities and nuances of dying in prison, all voices need to be included in research, otherwise what is left post-death of a person who died in prison is a Fatal Incidence Report. More empirical research is needed to illuminate the diversity of prison deaths and the lived reality of those dying behind locked doors.


Introduction
In England, people are dying in prison on an almost daily basis. Between September 2018-2019 there were 308 deaths in prison custody in England and Wales. Ninety deaths were self-inflicted, which means a person takes their own life in prison every four days (INQUEST 2020). The current COVID-19 pandemic has been a catalyst for more suicides, and in May this year five people took their own lives within six days in prisons across England and Wales (The Guardian 2020). Most of these deaths are not witnessed by the general public and remain unexamined or are misunderstood.
Yet, these deaths have wider implications on the lives of fellow prisoners (Turner and Peacock 2017), custodial staff (Barry 2019;Turner and Peacock 2017), prison healthcare staff (Humblet 2020), and the family and friends of people in prison. Liebling (2017, p. 20) argues that: "The ending of life in custody should be controversial. Deaths in prison raise issues of accountability, legitimacy, and quality of life as well as questions about the quality of death (not only for those who die of natural causes in prison as a result of their age or sentence)." Liebling (2017) outlines three versions of "ending life" in prison, namely, suicide, murder, and "whole life sentences". She argues that a whole life sentence is a form of "dying without death" (Liebling 2017, p. 20), as these prisoners have to live their entire life in prison with no chance of release. "Forcing prisoners to live without hope, creating a climate in which death is preferable to life, and organising prisons with an expectation of death take us far away from the principles of legitimate imprisonment" (Liebling 2017, p. 28). These types of ending life in prison or, in other words, dying in prison, challenge the purpose of prison and thus need to be scrutinised and understood carefully.
Recent years have seen an increase of self-harm and suicide in English custodial settings (Ludlow et al. 2015;INQUEST 2020). Secondly, as the prison population is ageing, there is also an increase in 'natural' deaths in prison. INQUEST, a charity interested in state related deaths, argues that "so called, 'natural cause' deaths (as defined by the Ministry of Justice) are the leading cause of mortality in prisons and are commonly attributed to the ageing prison popu lation. However, INQUEST's casework and monitoring show that these non-self-inflicted deaths often reflect serious lapses in healthcare and therefore, applying the term 'natural' is extremely problematic". (INQUEST 2020, p. 5) As the prisoner population is ageing, it is expected that increasingly people will age and die in a custodial setting (Mann 2012;Turner et al. 2018). These deaths differ drastically from suicide as they, to some extent, can be prepared and planned for. A worrying level of deaths occur post-release, particularly drug-related deaths in the two weeks after people leave prison (Bird et al. 2015).
While death and dying are often conflated, it is important to note that they are conceptually different. Kellehear (2014) suggests that "dying should be defined as the personal expectation and acceptance of death as an imminent event. This is substantially different from the philosophical idea that death will come to me one day. Rather, for dying people death is either imminent (on a specific date or time-in the next few minutes, hours, or months) or it is immanent, that is, the date may not be known but the person is aware that death may come at any time. Immanent death comes from a sense of an ending rooted in the conviction that life is being lived in the end times-as it is for those of advanced age, the seriously suicidal and people in death camps" (Kellehear 2014, p. 9). It is important to distinguish death and dying. Whilst attention is given to dying in prison post death (see the section on deaths in custody investigations below), little attention is given to processes of dying.
