The increasing number of deaths in prison custody from natural causes is linked to the rise in deaths of older sentenced prisoners and the ageing prisoner population who have more chronic and serious illnesses.  Of the 903 total deaths in police custody and custody-related operations between 1979-90 and 2010–11 in Australia, 15% (n=137) were due to natural causes.  Aboriginal and Torres Strait Islander people are overrepresented in Prisons. Of the 2008 total, 13 (15%) were Aboriginal and Torres Strait Islander people. 
Much of the literature on prisoners and palliative care comes from the US, and acknowledgement is needed of the differences in population and healthcare systems. However, many issues identified in the US are likely to become an increasing challenge in Australia.
A growing number of prisoners will live out a large portion of their lives and eventually die in prison. Many of these prisoners are aging and are more likely to have existing co-morbidities.  Women often have greater healthcare needs with 57% of women prisoners in one study with a history of sexual or physical abuse or both, with resulting higher rates of HIV, Hepatitis C. These women were also 16 times more likely to have a psychiatric disorder.  Poverty, homelessness, cognitive defects, learning disabilities, low health literacy and prior limited access to healthcare are also factors to consider. Prisoners have little or no choices regarding decision making.  Advocacy by healthcare professionals may be difficult, and conflict with prison regulations. 
Security is seen as a priority and may restrict or delay timely access to external healthcare,  as hospital transfers are costly and pose security risks.  Issues of litigation and liability (inferring neglect) may mean prisoners are sent to hospital to die (in custody), unless they agree to a ‘Do Not Resuscitate’ order. 
Inmates who die in prison potentially do so alone  as family visits may be limited or families may be estranged. In prison, family may also mean other prisoners. Access to compassionate leave (medical parole) varies, and is likely to be in the last few days of life. 
There can be restrictions on care delivery in prison,  with limited access to urgent facilities, restriction on drugs (due to concerns about addiction) and problems with dispensing drugs (such as breakthrough medication).  Prisoners may also be assaulted by other inmates to obtain the drugs they have been prescribed.
Prison medical staff need to work in collaboration with social workers, clinical psychologists, Aboriginal Health Workers and Aboriginal liaison officers  and collaboration is also needed between prison staff and community palliative care staff to support continuity of care for those prisoners who are terminally ill. 
Death in custody
If a prisoner dies while in a hospital or hospice, they are still considered to be in custody. The room the patient is in at the time of death is considered to be a crime scene and nothing must be touched including the patient, until the investigating officers have finished. The death then requires investigation by the State Coroner, who will look at the patient’s treatment during the course of their illness to ensure they have received fair and equitable treatment. Further information on coronial processes should be sought from State Coroner's Offices.
Prison has a certain culture of toughness. Issues such as masculine and / or cultural responses to grief, as well as prison restrictions (such as limited options for attending funerals) can have a strong impact on the ability of prisoners to resolve issues of loss and grief.