A death in custody is the one event in a prison sentence that the state is obliged to explain. In England and Wales the Prisons and Probation Ombudsman investigates every one. In New South Wales, a Corrective Services spokesperson said after Ivan Milat died in 2019, every death in custody goes to a coroner, natural causes included. In Canada and the United States the machinery differs from province to province and state to state, but the questions are the same: how did the person die, was the care adequate, and what should change?
Nine men convicted of multiple murders died in custody between 2004 and 2023: five of illness, three by suicide, one at the hands of another prisoner. A tenth case, that of Michael McGray, concerns a prisoner who was killed by his cellmate. The inquests and reports that followed did not all conclude the same thing, and some have never been published.
Anthony John Hardy pleaded guilty at the Central Criminal Court in London on November 25, 2003, to three murders in Camden Town. Mr. Justice Keith sentenced him to life imprisonment on each count and, on May 14, 2010, sitting in the High Court, made a whole life order. The case is remembered less for the sentence than for what happened to the first death in the series.
Sally White’s death in January 2002 was treated as natural. The pathologist, Dr. Freddy Patel, saw no positive evidence of the cause of death but concluded that she had died of a heart attack. The coroner, Dr. Stephen Chan, held the inquest at St Pancras Coroner’s Court. The Camden New Journal reporter Richard Osley, who attended as a junior reporter, wrote in 2011 that it lasted about 15 minutes. A statement from her father was read by a court official, a housing worker’s report was heard, and Dr. Patel gave evidence. Hardy was not called. The coroner recorded natural causes, accepting coronary artery disease as the medical cause.
What the coroner did not hear became the subject of later criticism. Police had supplied only basic details, mainly so that her body could be released to the family. A detective sergeant from the serious crime group wrote that there was no evidence Hardy was responsible, and the matter was classed as "No Crime." According to the Camden New Journal, a 2005 health authority review of Hardy’s care concluded that the police statement left out key facts, among them Hardy’s false claim that he had no key to the room where she lay. The Metropolitan Police later said detectives were never asked to attend the inquest, and accepted that the wider concerns had not been fully put to the coroner. Detective Inspector Alan Bostock, interviewed for the Channel 4 documentary The Hunt for the Camden Ripper, said he investigated suspicious deaths, not natural ones, and that the decision on how to classify a death was not his to make. The same review reported that mental health staff privately suspected Hardy even after the post-mortem result. One nurse called it "just a gut feeling."
The pathologist’s own career took a separate course. Channel 4 News reported on March 14, 2011, that Dr. Patel had been judged guilty of incompetence at a disciplinary hearing; on March 31, 2011, that he was suspended for four months; and on August 23, 2012, that he had been struck off. No fresh inquest was held into the deaths. Elizabeth Valad’s mother campaigned for a full public inquiry and later called the process a "whitewash"; an application brought in the name of Elizabeth’s daughter reached the Royal Courts of Justice in 2005, and Mr. Justice Bennett ruled that the government had met its obligations through the health authority’s independent review.
Hardy’s own death in custody was investigated by the Ombudsman. After sentence he was held first at HMP Wakefield, then for about 15 years at Broadmoor Hospital under the Mental Health Act, and from November 6, 2019, at HMP Frankland in County Durham. Why he was moved has not been made public. By then his health was poor: poorly controlled type 2 diabetes, heart disease and heart failure, chronic kidney failure and incontinence, frequent falls and memory problems. He was shielded during the first wave of the coronavirus pandemic from April 17, 2020, stopped shielding in July and began again in late August. On November 17, 2020, he collapsed on his way back from collecting his medication. He was tested and isolated in the healthcare unit, and the next day the test was positive for COVID-19. The Ombudsman concluded that he caught the virus inside the prison, since he had not left it during the incubation period.
On November 23 he was taken to hospital as an emergency, escorted by a custodial manager and two prison officers. He was put in a single handcuff and an escort chain, reduced to the chain alone the next day. He died in the early hours of November 25, 2020, and his death was certified at 5:27 a.m. He was 69. The hospital certified the cause as COVID-19 pneumonia, with type 2 diabetes and heart failure as contributing conditions. The coroner accepted the certificate, and no post-mortem examination was held.