Building on the available literature, this paper shows that little scholarly attention is given to dying in English prisons. Whilst the reporting of prison deaths and causes of deaths are receiving scholarly attention, to date no study in the UK has spoken with dying prisoners about their end-of-life experiences. There is a paucity of research investigating the diversity of dying in prison, and more research is clearly needed to understand the dynamics of dying in prison, especially as this is increasingly common. Two forms of dying, namely, self-inflicted death and dying in older age, are studied the most. Additionally, two emerging types of dying, namely deaths post-release and COVID-19 deaths, are being written about. While technically not a 'death in custody', post-release deaths show the porous boundaries between prison and the outside world, and underline the relationship between prison release and death. Lastly, the COVID-19 pandemic also has repercussions for people in prison. With the spread of the virus a new 'type' of dying has entered the prison estate. Here, again we see a wider trend that goes beyond the prison boundary, reducing COVID deaths to daily death rates and not acknowledging the person behind the death. These four 'types' of dying that will form the core of this paper. It is important to note that these 'types do not have clear boundaries and can overlap, and they are used for analytical purposes to outline what is currently on the research agenda.

Methods
This paper is a literature review on current scholarship around dying in prison in an English context. Papers about dying in prison from other geographical contexts were excluded. The majority of scholarly work on dying in prison is based on research conducted in the United States (US) (Burles et al. 2016). This is not surprising given the fact that the US houses the largest number of prisoners in the world. However, experiences of death and dying are very much shaped by the societal context they take place in and the healthcare systems available. The focus on a single geographical area reveals the priorities of research and the gaps in the literature in this specific area. In addition to societal context, emphasis was given to research that aims to understand dying in prison from the perspective of people in prison, and thus includes prisoners in research. The following databases were used to identify papers: Web of Science, Scopus, and CINAHL. Google Scholar was used to identify potential grey literature, and to explore whether identified papers from the databases had been cited by more recent papers. A combination of the following search terms was used: "prison or jail or incarceration or imprisonment or correction facilities" AND "end of life care or palliative care or death or dying or terminally ill" AND "England or Britain or UK or United Kingdom or Great Britain". The aforementioned search terms did not bring up many hits; thus, the scope of the search was broadened to include known causes of death by the author, including, COVID-19, suicide, and post-release deaths. As the readers of Religions will be interested in the religious or spiritual elements of dying in prison, additional searches were performed, but no literature was identified that deals with the spiritual needs of dying English prisoners.

Results
The literature on dying in English prisons is sparse, but in this paper, I develop four broad themes, which are all starting points for future research: (1) prison suicide, (2) dying in older age, (3) dying post-release, and (4) COVID-19 deaths. Before discussing these four types of dying, I will outline how deaths in custody are currently investigated in England.

Investigating Deaths in Custody
In 2013, the International Committee of the Red Cross (IRRC) produced guidelines for investigating deaths in custody (International Committee of the Red Cross 2013). This report describes legal, medical, and forensic aspects of investigating deaths in custody, and it emphasises the importance of these investigations, as "the right to life" is a fundamental human right (International Committee of the Red Cross 2013). The report states that "all deaths in custody must be investigated promptly by an independent and impartial body regardless of whether the relatives of the deceased request it" (2013, p. 25). The report presents a comprehensive overview of the practical elements involved in investigating prison deaths. Yet, it is surprising, since people have died in prison for as long as there have been prisons, that it has taken until 2013 to write these guidelines. Furthermore, as the purpose of these investigations is to "clarify the circumstances surrounding death", these guidelines do little to help us understand the wider repercussions of prisoner deaths and the impact this has on fellow prisoners, prison healthcare and custodial staff, and indeed the family of prisoners.
In England, the body responsible for the independent investigations of prisoner deaths is the Prisons & Probation Ombudsman (PPO). They produce a Fatal Incident Report for every death in custody, which is made available to the public online (Prisons and Probation Ombudsman 2020). PPO has been conducting these investigations since 2004. Prior to this, prison deaths were investigated by the Prison Service's own investigators (Tomczak 2018). In their 2019/2020 annual report, the PPO lists the investigations they have conducted: of the 311 investigations, there were 176 deaths from natural causes, 83 self-inflicted deaths, 2 apparent homicides, 31 other non-natural deaths, 17 deaths of residents living at probation-approved premises, 1 death of a resident of the immigration removal state, and 3 discretionary cases (Prisons and Probation Ombudsman 2020, p. 16). While it is important that these deaths are investigated, it is equally important to understand the circumstances that led to prisoner deaths. Thus, understanding and listening to people in prison is paramount in order to offer a fuller picture of prisoners' experiences and to prevent some of these deaths in the future. However, as will be highlighted throughout this paper, understanding dying from the perspective of dying people in prison is a clear gap in the literature.

