A WOMAN with psychiatric problems who hanged herself in prison should never have been jailed in the first place, an inquest found.
Mandy Pearson, 37, was found hanging in a dormitory cell in the healthcare centre at New Hall Prison, Wakefield, on October 11, 2004.
The mother of three young children, was serving a five-month prison sentence at the time of her death and had been due for release in a matter of weeks.
A jury of four men and five women at Wakefield Coroner's Court took less than four hours to arrive at their verdict after the two-week inquest into Ms Pearson's death.
The inquest heard that before Ms Pearson was admitted to New Hall in August 2004 her consultant psychiatrist had decided to remove her from psychiatric care.
The jury found this prevented her from receiving appropriate treatment for her disorder.
The foreman said: "The decision by Mandy's consultant psychiatrist to discharge her from psychiatric care and the decision of the court not to seek psychiatric review as recommended by the probation service meant that prison was the only sentencing option remaining for Mandy.
"The jury feel that this was not the best option for Mandy and for others in a similar position.
"But there appears to be a dearth of effective alternatives, which means that they are imprisoned within the justice system."
The inquest heard that when Ms Pearson entered the prison's healthcare centre she was assessed by a nurse who decided she was not a self-harm or suicide risk.
She was then seen by a prison doctor and a prison psychiatrist.
Both of them assumed she had already been placed under the careful monitoring procedure for patients with psychiatric problems, and failed to put her on the list of high-risk patients in need of half-hourly checks.
Ms Pearson reportedly told the psychiatrist she was looking for somewhere to kill herself.
The jury found there was a “lack of appropriate training and inadequate support of the staff responsible at the time as well as confusion over the interpretation of local instructions.”
This meant Ms Pearson, who was diagnosed with emotionally unstable personality disorder, and who had a history of self-harm, was never placed under careful monitoring procedures.
The jury found that if all inmates at New Hall with psychological problems were carefully monitored, as the prison policy dictated, the system would have become “unworkable“.
After she was found hanging at around 1pm on October 11, Ms Pearson was transferred to Pinderfields General Hospital.
She was pronounced dead at 4.10pm the following day, just days before the anniversary of her husband’s death on October 15 the previous year.
The jury said the lack of accommodation available on her release was a “considerable concern” for Ms Pearson.
Anne Owers, the Chief Inspector of Prisons, told the inquest that vulnerable women with psychiatric problems were being sent to prison by default because there were not enough resources available to look after them properly.
It was the first time Ms Owers, who took up the role of inspecting prisons in England and Wales in August 2001, had given evidence at an inquest.
The inquest heard there were 11 deaths by hanging at New Hall between January 2002 and May 2006.
After the verdict, West Yorkshire Coroner David Hinchliff offered the family his “personal condolences”.
Ms Pearson’s mother, Cynthia Keast, was not in court because she was unwell, but family solicitor Fiona Borrill read a statement on her behalf.
She said: “Mandy is much missed by her family and friends. We all hope that lessons will be learned, changes made, so that vulnerable women like Mandy are properly supported and cared for outside of prison.
“Prison was and still is not an appropriate place for many women with mental health difficulties like Mandy.”