19 January 2024

Before HM Area Coroner Victoria Davies 
Cheshire Coroner’s Court, St James Business Centre, Warrington
15 – 19 January 2024

Annelise Sanderson, 18, died after ligaturing at HMP Styal only five days after being discharged from mental health services. Now an inquest has found a lack of record keeping and communication failures at the prison.

Annelise’s death is one of 11 self-inflicted deaths at the prison since 2007, more than any other women’s prison in England. She is the youngest person to have died in a women’s prison in 20 years.

Annelise grew up in Runcorn, Cheshire. A tomboy from an early age, Annelise was interested in biking and playing football. A passionate, loving and forgiving person, her family said she cherished the relationships of those to whom she was closest. 

Annelise had a complex history of mental ill health, self-harm and suicide attempts. She had spent time in local authority care and had experienced significant trauma. At the time of Annelise’s death, she was under the social services care leavers’ team. 

In June 2020, shortly after turning 18, Annelise was arrested after she had been witnessed trying to drink or pour petrol on herself at a petrol station and had assaulted emergency workers who tried to intervene. 

She was very unwell and was taken to A&E before being transferred to court.  She was subsequently sentenced to 52 weeks in prison and was sent to HMP Styal. 

Upon arrival at the prison, her behaviour was described as volatile and erratic, and she was observed acting bizarrely, removing her clothes and threatening staff. After three days, a safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place. 

Over the next few days, Annelise attended a review with a ligature around her neck, and told staff she was sleeping on the floor as she felt safer there. 

On 1 July, she told staff she had swallowed a battery and, on 5 July, she attempted to climb over the railings on the prison landing. Her ACCT was closed on 7 July, only eight days after it had been opened.

On 5 August, Annelise asked whether she could be prescribed a mood stabiliser. She did not receive antidepressant medication until 17 September. The GP had had no contact with Annelise before prescribing the medication, and no formal mental health diagnosis had been made.

In September and November Annelise continued to report low mood and told staff her medication was not working.

On 11 December, Annelise was sentenced to a further 12 weeks in prison, which meant she would spend Christmas in prison.

Five days before her death, on 17 December, Annelise was discharged from the mental health team. 

On 22 December 2020, a prison officer found Annelise ligatured in her cell. Staff commenced CPR and an ambulance was called. She was pronounced dead shortly after. 

The jury concluded that Annelise died by suicide and returned a narrative conclusion. They found that:

• There were significant issues with the recording of the [initial] assessment information due to not being near a computer.
• The staff nurse team leader said she had seen notes of past history, she would’ve opened ACCT on arrival, instead of three days after. 
• The ACCT was closed on 7 July 2020, despite a number of incidents taking place during this period, which were of concern. These were missed off notes, meaning some staff were unaware.
• Annelise was not informed about [her prescription] to begin with which resulted in a delay of starting the medication sertraline – an anti-depressant. There was a failure to ensure adequate follow up for side effects. 
• There was a clear failure of the system to ensure adequate communication between professionals, meaning a lack of ownership regarding decisions.
• Despite her saying she felt no benefits of the sertraline, Annelise was discharged from mental health services on 17 December.
• There appears to be a lack of communication, accessibility and recording of records. 

Angela Gray, Annelise’s mother, said: “Annelise was a loving daughter, sister, niece, aunt and friend. She was not just another prison number. She was bright, and cheeky, and complicated. She liked to make people laugh. 

But she was also a vulnerable person, who faced serious difficulties with her mental health. When she entered HMP Styal, she had only just turned 18. You could tell from just looking at her she was still a child.

Her death has been incomprehensible and devastating, and we think it could have been prevented. Over the course of this week we have seen for ourselves how  Annelise was treated in prison; she was just another number to them. 

Her mental health issues were seen as bad behaviour, and when she withdrew into herself she was just left to her own devices. She fell through the cracks despite asking for help from people who should have kept her safe. The past few days have been painful and enraging.

We thank the jury for the attention they have given Annelise’s case and for recognising that there were failures in her care.

Annelise was a special person, but in her fate she is not unique. Since her death, three more women have died in Styal. Our condolences go out to their families. Styal was not a safe place for Annelise, and we feel it is not a safe place for vulnerable women now.”

Deborah Coles, Director at INQUEST, said: “What do we do in response to young women in obvious need of care and support? We can't keep locking them up to die. 

Annelise had a history of trauma, and the mental ill health that often accompanies this. She deserved our understanding, care and support. Instead, she was viewed as a discipline and control problem by our public services. The fundamental question for all of us, is why was she sent to prison in the first place?

Deaths in Styal prison are at a record high and two self-inflicted deaths in December raise serious renewed questions about women’s health and safety. Each of these deaths is a stark reminder that prison is a disproportionate, inappropriate, and dangerous response to women in conflict with the law, not least for those with mental ill health.

How many deaths must it take before the Government finally takes action and ends the needless imprisonment of women to save lives? We need to dismantle prisons and redirect resources to holistic, gender responsive community services. Only then can we end the deaths of women in prison.”

Michela Carini and Amy Ooi, at Bhatt Murphy Solicitors, said: "Annelise was a vulnerable young woman with complex needs which were not recognised or appropriately acted on. Information relevant to her risk to herself was not adequately shared between the agencies and staff involved with Annelise.

She was discharged from mental health services into the care of the GP, despite reporting on a number of occasions that the antidepressant she had been prescribed was not working. The GP’s evidence was clear that the system operated within healthcare prevented her from appropriately managing Annelise’s care. 

The death of someone as young and vulnerable as Annelise in state custody is shocking and incomprehensible, and the indifference with which she was treated by the system in which she found herself was unacceptable."

ENDS

NOTES TO EDITORS

For further information, please contact Leila Hagmann on [email protected].

The family is represented by INQUEST Lawyers Group members Amy Ooi and Michela Carini of Bhatt Murphy Solicitors and Leonie Hirst of Doughty Street Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav, and Jordan Ferdinand-Sergeant.

Other Interested persons represented are HMP Styal; Halton Borough Council whose social services team had responsibility for Annelise as a care leaver; Greater Manchester Mental Health NHS Foundation Trust, who are responsible for mental health provision within HMP Styal; and Spectrum Community Healthcare, the organisation providing healthcare and additional services within HMP Styal.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests. 

Useful resources

Annelise Sanderson’s inquest is the first inquest into self-inflicted death in HMP Styal since 2018. Since her death, there have been a further three self-inflicted deaths at the prison.

 A recent critical report by the Independent Monitoring Board found that:

“A number of prisoners have been identified as mentally unwell or a significant risk to themselves, to the point of likely needing a secure mental health placement to address their support needs. It has been incredibly difficult securing the appropriate mental health assessments and placements needed for these individuals. The Board have observed prison has worked hard to find ways to best support and manage them, but it is clearly not resourced to provide the level of mental health support needed.”