Prison Suicides
Suicide is the most common form of dying in prisons worldwide, with mortality rates three times higher than the general population (Forrester and Slade 2014;Slade and Edelman 2014). Various studies in England and Wales have focused on the prevalence of self-harm and suicide in prison (Fazel and Benning 2009;Slade and Edelman 2014;Fazel et al. 2017;Hawton et al. 2014), thus underscoring the need to empirically understand this issue. Awenat et al. (2018) highlight the importance of including people with lived experience of both prison as well as suicidal behaviour in the development of future research. They suggest that the involvement of people with lived experience in the design and conduct of research can be paramount in better understanding and potentially preventing suicide in prison.
One way to understand suicide in prison is to investigate near-lethal suicide attempts. Rivlin et al. (2012) interviewed 60 men and 60 women who had engaged in near-lethal self-harm. The conclude that: "Studying near-lethal suicide attempts appears to a valid proxy for studying completed suicide in prisons. It has the advantage that it allows detailed investigation of characteristics that may contribute to suicide risk, such as psychological characteristics, the process leading up to suicidal acts and the influence of early and contemporary experiences, as well as providing the opportunity for follow up of individuals." (2012, p. 23) Byng et al. (Byng et al. 2015) interviewed 35 people either currently in prison or post-release who had either attempted suicide multiple times, a single time, or never. The interviews revealed the complex and diverse pathways that can lead to a suicide attempt. Care for those at risk of suicide will require not only a full assessment of risks, strengths, and needs, but also an acute understanding of where, on the pathway to suicide, any individual is at any point in time (Byng et al. 2015, p. 949).
Interviewing 15 men from two different prisons who experienced suicidal and or violent thoughts and/or behaviours, Hemming et al. (2020) suggest that a cultural shift is needed that encourages men in prison to be able to speak about their emotions. Additionally, individual support, particularly in helping men express their emotions, could potentially prevent self-harm and suicide attempts.
The aforementioned studies show that there is no singular path that leads to a suicide. In contrast, the life histories of people and the trajectories that lead to suicide attempts are complex. Additionally, the masculine environment and the fact that it is difficult to be vulnerable and emotional in prison all contribute to an environment where self-harm and suicide are common. Surprisingly little research has been conducted on the impact of witnessing suicidal-related behaviour (Tomczak 2018;Hales et al. 2014).
The make-up of the prison population has changed drastically in the last decades. In 1999, Liebling identified three groups at the highest risk of taking their own life in prison, namely life-sentence prisoners, people with severe mental health problems 1 , and "poor copers". The last category consists of people who have trouble coping with being in prison. Importantly, Liebling argues, these groups are not mutually exclusive and can overlap (Liebling 1999). As the prison population is increasingly diverse, Read and McCrae (2016) suggest that more attention needs to be given to the prevention of suicide in lesbian, gay, bisexual, and transgender prisoners. They note that these groups of prisoners might be exposed to increased levels of abuse and sexual assault when imprisoned, which can lead to both self-harm and suicide. Women only make up a small proportion of the English prison population, but are overrepresented in suicide statistics (Humber et al. 2011). As women are a minority in prison, it is not surprising that the studies concerned with preventing and understanding suicidal behaviour predominantly use men as their participants, and more empirical research is needed to understand the lived experience of women in prison.
Dying in general, but suicide specifically, is particularly difficult to research in prison. The literature search for this paper shows that to date in England, no ethnographic studies or longitudinal qualitative studies have been conducted to understand the phenomenon of suicide in prison. This is not surprising given the difficulties of gaining access and the ethical considerations in these types of research.