The Acting Prisons and Probation Ombudsman, Kimberley Bingham, published her report in September 2022. An independent clinical reviewer concluded that his healthcare at Frankland had not always been equal to what he could have expected in the community. The report criticized delayed health assessments, gaps in his clinical observations, and the failure to pass his medication doses to the ambulance service. The Ombudsman said she was concerned that he had remained restrained while gravely ill and receiving treatment, and that the restraints were removed only after he died. The report also recorded an error over his next of kin: the family liaison officer could not reach the woman listed, and police went to her address, where she turned out to be the partner of another prisoner with the same surname. The Ombudsman called this unacceptable. Two of Hardy’s sons contacted the prison on November 27 after reading about his death in a newspaper. The Camden New Journal wrote in 2023 that he died of Covid; the cause, place and date given here are the Ombudsman’s.
Harold Shipman, a family doctor in Hyde, Greater Manchester, was convicted at Preston Crown Court on January 31, 2000, of murdering 15 of his patients and of forging the will of one of them, Kathleen Grundy. The judge, Mr. Justice Forbes, passed 15 life sentences and told him that life must mean life. A public inquiry under Dame Janet Smith reported in July 2002 that he had killed at least 215 patients; those figures are the Inquiry’s findings and not convictions, and Shipman never admitted a killing.
The Inquiry’s later reports are the closest thing the Shipman case has to an inquest on the system rather than on a person. The Second Report, published on July 14, 2003, dealt with the police investigation of March 1998. On March 24 of that year Dr. Linda Reynolds, a Hyde GP, had telephoned the coroner for Greater Manchester South, John Pollard, to say that Shipman had signed 16 cremation certificates in three months, against 14 (later corrected to 15) in her much larger practice. Mr. Pollard referred the matter to police the same day. The investigation was closed on April 17 without a written report. Dame Janet identified a failure at every level. Of the chief superintendent responsible she wrote that he "should have instructed a suitably experienced detective officer to undertake this unusual and potentially serious investigation," and she concluded: "I think that, if the police and the Coroner had moved with reasonable expedition, the lives of Shipman’s last three victims would probably have been saved." Greater Manchester Police apologized to the Grundy family.
The Third Report, published the same day, dealt with death certification and coroners. It concluded that the systems for certifying deaths and reporting them to coroners "had failed to both deter Shipman from killing his patients and to detect his crimes after they had been committed." A doctor effectively decided whether a death went to the coroner, an arrangement the report called "not satisfactory and should not be allowed to continue." The second cremation certificate was "wholly inadequate as a safeguard against concealed wrongdoing." Dame Janet recommended that the coroner system be "retained, but in a form entirely different from at present," with medically qualified coroners, judicial coroners and trained investigators, and a single system of certification for every death. A Welsh Government written statement dated September 9, 2024, announced the coming into force of death certification and medical examiner reforms.
Shipman’s own death was the subject of a separate report. After conviction he went to HMP Frankland on February 7, 2000, and stayed until June 18, 2003, when he was moved to HMP Wakefield as a category A prisoner. He was held in a single cell in both prisons. He was placed on suicide and self-harm monitoring four times, the last on July 17, 2002, closed on August 30, 2002. In a diary entry of March 27, 2001, he wrote: "I’m looking at dying, the only question is when and can I hide it from everyone?" He spoke repeatedly of suicide as a possibility once his appeals had failed and his wife was financially secure. Frankland did not pass that history to Wakefield, the Ombudsman later concluded. On July 17, 2002, the Health Secretary ordered the forfeiture of Shipman’s own benefits under the NHS pension scheme. In December 2003 his privilege level was cut to "basic" at an annual review, with loss of his television and own clothes and visits reduced; he was restored to the standard level on January 8, 2004. The Ombudsman concluded that the marks used to downgrade him had been harsh and that he should not have been on the basic regime at all.
On the morning of January 13, 2004, at about 6:10, an officer doing the roll count came upon him dead by suicide in his cell. Staff tried to resuscitate him for about half an hour. No ambulance was called. A doctor, called at 6:43, arrived at about 8:00 and pronounced him dead at 8:10. He was 57. The Prison Service gave the time he was discovered as 6:20, and a spokeswoman said he had shown "no signs whatsoever of pre-suicidal behaviour." The police had been given the wrong address for his wife, and she learned of his death from a relative who had heard it on the radio. The Ombudsman, Stephen Shaw, submitted his report in March 2004; it was published in May 2005. In Parliament in 2007 a member said his death had "robbed all those families of the one thing that he could have given them: the truth."
