Vikki Thompson, 21, was found dead in her cell at the men's prison in November 2015.
A two-week jury inquest into her death ended this morning (Friday May 19) with a jury concluding that she did not intend to take her own life.
Ms Thompson, 21, from Keighley, who had been on remand for a month, was found dead in her cell with a ligature around her neck.
The inquest juy heard she had repeatedly told prison and court escort staff she would be “carried out in a box” and had written to her partner Robert Steele, saying she did not want to be in a male jail, telling him: “I know I’m going to do something silly.”
Ms Thompson's mother Lisa Harrison, said after the inquest: “Words cannot describe the upset of losing my daughter Vikki.
"She was such a bubbly personality and so full of life. As a transgender woman, she experienced a number of difficulties throughout her life.
"Vikki was anxious to be back in prison and repeatedly expressed her concerns. I do not feel that the prison fully appreciated Vikki’s vulnerabilities and I believe their lack of insight has resulted in her death.”
The jury foreman said in the narrative conclusion: "Throughout her chaotic life, Vikki has been let down by various departments including the NHS, Leeds Community Healthcare NHS Trust, the Prison Service and also by her family."
"Although these departments were individually aware of Vikki's history, the overall coordination of her mental and health state were lacking in any form of organisational structure
"During her last stay at HMP Leeds, the management of her treatment and mental state of mind were also lacking in professionalism and inadequate for an individual of such complex issues."
He said: "On October 19, 2015, Vikki was remanded to HMP Leeds, a male prison, and we, the jury, feel this was the right one for Vikki.
"More attention should have been paid to Vikki as a transgender woman with a history from a previous stay in the prison."
The jury concluded that the co-ordination and management of Vikki’s risk of self-harm in prison and the community by the NHS made more than minimal contribution to her death;
They also found observations of Vikki’s cell paid only "lip service" to the standard and frequency required;
The jury also recognised the day to day pressures on all services involved, which were under "immense pressure, understaffed and working in extremely difficult day to day situations."
Speaking on behalf of Ms Thompson's family, Philip Goldberg, managing director of Minton Morrill Solicitors, said: "Vikki’s case is a deeply tragic one. She is one of three transgender women to die within the male prison estate since November 2015.
"Yes, Vikki was a transgender woman housed in a male prison but like many others in prison her vulnerability did not make her unique. It was the responsibility of HMP Leeds to ensure
she was properly looked after and safe. The jury heard that Vikki experienced bullying and sexual harassment on E-Wing that caused her to self-harm before she was moved to the
Vulnerable Prisoner’s wing. HMP Leeds has the second-highest number of self-inflicted deaths in the UK and an inability to learn from their mistakes.
"Vikki’s mother remains deeply distressed by the loss of her daughter. Yet hopes that if any good is to come of her death, it’s that the Ministry of Justice also undertakes a complete
overhaul of HMP Leeds.
"Vikki identified as a woman from a young age and was vulnerable because her complex history of sexual and violent abuse, drug use and mental health problems.
"Vikki’s vulnerabilities echo many of those experienced by women who find themselves in the criminal justice system.
"Just a few months before she was remanded into HMP Leeds for the first time in March 2015 for offences of theft, she had provided evidence to WYP to support three allegations of
sexual offences against her, which at the time of her death were still being investigated. When Vikki went into HMP Leeds in October 2015 she told staff that she would “come out in
Her death echoes the experiences of other vulnerable prisoners who have died whilst in custody at Leeds. This is yet another Inquest that has identified the serious failings both on
the ground and in the management at the prison.
"Vikki’s death has led to a review of the Prison Service Instruction that governs the management of Transgender Prisoners. Whilst we welcome the policy reform, what really
matters is that prisons protect those prisoners in real terms. This will require a radical shift in prison staff culture and training."