Deaths of Older People in Prison
A type of prison dying that increasingly receives more (academic) attention, perhaps because it is more socially acceptable than suicide, are the deaths of older people in prison. Since 2002, the proportion of people aged 50 and over has increased by 150 per cent, making them the quickest-growing group in prison (Public Health England 2017). It is worth noting that people aged 50 and over are considered "older" within the context of the criminal justice system. This is a stark contrast to those residing in the community, as, for example, the UK census considers people "older" when they are 65 or over. There are numerous reasons for the lowering of the age threshold to 50; most notably, it is often suggested that people in prison experience "accelerated ageing" (Kouyoumdjian et al. 2017;Greene et al. 2018). There are multiple reasons for the increase of older people in the criminal justice system: tougher sentencing practices and mandatory life sentences are given for a wider range of crimes, license conditions allow people to be released towards the end of their sentence have become stricter, and there is a growing number of men convicted for historic sex offences (Turner and Peacock 2017;Mann 2012).
In 2019, 13,609 people were aged 50 and over, making up 16.5 per cent of the total prison population in England and Wales (Ministry of Justice 2019). Older people in prison are a heterogeneous group with a range of life experiences, convictions, and healthcare needs. It is often suggested that people in prison have a much lower life expectancy compared to those living in the community and that people in prison experience more physical and mental health problems at a younger age (Parrott et al. 2019;Yorston 2013;Public Health England 2017). The number of older people in prison combined with reduced life expectancy makes it very likely that increasingly people will die in prison. Furthermore, older prisoners have many healthcare needs that need to be met, and ageing and dying prisoners thus challenge the purpose of prison, as they transform a custodial environment into a caring environment.
In 2018, the Dying Well in Custody Charter was launched in the UK. The aim of this charter is to have a national framework regarding end-of-life care and palliative care in custodial environments. The charter comprises six ambitions: (1) each person is seen as an individual; (2) each person gets fair access to care; (3) maximising comfort and wellbeing; (4) care is coordinated; (5) all staff are prepared to care; and (6) each community is prepared to help (Ambitions for Palliative and End of Life Care Partnership 2018). Importantly, this charter labels these points as ambitions, and more empirical work is needed to explore how this framework is carried out, and what it means in practice in different prisons. What it does show is the awareness that people are dying in custodial environments. Peacock et al. (2018) describe the deaths of older people in prison as "anticipated deaths", as they are deaths that are foreseeable and that require end-of-life care. However, providing end-of-life care and palliative care in a secure environment is not straightforward. Previous studies on the delivery of healthcare in a custodial setting have noted the tension between care and custody (Pont et al. 2012;Sufrin 2017;Turner et al. 2011). A study conducted among prison healthcare staff and palliative care specialists in the North West of England highlighted the many tensions that arise when healthcare specialists try to provide care in a custodial environment (Turner et al. 2011). The study revealed that healthcare professionals working in a hospice have limited understanding of prison and, similarly, prison healthcare has limited understandings of hospice care and dying. Providing palliative care was sometimes very challenging for prison healthcare staff, as one nurse notes: "Initially some [staff] thought, 'We can't manage this [patient] here.' But a lot of people got a lot out of it-they remembered why they became a nurse.". (Nurse in: Turner et al. 2011, p. 375) For prison healthcare staff, palliative and end-of-life care is often something for which they have not received training. Prison officers working with older prisoners similarly describe not anticipating having to work with this group when they started working in the prison service: "(Prisoners now are in) their late 60s, 70s-even now into the 80s . . . Their needs are different . . . it's more around medical, health issues; not really any control problems as you get in the younger population . . . a lot of family problems because of the offence, if it was committed in the family . . . How you deal with people as well. I think some of the staff probably find it difficult -because with the younger population it's more you front it out and shouting, and the older guys you don't . . . they don't need that." (Governor in Peacock et al. 2018Peacock et al. , p. 1160 For professionals working with ageing and dying prisoners, there is thus an ongoing learning required to try supporting this group. The presence of older people in the criminal justice system also challenges the discourse around patient choice that is present in the current end-of-life care policy (Department of Health 2008). Turner et al. note that people dying in prison bring up many questions around place of death. 