David Birnie and his partner Catherine Birnie pleaded guilty to four murders committed in Perth in 1986 and were sentenced to life imprisonment in 1987. Justice Wallace said David Birnie should never be released. On October 7, 2005, aged 54, he was dead in his cell in a high-security unit at Casuarina Prison. The Western Australian Department of Justice confirmed that he had taken his own life.
The state’s Justice Minister, John D’Orazio, said that day that officers checked on Birnie every four hours, and that he had been checked just after midnight and again just after 4:00 a.m., when he was discovered. ABC News had first reported the time as about 3:00 a.m. The minister defended prison procedures, saying normal procedures had been followed, and he and the department would not say at the time how Birnie had died. The prison service’s executive director, Ian Johnson, said Catherine Birnie had been told of the death but would not be allowed to attend the funeral; the minister said she could apply.
The inquest was held at the Coroner’s Court in Perth before the Deputy State Coroner, Evelyn Vicker, in December 2007, and resumed in April 2008. It heard that Birnie had gone three days without his antidepressant medication because of a paperwork error. Constable Shane Graham, the investigating officer, said Birnie had accepted that he would spend the rest of his life in prison, that the preparations for his death would have taken hours, and that procedures had since been changed. Two men who had been in prison with him told the coroner that they had become his friends, that he was a model prisoner, and that they had always known he would one day take his own life. They said he became depressed in his last months: his computer had been confiscated permanently, he had been banned from telephone contact with a woman journalist, and he had missed his medication. A psychologist who had counselled him over several years said he was a chronic suicide risk, that she had always been aware of it, and that the task for prison authorities was to manage that risk. The superintendent of Casuarina, Robert Jennings, said Birnie had written to Catherine, held at Bandyup Prison, until about five months before he died. She had ended contact in 1993, and his letters went unanswered.
In April 2008 counsel assisting the coroner, Felicity Zempilas, said that although witnesses believed Birnie would eventually take his own life, prison authorities still had a duty to take reasonable steps to look after him. Ms. Vicker released her findings on June 18, 2008. She concluded that Birnie had gone three days without his antidepressant even though he held two valid prescriptions. She said she would not conclude that the missed medication caused his death, but that she believed it contributed to his decision to take his own life. She recommended a change to the approval process for restricted medications in prisons, which then required both a prescription and authorization from the Director of Health Services, and called for risk management plans for prisoners who need essential medication.
Dennis Nilsen was convicted at the Old Bailey on November 4, 1983, of six murders and two attempted murders. He was given life imprisonment with a recommendation that he serve at least 25 years, a term later raised to a whole life tariff. The Ombudsman’s report attributes the increase to the Lord Chief Justice; the date was not reported. He was a Category A prisoner throughout and was held at HMP Full Sutton, East Yorkshire, from November 27, 2001.
At Full Sutton he rarely engaged with prison healthcare. The Prisons and Probation Ombudsman’s report records that he refused in 2012 to go to hospital for an eye operation, declined a flu vaccination every autumn from 2012, and declined NHS screening in 2014 and bowel cancer screening in 2017. On December 20, 2016, he declined screening for an abdominal aortic aneurysm, saying he did not want to engage with healthcare. The Ombudsman concluded that if he had accepted it, the aneurysm would probably have been detected at an early stage.
On the morning of May 10, 2018, he rang his cell bell complaining of severe stomach pain. A mental health nurse saw him at 7:20 a.m., and a nurse reviewed him in the clinic at about 9:30; his early warning score was normal. A prison GP suspected a urine infection or kidney stone and asked for a urine sample. At about 2:15 p.m. two officers came upon him slumped on the toilet, disoriented and barely responsive. Through the afternoon officers repeatedly contacted healthcare, and he was not reviewed for about two and a half hours. At about 4:50 p.m. the GP saw him and suspected a ruptured aneurysm. An ambulance was requested at 5:20 p.m. and reached the prison at 6:03 p.m.; it left with him at 6:52 p.m. At York District Hospital he had emergency surgery that succeeded technically, but his condition worsened. He died at 9:20 a.m. on May 12, 2018, aged 72. The post-mortem gave the cause as a pulmonary embolism and retroperitoneal haemorrhage, due to deep vein thrombosis and the repaired aneurysm rupture.
