26 May 2017 

Before HM Senior Coroner Dr Robert Hunter
Derby Coroner’s Office
15 – 25 May 2017

On 25 May 2017 the inquest into the death of Caroline Ann Hunt, a prisoner at HMP Foston Hall concluded. Aged 53 she was found hanging in her cell on 26 September 2015 and died 3 days later in Hospital.

The jury found many serious failings in the way Caroline was managed and cared for, including that: staff underestimated the risk she posed to herself, that she should have been referred for a formal psychiatric assessment, that it was inappropriate given her risk to move her to a single cell, and that the level of observations set was not appropriate.

The jury concluded that Caroline took her own life in part because the risk of her doing so was not adequately recognised and appropriate precautions were not taken to prevent her doing so.

Following her death, the overnight custody manger, who was the most senior officer on duty at the prison the night before Caroline was found hanging, was immediately suspended for his actions surrounding the assessment and management of her risk that night. He thereafter faced disciplinary proceedings, but resigned before any hearing took place.

During the course of the inquest hearing, on 19 May HM Senior Coroner Dr Hunter took the exceptional course of issuing a Prevention of Future Death report before the inquest concluded. The report was addressed to the Governor of HMP Foston Hall and it raised the Coroner’s immediate concerns about another member of prison staff, a prison officers who gave evidence on that day. He stated that he had “grave concerns” about her understanding of safer custody procedures and that “should she remain operational she is endangering the lives of current prisoners.”

The Ministry of Justice has indicated that that officer has been suspended from operational duties while she undertakes urgent training.

The daughter of Caroline Hunt said:
“On 29th September 2015 my mother, Caroline Hunt, passed away aged 53. She was found hanging by a bedsheet in a cell in HMP Foston Hall.  Since then my life has been a whirlwind of difficult decisions and emotions. I have learned some very sad truths about life inside prison, and just how difficult prison is for the most vulnerable people in society.

My Mother was a very kind person, who cared deeply for her friends and family members. I believe she was sadly blighted with various mental health issues throughout her lifetime, which led directly to the circumstances surrounding her committing an offence, the first she ever committed. In prison, she felt hopeless and frightened about her future.

Tragically for my Mother, there were many missed opportunities to protect her from the obvious risk she posed to herself, including concerns raised by other prisoners about her risk to herself, and to provide the support she clearly needed. Had the opportunities been taken my mother would probably be here with us all today.

My mother was the fourth person to die while in custody in HMP Foston Hall in 2015. I hoped that her death would be the last, and no other family would have to go through what I have. I was very saddened to hear that in 2016 a further two women took their lives there: six women in two years who ended their lives. These deaths leave families with endless pain and countless what ifs.”

Jane Ryan of Bhatt Murphy solicitors who represented the family said:
“The fact that a Preventing Future Death report was issued by HM Senior Coroner before these proceedings had even concluded is an indication of the high risk faced by women prisoners at HMP Foston Hall. Urgent action is required, including addressing deficits in training on a wider level, to address that risk.”

Deborah Coles, Director of INQUEST said:
“The familiar failings which contributed to Caroline’s death point to the urgent need to stop imprisoning women and invest in women centred community services. It is truly shocking that at the point of giving evidence over 18 months on, the coroner found a key member of staff had a lamentable lack of understanding of suicide prevention policies. This begs questions about the state of governance at Foston Hall, a prison in which four of the five self-inflicted deaths across the women’s prison estate took place in 2015.

One year after Caroline’s death the number of women’s self-inflicted deaths in prison doubled, with 12 in 2016. Had the recommendations of Baroness Corston’s report 10 years ago been implemented, Caroline and many other women who have died in the last few years should have never have gone to prison in the first place. Prisons are failing those in their care, and by extension failing victims and communities. Until there is a dramatic reduction in the use of prison and a redirection of resources into community alternatives, these needless deaths will continue.”


INQUEST has been working with Caroline’s family since November 2015.  The family is represented by Inquest Lawyers Group members Jane Ryan from Bhatt Murphy Solicitors and barrister Alison Gerry from Doughty Street Chambers. ENDS

For further information please contact:
• the legal representative for the family Jane Ryan [email protected] 
• communications at INQUEST Lucy McKay on 020 7263 1111 or [email protected]

  1. Caroline had no criminal history and not been in prison before until 29 May 2015 when she was remanded in HMP Foston Hall for threatening to kill her daughter during an argument.
  2. The circumstances prior to Caroline’s death are as follows:
    • During the two weeks following her reception, until her death Caroline was seen to be distressed and anxious. She made statements that she planned to kill herself and other prisoners similarly reported her expressing suicidal thoughts.
    • The day after being remanded back into custody she cut her wrists with a plastic knife.
    • The night before her death she attempted to suffocate herself by placing a bag over her head and her cell mate twice expressed serious concerns to prison officers that Caroline would kill herself.
    • Staff decided to put her in a cell on her own and while her observations were increased from two to three times an hour, the next morning, Caroline was found hanging in her cell.
  3. Caroline’s death was the fourth self-inflicted death at HMP Foston Hall in 2015. There were a total of five deaths in women’s prisons that year. In 2016 there were two further deaths in Foston Hall, both in November.
  4. In 2016 the rate of self-inflicted deaths in women’s prisons more than doubled, with 12 deaths. 
  5. The rate of self-inflicted deaths across the men and women’s prison estates have more than doubled since 2013. See: Ministry of Justice (MOJ) stats.
  6. For more information on the deaths of women in prison see:
    • The Corston Reportwhich celebrated it’s 10th anniversary this year yet it’s recommendations and concerns still resonate strongly today.
    • The Prison and Probation Ombudsman’s March Learning Lesson’s bulletin on self-inflicted deaths of female prisoners.
    • The Independent Advisory Panel on Deaths in Custody (IAP) March working paper on Preventing Deaths of Women in Prison


INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.