10 May 2024

This is a medial release by Bhatt Murphy, reshared by INQUEST

Before HM Assistant Coroner Charlotte Keighley
Cheshire Coroner’s Court, Warrington
29 April - 10 May

Christine McDonald died by suicide contributed by neglect at HMP Styal in Cheshire in March 2019, just days after a traumatic arrest which related to challenges with addiction. Christine’s death is one of 26 at the prison since 2007, eleven of which were self-inflicted. This is more deaths than in any other women’s prison in England and Wales.

Today, a jury concluded that there was a gross failure to provide care and attention to Christine that directly contributed to her death.

The jury concluded that the following factors contributed to Chrstine’s death:

  • Christine had used her cell bell to ask to see a nurse shortly before she ligatured
  • The prison officer did not action the request
  • Christine should have been assessed by healthcare on her return from hospital but was not
  • That the message in relation to the well-being of Christine’s daughter should have been communicated to Christine but was not
  • There was a failure by healthcare to follow the clinical guidance about the assessment and treatment of Christine’s drug dependency
  • There were failings in communications between healthcare staff and prison staff at HMP Styal 

Christine was 55 years old at the time of her death and had four children. She was kind, loving, and had a good sense of humour. She was someone who always put others before herself. She was loved and is missed immensely by her family.

Christine struggled with opiate addiction and had convictions for shoplifting related to her addiction.

At the time of her death, Christine was serving a 12-week sentence at HMP Styal for two offences of shoplifting small value items of shampoo, bubble bath, hair dye and cheese and one offence of failure to comply with a community requirement of a suspended sentence.

The circumstances of the arrest for the above mentioned offences had a significant impact on Christine. During the arrest her eldest daughter Kristy fell from the third floor suffering serious injuries. Christine witnessed her daughter sustain serious injuries before she was arrested.

Upon arrival at the prison on 1 March 2019, her behaviour was described as being anxious, suffering from opiate withdrawal symptoms and being concerned for her daughter who had sustained serious injuries from the fall.

The jury heard evidence that opiate dependency is a serious health issue, it is complex to treat, and that rapid detoxification should be avoided. The jury heard that withdrawal symptoms appear about 6 hours after last use and peak after 36 -72 hours and that there should have been additional observations for those withdrawing.

Christine continued to suffer from withdrawal symptoms, had low mood and continued expressing concern for her daughter the following day, on 2 March 2019. Later that day, Christine was taken to Wythenshawe Hospital in Manchester following concerns raised during a healthcare assessment in the prison. She was subsequently returned to HMP Styal.

The jury heard evidence that previous entries and records concerning Christine’s drug dependency and concerns about her daughter were not referred to or read, and information, in particular with regards to her daughter Kristy, were not passed on or acted upon. Further, that a full clinical assessment on Christine’s return from hospital with additional observations overnight should have been conducted.

On the evening of 2 March 2019 at around 23:00, two prison officers found Christine hanging in her cell. She was found to have a pulse and was taken back to Wythenshawe hospital. The jury heard evidence that Christine asked a prison officer for help and requested a nurse at 22.30 prior to her death, but that a nurse was not requested by the prison officer.

On 3 March 2019 she was pronounced dead, with her family at her side.

Cheri McDonald, Christine’s daughter, said:  “My mum was left alone crying out for help dismissed and ignored by staff until she could not longer cope and ended her won suffering. Throughout this inquest evidence has been heard about the failings of HMP Styal and Spectrum Healthcare staff.

I am horrified and disappointed by the lack of transparency, compassion or accountability taken by both providers. The prison and healthcare staff had a responsibility and duty of care to at the very least ensure she remained alive they did not do this.

We will never get over the loss of my mum but I speak out in the hope that this doesn’t keep happening and if it does other families realise there are ways to identify and expose any failings and stand against this. 

I would like to thank the charity INQUEST who have supported me throughout this journey without their instruction I would have been unaware of my rights as a family member subject to a death in custody.”

Jordan Ferdinand-Sargeant, caseoworker at INQUEST, said: "Christine was a vulnerable woman in prison for shoplifting small value items: shampoo, bubble bath, hair dye and cheese. Two days later, she was dead. She needed care and support, not a prison sentence.

Time and time again we see the dangerous and fatal consequences of sending women to prison, not least those with complex needs like Christine.

Deaths at Styal prison are at a record high and two self-inflicted deaths in December yet again raise serious questions about women’s health and safety.

We must urgently dismantle prisons and redirect resources to holistic, gender responsive community services. Only then can we end the deaths of women in prison.”



Christine’s family are represented by Alison Gerry of Doughty Street Chambers and Jane Ryan, Catherine Shannon, and Basanti Mardemootoo of Bhatt Murphy solicitors.

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