The Ombudsman, Sue McAllister, concluded that the clinical care he received before May 10 and on the morning of that day was equivalent to what he could have expected outside prison. She criticized what followed: poor communication between officers and healthcare staff, the failure to review him in the afternoon, and a delay of about half an hour between the GP’s assessment and the request for an ambulance. The report called the delay before paramedics reached him unacceptable and attributed it to a GP’s ignorance of emergency procedures in a prison. It could not say whether earlier action would have changed the outcome, but concluded that he could have been taken to hospital sooner. It made eight recommendations, among them that healthcare staff must review prisoners when officers raise serious concerns and that seriously ill prisoners must not be left without medical help.
The inquest was held at Hull Coroners' Court on October 23, 2019, before Professor Paul Marks, senior coroner for the East Riding of Yorkshire. It heard from officers, healthcare staff and the paramedic who reached him, who described him as ashen and extremely unwell. Prison staff who gave evidence described him as polite, independent and stubborn. The coroner recorded a conclusion of natural causes and said he would write to NHS England about the delays and about the level of life-support training for prison healthcare staff.
Donald Neilson was convicted at Oxford Crown Court in July 1976 of four murders, with kidnapping. The trial judge said life should mean life. In June 2008 Mr. Justice Teare refused his application for a minimum term and imposed a whole life order.
By 2009 Neilson had motor neurone disease. He was moved from Full Sutton to Norwich prison, where staff said he needed a specialist level of care, the Yorkshire Post reported. In March 2009 the Shropshire Star, quoting a prison source, said he could no longer use his arms or legs and was due to move to the unit for elderly life-sentence prisoners at Norwich: "His deterioration has been rapid," the source said.
In December 2011 he became ill with breathing difficulties and a cough. On Saturday, December 17, he was taken from HMP Norwich to the Norfolk and Norwich University Hospital. A Prison Service spokesman said he was pronounced dead at about 6:45 p.m. on Sunday, December 18, 2011. He was 75 and had served 35 years. "As with all deaths in custody, the independent Prisons and Probation Ombudsman will conduct an investigation," the spokesman said. No report of the Ombudsman’s findings on his death has appeared.
An inquest opened within days and heard that he had died of pneumonia, the Express & Star reported on December 21, 2011. Prison staff said he had been unwell for two days, short of breath, coughing and feeling cold, and that motor neurone disease left him vulnerable to pneumonia. The full inquest began in August 2012 before the Norfolk coroner, William Armstrong, and the jury returned a verdict of natural causes, the Yorkshire Post reported. Neilson had asked not to be resuscitated if his heart stopped. The coroner said that by the end he could barely manage basic tasks. A health commissioner who reviewed his care said staff had been surprised at how quickly he died, though a rapid death is not unusual with the disease, and praised the prison’s specialist wing. His family had been told of the inquest and did not attend.
Colin Ireland pleaded guilty at the Central Criminal Court on December 20, 1993, to five murders committed in London between March 8 and June 12 of that year. He was sentenced to life imprisonment with a whole life tariff. He died at Wakefield Prison in West Yorkshire on the morning of February 21, 2012, aged 57.
Earlier in February, the coroner’s officer later told the opening of the inquest, Ireland had fractured his hip in a fall in the prison exercise area, and after that he needed a walking frame or a wheelchair. The Yorkshire Post reported the next day that he had died in the prison’s healthcare center and that his death was presumed to be from natural causes. A Prison Service spokeswoman said the independent Prisons and Probation Ombudsman would investigate, as it does every death in custody.
An inquest opened at Wakefield Coroner’s Court, and PinkNews reported the hearing on February 29, 2012, relaying the Yorkshire Evening Post. The coroner’s officer told the hearing that Ireland had been on the floor of his cell, face down, when staff reached him. The preliminary causes of death from the post-mortem examination were given as pulmonary fibrosis and the fractured hip. The inquest was adjourned for further reports. The Yorkshire Evening Post repeated the pulmonary fibrosis cause in 2021, but no final inquest conclusion and no Ombudsman report on his death have been reported.
Ivan Milat was convicted in 1996 of murdering seven young travelers and of detaining a British backpacker, Paul Onions, for advantage. On July 27, 1996, Justice David Hunt imposed life imprisonment on each murder count. Milat never admitted any of the killings. He spent most of his sentence at Goulburn’s Supermax prison and died in the hospital at Long Bay Correctional Complex, Sydney, at 4:07 a.m. on Sunday, October 27, 2019, aged 74.