2 They state that: "The issue of where prisoners should die raises important questions about how much choice they should have about their preferred place of care at the end of life, and whether or not they should be granted compassionate release. Although the NHS strongly promotes choice for patients, those in prison are obviously subject to certain restrictions." (Turner et al. 2011, p. 376) The studies cited in this section have predominantly focused on the experiences of professionals working in prisons. While end-of-life care and palliative care in prison increasingly receive academic attention (Burles et al. 2016;Turner and Peacock 2017), little is known about the experiences of dying prisoners themselves. An exception is a study conducted by Aday and Wahidin (2016), which compared perspectives on death and dying of older women in prison in the United States and the United Kingdom. However, this study was based on qualitative date from the US and quantitative data from the UK, showing that whilst there is interest in the perspectives of prisoners dying, actual research exploring those perspectives is still missing. There is a growing body of work on the ageing experiences of English prisoners (Wahidin 2011(Wahidin , 2004Mann 2012;Sparks 2005, 2013), but how English older people think about dying, and experience dying in prisons, has received little attention to date. This follows the trend within ageing studies and death studies to discuss either "ageing" or "dying" in research, whereas naturally ageing is followed by death (and a different paper could be written to what extent ageing and dying are overlapping or differing categories).

Deaths Following Release
The number of people dying shortly after release from prison has been rising over the past years. Recently released prisoners are at a much higher risk of suicide than the general population (Pratt et al. 2006). An INQUEST report notes that the number of deaths post-release started to increase more rapidly after the implementation of the Transforming Rehabilitation and the Offender Rehabilitation Act 2014 (INQUEST 2019). This report also suggests that women released from prison are at significantly greater risk of taking their own lives compared to women in the general population (INQUEST 2019). Between 2018 and 2019, 10 people died each week following their release from prison (INQUEST 2019). During that time, 515 people died who were under post-custody supervision and another 153 were self-inflicted deaths without post-custody supervision (INQUEST 2019). These numbers tell us little about the motivation and experiences of those who take their own life post-release. Crucially, the accuracy of these numbers has to be considered. A report from The Howard League (2012) states that local areas were not required to report deaths under supervision until October 2005. Furthermore, in 2007 alcohol-related deaths started to be reported separately, thus no longer being labelled as a post-release death (The Howard League 2012). Drug-related deaths remain a problem, and it has been noted that the number of opioid-related deaths is particularly high in the fourteen days after leaving prison (Bird et al. 2015). A Scottish study investigating whether the introduction of a prison-based opiate substitution therapy policy would reduce drug-related deaths in those fourteen days post-release found that, while there was a reduction of deaths in the 12 weeks following prison, this programme did not reduce early deaths in those fourteen days (Bird et al. 2015).
At present, very little research has been conducted exploring this topic from the perspective of those attempting suicide post-release. This is not surprising given the difficulty to reach this "group" of people and the sensitivity that is required to carry out this type of research. An exception is an interview study with seven people who made a "near-lethal suicide attempt" whilst on probation (Mackenzie et al. 2018). These interviews suggest there is a relationship between suicidal feelings and experiences of loss, including bereavement. Furthermore, participants found it difficult to disclose these types of feelings due to trust issues and cynicism concerning the Criminal Justice System (Mackenzie et al. 2018). Participants also emphasised that having a purpose in life including feeling valued by family or friends or having a job decreased suicidal thoughts (Mackenzie et al. 2018). Mackenzie et al. (2018) note the importance of having a national strategy for the prevention of suicide post-release, and they recommend having support available that is independent of the criminal justice system to help diminish trust issues. At the same time, probation officers should be trained to help clients in these types of situations.

