An inquest jury has criticised a Wakefield prison where a 21-year-old Leeds woman with a history of self harm and suicide attempts was found dead.
Emily Hartley, of Roundhay, Leeds, was found hanged at HMP New Hall, Wakefield on April 23 2016.
An inquest jury at Wakefield was told it took prison staff two-and-a-half hours to notice Miss Hartley had gone missing and find her body in an out of bounds area behind a building where prisoners exercised.
The inquest jury was told she should have been checked every half-an-hour because she was considered at risk.
The inquest jury found that lack of professionalism at HMP New Hall – including in the implementation of suicide and self-harm procedures – contributed to Miss Hartley’s death.
Pressure group INQUEST said Miss Hartley was the youngest of 22 women to die in women’s prisons in 2016, the highest annual number of deaths on record.
INQUEST said a total of five women have died at HMP New Hall since 2016.
Miss Hartley, who had a history of serious mental ill health problems including self-harm, suicide attempts and drug addiction, had been remanded in custody in May 2015 after she set fire to herself, her bed and curtains.
In November 2015 she was sentenced to over two years imprisonment for arson and returned to New Hall.
The inquest jury concluded that at the time of sentencing, New Hall prison was an appropriate place of detention.
However they concluded the deterioration in Miss Hartley’s mental state from January 2016 should have sparked a review and a move to a therapeutic unit, which would have been more appropriate.
In their conclusions, the jury also found:
* The failure to apply the suicide and self-harm procedures process was a contributing factor to Miss Hartley’s death;
* A lack of professionalism in the implementation of the suicide and self harm procedures process, with insufficient importance given to the procedure by some staff;
* An absence of meaningful physical checks in the days leading up to Miss Hartley’s death which contributed to the deterioration of her mental health;
* A lack of professionalism by some staff in the ‘care and support’ unit of the prison (Holly Ward) where Miss Hartley was held;
* The exercise yard where Miss Hartley died was not fit for purpose, and risk assessments should easily have identified that prisoners could disappear from view.
Miss Hartley’s family said after the inquest: “Whilst we were shocked to find Emily sent to prison, the one consolation was that we believed she would be kept safe.”
Deborah Coles, Director of INQUEST, said: “This inquest is a damning indictment of a justice system that criminalises women for being mentally ill.
“Ten years ago to the day, at the inquest of Petra Blanksby the very same coroner read out remarkably similar conclusions.
“Petra was 19 and died at HMP New Hall in 2003; she had also been imprisoned for arson. The coroner urged the prison and health service to invest in therapeutic settings. Yet nothing has changed. This a life or death issue for public policy, which government cannot continue to ignore.
Ruth Bundey of Harrison Bundey solicitors who represented the family said: “Emily’s constant struggle to cope with prison and with her mental health issues led her to self- harm again and again.
“But her behaviour dramatically escalated eight-days before her death when she used a ligature and showed a mental health nurse a ‘suicide file’ with a letter for ‘who finds me.’
“This development, showing a dangerous move from ‘impulsive’ actions to planning for death, was insufficiently shared with staff responsible for her care.”
A Prison Service spokeswoman said: “This is a tragic case and our deepest sympathies are with Emily Hartley’s family and friends.
“The welfare of those in our custody is our absolute priority. HMP New Hall has taken urgent action to address the concerns raised, including reviewing care procedures for those most at risk and new suicide and self-harm training for staff.
“We will carefully consider the inquest findings to see what further lessons can be learned alongside the ombudsman’s investigation.”