In May 2019 he had been taken from prison to the Prince of Wales Hospital in Randwick, where he was diagnosed with terminal cancer of the oesophagus and stomach. After about two weeks he was returned to the hospital at Long Bay, handcuffed at the hands and ankles, the ABC reported. The Corrective Services Commissioner, Peter Severin, said he would facilitate any police request to speak to Milat and hoped Milat would share what he knew about other possible crimes. In a three-page handwritten letter dated July 11, 2019, Milat again said he was innocent. On October 11, 2019, he was moved back to the Prince of Wales Hospital for pain relief; the corrections minister, Anthony Roberts, said he and the commissioner had agreed Milat should not occupy a public hospital bed.
After his death Corrective Services said his body would be transferred to the State Coroner. "All deaths in custody are subject to a coronial inquest, including deaths resulting from natural causes," a spokesperson said. The outcome of that inquest was not reported. Mr. Roberts said Milat had been "sentenced to die in jail and he was going to die in jail," and added: "He can rot in hell. He showed no remorse."
A different coronial finding concerns Milat’s life rather than his death. A police unit, Strike Force Fenwick, was set up in the late 1990s to examine the deaths of three young women, Leanne Goodall, Robyn Hickie and Amanda Robinson, in the Newcastle area in 1978 and 1979. At an inquest at Toronto, New South Wales, in 2001, the State Coroner, John Abernethy, ruled that the three had been murdered by persons unknown. He named Milat as one of six persons of interest, said he was of major interest and had "definite links to the Hunter Region" in the late 1970s, when he was working in the region. Milat gave evidence, denied knowing the young women and then declined to answer further questions. In a letter later sent to the families through the Newcastle Legal Centre and first published by the Newcastle Herald in 2009, he wrote that he "still would not have been able to assist you." Amanda Robinson’s mother told the paper: "I just don’t want it to be him." Lake Macquarie detectives set up Strike Force Arapaima in April 2019 to re-examine two of the cases, and two rewards of one million dollars each were offered. Milat was never charged in connection with any of the three. In June 2026 a New South Wales parliamentary inquiry began hearing from families who believe he was responsible for other deaths for which he was never charged; no court or coroner has ruled on those claims.
Michael Wayne McGray was convicted on guilty pleas between 2000 and 2001 of six murders committed between 1985 and 1998 in Nova Scotia, New Brunswick and Quebec, and received a series of life sentences. He told reporters in 2000 that he had killed 16 people; police could confirm far fewer. In 2003, according to a letter written from segregation and later published by the Halifax Examiner, he described a fellow inmate as a "suitable victim." Seven years later, on November 21, 2010, at Mountain Institution, a medium-security prison at Agassiz, British Columbia, he killed the man assigned to share his cell, Jeremy Phillips, 33. Phillips was serving a six-year sentence for aggravated assault.
The transfer to Mountain was McGray’s own request. According to evidence at the later inquest, reported by The Canadian Press, he had applied to move to a lower-security prison but twice refused to go after learning that he would have to share a cell. One assessment placed him in the medium-security range, but "just barely." When the move was approved, officials had not received information that he had recently assaulted another inmate. At Mountain he was on a waiting list for a cell of his own. Phillips had reportedly asked to be moved out of the shared cell because he feared for his safety, and another inmate testified that Phillips had been worried about his cellmate. Prison officials told the inquest that a thorough assessment had concluded it was safe to house the two men together.
Guards did not realize Phillips was dead until McGray told them, and Phillips had been dead for hours. A guard later testified that it was hard to see through the cell window with a flashlight. Five guards were disciplined for failing to notice. Less than 24 hours after the killing McGray confessed to police. In the recorded interview he called himself a psychopath and blamed federal corrections officials for moving him. The RCMP charged him with first-degree murder; Corporal Dale Carr said there was "no concern for public safety," since McGray would remain in custody for the rest of his life. In 2011 McGray pleaded guilty to first-degree murder and received another life sentence.
British Columbia’s chief coroner called an inquest to examine inmate safety. It opened in Burnaby in October 2012 before a jury of three men and two women, who watched the video of McGray’s statement to police. The Canadian Press reported that McGray repeatedly described himself as a sociopath in the video and said he would kill again. A corrections officer at Mountain whose job included checking that cellmates were compatible told the jury he had never seen any behavior that concerned him. Phillips’s mother told the inquest she was mystified that staff could place her son with someone "so evil," and said the person who made the decision should be fired, CTV News reported.
