Woman, 21, jailed after setting fire to herself killed herself behind bars because prison staff 'failed to monitor her'
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A 21-year-old girl who was "criminalised because she was mentally ill" was able to kill herself while behind bars because of failings by prison staff, an inquest has heard.
An inquest jury has raised concerns about a “lack of professionalism” among officers at New Hall Prison over failings in the care of Emily Hartley who hanged herself.
Emily was found dead in an outside ‘out of bounds’ area of the Flockton prison on April 23 in 2016.
She had a history of serious mental ill health including self-harm and suicide attempts.
An inquest jury heard how prison staff had lost Emily's final notes to her family, including a list of songs to be played at her funeral, until nine months after her burial.
(Image: examiner/ WS)
Failings in her care led to disciplinary action being taken against a number of officers at New Hall Prison in Flockton West Yorkshire - though none have been sacked, the Huddersfield Examiner reports.
Emily had been remanded in custody in May 2015 after setting fire to herself, her bed and curtains. It was the Leeds woman’s first time in prison.
Her death took place behind the building where exercise took place, in an out of bounds area.
It took prison staff two and half hours to notice that she had gone missing and to find her body, despite the fact that she should have been checked every half an hour because she was considered at risk.
The inquest jury concluded the deterioration in Emily’s mental state from January 2016 should have sparked a review and a move to a therapeutic unit, which would have been more appropriate.
The jury also found:
The discovery of a suicide note should have triggered the implementation of suicide and self-harm procedures known as ACCT.
There was a “lack of professionalism” in the implementation of the ACCT process, with insufficient importance given to the procedure by some staff.
There was an absence of meaningful physical checks in the days leading up to Emily’s death.
A “lack of professionalism” by some staff in the ‘care and support unit’ where Emily was held could have been perceived by her as “bullying”.
Contradictory evidence was given under oath by staff which the jury described as “fictional accounts”.
The exercise yard where Emily died was not fit for purpose and risk assessments should have identified that prisoners could disappear from view.
(Image: examiner/ WS)
The inquest also heard that when Emily left for exercise on the day of her death, she had tried to take an envelope with her but this was confiscated.
Her family asked again and again about what it contained, but documents including its contents were only supplied three weeks before the inquest began.
Included in the envelope was a letter to her family, including her wishes for songs to be played at her funeral - which they did not receive on time.
The jury expressed compassion towards Emily’s family regarding what they ruled was a failing by the West Yorkshire Police, who cleared Emily’s prison room after her death.
Following the inquest Emily’s family said: “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 the charity INQUEST said: “This inquest is a damning indictment of a justice system that criminalises women for being mentally ill."
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 by cutting.
“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.” The jury agreed.”
Emily was the youngest of 22 women to die in women’s prisons in 2016, the highest annual number of deaths on record. Including Emily, there have been five deaths in New Hall since 2016.
A Prison Service spokesman 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.