COVID-19 Prison Deaths
The current COVID-19 pandemic has not left prisons untouched. In contrast, they have been described as "petri dishes" 3 for infection; people in prison have limited access to face masks and other protective gear, and social distancing is difficult for people sharing a cell. The measurements implemented in English prisons included the requirement for prisoners to remain in their cells for 23 out of 24 h a day (Braithwaite et al. 2021). Between March 2020 and February 2021, there were 121 deaths related to COVID-19 (Braithwaite et al. 2021). This death rate is 3.3 times higher compared to people of the same age and gender in the general population, showing that being in prison exacerbates the effects of COVID-19 (Braithwaite et al. 2021). In addition to deaths caused by the virus, the 23 h a day lock-up will have a knock-on effect on people's mental health and self-harm rates. How many additional deaths in custody will be a direct result of the COVID-19 pandemic is something that requires further investigation.
While it is difficult to get access to prisons in non-pandemic times, COVID-19 and lockdown measures have caused all research conducted in prisons to stop. Similarly, all family visits in English prisons have been halted for almost a year. 4 As a consequence, we know very little about the prison COVID deaths beyond what is reported in newspapers and the aforementioned Death in Custody Reports. 5 COVID-19 deaths are listed as "natural deaths". Like many deaths in the general public, people dying from COVID in prison will be reduced to a number in most reporting. As can be seen in the report in the footnote, people in prison dying of COVID-19 are named in their investigative report. This is exceptional as many members of the general public will be left unnamed in reports. However, how these deaths are experienced by the dying prisoner, other prisoners, members of prison staff, and the family and friends of the dying person is something that remains unclear.

Discussion
There is a paucity of research focused on dying in English prisons, particularly from the perspective of dying prisoners. Dying in custody reports and the statistics on prison deaths show that dying, in various forms, is common within prison settings. The increase in prison suicides and the rate of self-harm in prison can normalise these actions within in the context of a prison. However, it is important to understand the experiences of people dying in prison and those working with or caring for prisoners to help prevent these types of death in the future. Most of the literature cited is concerned with the experience of men in prison, as women are a minority in prison, and older women in prison are a minority within a minority (Wahidin 2011). Women in the criminal justice system can easily be forgotten in research, but their end-of-life and dying experiences are equally important to understand. Tomczak (2018) analysed how post-suicide investigations operate in England and Wales. She notes that these investigations, whilst required by the law, "do not require that lessons be learnt and does not direct accountability to those with the capacity to implement said lessons" (Tomczak 2018, ebook). An interviewee in her study states: "Prison officer culture is one of the biggest problems of suicide that's unreported. [ . . . ] Treating prisoners with contempt. Telling them to go and kill themselves. If they say they feel like taking their own lives, say, "well why should I care?" [ . . . ] Those are the things that happen in prison." (Interviewee in : Tomczak 2018, ebook) The response of some prison officers shows how prisoners might be reluctant to disclose mental health problems or suicidal thoughts to prison staff. However, even if they do, as can be read in the quote, they might not be met with the level of understanding necessary in dealing with these situations. Distrust of people working in the criminal justice system is also a driver of suicides or suicide attempts post-release (Mackenzie et al. 2018). This shows the complexity of the environment in which prison suicides take place, and careful consideration of everyone affected by and involved with both prison suicides and other types of dying is paramount.
Dying in prison does not only affect the dying prisoner. An Irish study exploring how prison officers cope with the death of a prisoner shows how difficult it is for officers to be open and honest about their feelings (Barry 2019). An officer in Barry's study notes: "At times it does come back to me, mainly if you see it in films or TV, someone hanging. It kind of brings you back to what happened that day." (Prison officer in: Barry 2019, p. 7) Suicides and other types of dying affect prison officers as well, and thus it is important for prison officers to be equipped to deal with someone who is experiencing suicidal behaviour, as well as have the tools to deal with these kinds of losses.