The jury’s recommendations were reported on October 31, 2012. People serving time for multiple murders should be kept in single cells unless there was evidence that sharing was "safe and practical." Wardens should be allowed to set aside waiting lists to move dangerous offenders into cells of their own. Staff should receive all information about a prisoner before a transfer was approved. The recommendations of Mountain Institution’s internal investigation should be applied across the country. And the Correctional Service of Canada should look at technology that detects body heat and review its policy on flashlight brightness.
The Correctional Service said it had already made significant changes to its procedures after Phillips’s death and welcomed the jury’s advice. It said about 19 percent of its inmates, 2,780 people, were double-bunked. Tim Veresh of the John Howard Society said the service’s procedures for assessing cellmate risk appeared not to have been followed in this case. Phillips’s parents sued the Correctional Service for reckless indifference and negligence, and the suit was settled out of court in 2012, according to The Canadian Encyclopedia. After the killing McGray was moved to the super-maximum-security institution at Sainte-Anne-des-Plaines, Quebec, where the Halifax Examiner reported he had been held since 2012.
Altemio Sanchez, a factory worker from Cheektowaga, New York, was arrested on January 15, 2007, and on May 16, 2007, pleaded guilty to three counts of murder in the second degree, for the deaths of three women in Erie County in 1990, 1992 and 2006. On August 14, 2007, Justice Christopher Burns sentenced him to 75 years to life, the maximum. He was linked by DNA to earlier assaults in the Buffalo area that were never charged, among them two for which another man, Anthony Capozzi, had been wrongly convicted.
The State Commission of Correction’s final report, dated December 18, 2024, gives his path through the prison system. He entered it on August 14, 2007, under the identification number 07B2617, went to Clinton Correctional Facility in Dannemora on September 13, 2007, and spent the next 15 years there. On October 27, 2022, he was transferred, for what the report calls an area of preference, to Wende Correctional Facility in Alden, in Erie County. His disciplinary record shows a 2013 infraction and, on September 19, 2023, a ticket for fighting with another prisoner, which ended when officers gave a direct order.
On September 20, 2023, Sanchez declined an interview and refused voluntary protective custody. On the morning of September 22, staff came upon him unresponsive in his cell at Wende, and a medical emergency was called at about 7:15 a.m. An ambulance arrived at 7:50. He was taken to Millard Fillmore Suburban Hospital in Amherst, where he was pronounced dead just before 3 p.m., the Department of Corrections and Community Supervision told reporters. He was 65.
Investigations by the department’s Office of Special Investigations and the State Police concluded that he had been alone in his cell and that his injuries were self-inflicted. The Commission’s Medical Review Board gave the cause of death as hemorrhagic complications and the manner of death as suicide. The Commission also criticized the prison’s handling. The housing unit’s logbook had no entries for Sanchez from the evening of September 20 to the morning of September 22. The physician’s notes did not record the emergency response or the care given, which the Commission said broke state rules on medical records. A delay in calling the ambulance led to staff retraining. The Commission directed a quality assurance review at Wende, and the department reported in November 2024 that it had been completed.
Donald Harvey, a hospital orderly and nurse’s aide, pleaded guilty in Ohio and Kentucky in 1987 and 1988 to the deaths of patients and others, and news reports have given his total as 37 killings. He served his sentences in the Ohio prison system and was held at the Toledo Correctional Institution in Lucas County, where, the guards' union said, he was in a protective custody unit.
He was assaulted in his cell at Toledo, was discovered there on March 28, 2017, and died on March 30, aged 64. The Lucas County coroner attributed his death to the injuries from that assault, according to the Associated Press. Lieutenant Robert Sellers of the State Highway Patrol said a fellow inmate was suspected, but no charges were filed then and the suspect was not named.
The suspect was James D. Elliott, 44 when prosecutors named him in 2019, a prisoner from the Knox and Whitley County area of Kentucky who had been serving a sentence for a series of burglaries since 2006. The union said Elliott was in the same protective custody unit. In 2018 Elliott wrote to newspapers in Toledo and Kentucky admitting the killing. He said he had grown up near relatives of Harvey’s victims. "Hopefully, everyone from our area will take some solace in the fact that one of their own gave Harvey the punishment," he wrote. He also wrote that he had planned it for at least a week and meant it to draw officials' attention to inmates' complaints about food. His mother said he did not know any of Harvey’s victims and that he had been angered by Harvey bragging about what he had done to old people.
In March 2019 Michael Loisel, chief of the criminal division in the Lucas County Prosecutor’s Office, said the case would go to a grand jury and that investigators had checked whether anyone else was involved. In May 2019 a Lucas County grand jury indicted Elliott on charges of aggravated murder and felonious assault, each with a repeat violent offender specification, and tampering with evidence. In September 2019 Elliott pleaded guilty to aggravated murder in Lucas County Common Pleas Court in Toledo, and the other charges were dismissed. Judge Myron Duhart sentenced him at once to life in prison with parole eligibility after 25 years. "No matter how bad a person is, that does not give you the right to be the judge, jury, and executioner," the judge told him. Reports differ on whether the term runs consecutively to the 24 years Elliott had left to serve, as the News Journal of Corbin, Kentucky, reported on September 26, 2019, or concurrently, as The Blade of Toledo reported in October 2019.
The conclusions that came out of these deaths are of three kinds. Some were verdicts on the cause of death, and in five of the cases (Hardy, through the coroner’s acceptance of the hospital certificate; Nilsen; Neilson; Ireland, in its preliminary form; and Milat) the cause was illness. Some were verdicts on the care that preceded it: the Ombudsman’s criticism of the wait for an ambulance at Full Sutton, of the restraints and delayed assessments at Frankland, of the logbook at Wende, and a Western Australian coroner’s reluctance to say that a paperwork error caused a suicide while recommending that no prisoner go without essential medication again. And some were verdicts on the system that surrounded the crimes rather than the deaths: Dame Janet Smith on the certification of Harold Shipman’s patients, a British Columbia jury on the double-bunking of a man who had killed before.
Several questions remain open. No final inquest conclusion for Colin Ireland has been reported. The outcome of the New South Wales coronial inquest into Ivan Milat’s death was not reported. The Ombudsman’s findings on Donald Neilson’s death have not been reported either. In the cases where a verdict exists, it is often short: natural causes at Hull and Norwich, suicide at Perth and Wende, an assault at Toledo. What the reports add is the sequence of hours and the list of things that were not done.
• July 27, 1996: Ivan Milat sentenced to life on each of seven murder counts.
• January 31, 2000: Harold Shipman convicted of 15 murders and forgery.
• 2001: A New South Wales coroner rules that three young women in the Newcastle area were murdered by persons unknown and names Milat as one of six persons of interest.
• January 2002: Sally White’s death is treated as natural; an inquest of about 15 minutes records natural causes.
• November 25, 2003: Anthony Hardy pleads guilty to three murders.
• January 13, 2004: Shipman dies by suicide at HMP Wakefield.
• May 2005: Ombudsman’s report on Shipman’s death published.
• October 7, 2005: David Birnie dies by suicide at Casuarina Prison.
• June 18, 2008: Deputy State Coroner Evelyn Vicker releases findings on Birnie’s death.
• May 14, 2010: Hardy made subject of a whole life order.
• November 21, 2010: Jeremy Phillips killed by his cellmate, Michael McGray, at Mountain Institution.
• 2011: McGray pleads guilty to first-degree murder.
• December 18, 2011: Donald Neilson dies at Norfolk and Norwich University Hospital.
• February 21, 2012: Colin Ireland dies at HMP Wakefield; inquest opened and adjourned in February.
• August 2012: Neilson inquest jury returns a verdict of natural causes.
• October 31, 2012: British Columbia coroner’s jury recommends single cells for multiple murderers.
• March 30, 2017: Donald Harvey dies after being assaulted in his cell at Toledo.
• May 12, 2018: Dennis Nilsen dies at York District Hospital.
• September 2019: James D. Elliott pleads guilty to aggravated murder of Harvey.
• October 23, 2019: Inquest at Hull records natural causes for Nilsen.
• October 27, 2019: Milat dies at Long Bay.
• November 25, 2020: Hardy dies of COVID-19 pneumonia.
• September 2022: Ombudsman’s report on Hardy’s death published.
• September 22, 2023: Altemio Sanchez dies at Wende.
• December 18, 2024: New York State Commission of Correction final report on Sanchez.