In England, the Prisons and Probation Ombudsman investigates all deaths in custody to establish cause of death and whether there was any negligence in the provision of care for the person who died. In these reports, a person's life is reduced to bullet points. Understandably, as people cannot speak to the dead, the lived experience of the person who died is absent from these reports. Equally, the experience of other prisoners and prison healthcare staff and custodial staff seems absent. Deaths in custody are reduced to a one-and-a-half-page summary. As deaths in custody are quantified in yearly reports, it is known that people in prison are dying and that this number is on the rise (INQUEST 2020; Prisons and Probation Ombudsman 2020). This paper has outlined the evidence demonstrating that there is awareness of both suicides in prison as well as deaths in older age. Further research including the voices of people in prison is necessary to understand how these deaths can be prevented (when talking about suicide) or how these deaths can be as "good" as they can be in the environment in which they are taking place (when considering deaths by 'natural causes') (Burles et al. 2016).
The Dying Well in Custody Charter (2018) implies an awareness of the dying needs of people in prison. Yet, more empirical evidence is needed to explore how these guidelines help dying people in prison in practice. While these guidelines are handy tools for professionals working inside secure environments, it is unclear to what extent people in prison are aware of these guidelines and are able to advocate for their rights at the end of life. Crucially, while increased attention for palliative and end-of-life care in prison is important, there is a risk of overmedicalising death. Alongside these developments, it is important to unpack and understand the social environment in which these deaths take place and how people dying in prison, other prisoners, prison staff, and the loved ones of prisoners on the outside are impacted and affected by death and dying. Turner et al. have suggested that "despite popular misconception, the stated primary purpose of prisons in the UK is rehabilitation not punishment" (Turner et al. 2011, p. 370). If this is the case, this poses many questions around the purpose of prison in relation to dying people. People in prison are deprived of their liberty but should not be deprived of discussions around life and death. The current end-of-life care strategy emphasises the importance of choice in place of death (Department of Health 2008), and if prison is increasingly a place where death and dying take place, the complexity of deaths in custody need to be clearly understood from the perspective of those that matter the most: those dying in prison.

Conclusions
This paper can be read as a starting point for future research on dying in English prisons. While dying in prison has wider implications for various groups within prison, the majority of dying in prison is not witnessed by people in the general population and thus not clearly understood. There is little evidence that helps understand the experience of dying from the perspective of those dying in prison. While deaths in custody are investigated, more attention could be given to what happens prior to death. This paper has looked at four types of dying related to prison: suicides in prison, deaths in older age, deaths post-release, and COVID-19 deaths. These four "types" only begin to scratch the surface of how loss, death, and dying are inherent within custodial environments. In England, there is a paucity of research that tries to understand dying from the perspective of people in prison, yet there is increased awareness that deaths in custody require emotional labour from prison healthcare staff and prison officers (Turner and Peacock 2017;Humblet 2020;Barry 2019). Involving dying prisoners in research will help illuminate the complexity and diversity of dying that occurs in prison. Putting dying in prison on the research agenda can help to take dying in prison out of the margins and into the collective conscious of society. Furthermore, open and honest conversations about dying in prison, and acknowledging that prison is in fact a place where people die, will help those dying in prison to achieve a "good death" and can help making the Dying Well in Custody ambitions a reality.
Funding: This research received no external funding.

Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.

Conflicts of Interest:
The authors declare no conflict of interest. Notes 1 NB: Liebling (1999) uses the term "psychiatrically ill" but I prefer the term "people with severe mental health problems". 2 It is important to note that their study was conducted before the introduction of both the current end of life care strategy as well as the Nelson Mandela Rules. 3 See: https://www.theguardian.com/society/2020/apr/07/coronavirus-thrive-british-jails-prisoners-face-death-sentence (accessed on 7 April 2021).