1 February 2018

Before HM Senior Coroner for West Yorkshire David Hinchliff
Wakefield Coroner’s Court

15 January – 1 February 2018

The inquest into the self-inflicted death of Emily Hartley has concluded with the jury finding a lack of professionalism at HMP New Hall, including in the implementation of suicide and self-harm procedures (ACCT*), contributed to the 21 year old’s death on 23 April 2016. She 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 HMP New Hall since 2016.

Emily had been remanded in custody in May 2015 after she set fire to herself, her bed and curtains. She had a history of serious mental ill health including self-harm, suicide attempts and drug addiction. This was her first time in prison.  Emily’s 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 believed at the time of sentencing, New Hall prison was an appropriate place of detention. However they 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.

In their conclusions, the jury also found:

  • The failure to apply the ACCT process was a contributing factor to Emily’s death.
  • A lack of professionalism in the implementation of the ACCT process, with insufficient importance given to the procedure by some staff.
  • An absence of meaningful physical checks in the days leading up to Emily’s death which contributed to the deterioration of her mental health.
  • A lack of professionalism by some staff in the ‘care and support’ unit of the prison (Holly Ward) where Emily was held, whose behaviour could have been perceived as bullying by Emily. Further demonstrated by contradictory evidence given by these staff at the inquest, which they found to be “fictional”.
  • The exercise yard where Emily died was not fit for purpose, and risk assessments should easily have identified that prisoners could disappear from view.

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 was a heart wrenching letter to her family, including her wishes for songs to be played at her funeral: nine months too late. The jury expressed compassion towards Emily’s family regarding this failing by the West Yorkshire Police, who cleared Emily’s prison room after her death.

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 INQUEST said: “This inquest is a damning indictment of a justice system that criminalises women for being mentally ill. For decades, recommendations from investigations, inquests and the Corston review have not been acted upon. This inquest adds to the plethora of evidence about the dangers of imprisonment for women, and the need to invest in community services that can address mental ill health and addiction.

Ten years ago to the day, at the inquest of Petra Blanksby the very same coroner read out remarkably similar conclusions. Petra was 19 and died at HMP New Hall in 2003; she had also been imprisoned for arson. The coroner urged the prison and health service to invest in therapeutic settings. Yet nothing has changed. This is a life or death issue for public policy, which government cannot continue to ignore.”

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 8 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.



For further information, please contact Lucy McKay on 020 7263 1111 or here.

INQUEST has been working with the family of Emily Hartley since her death. The family is represented by INQUEST Lawyers Group member Ruth Bundey of Harrison Bundey Solicitors.

  • Emily Hartley lived in Leeds prior to her arrest. Photos of her are available on request. Further background can be found in the press release issued at the opening of the inquest, available here. The family will not be giving further comment to the media at this point.
  • More information on the life and inquest of Petra Blanksby who also died in HMP New Hall is available here. Her inquest concluded on 1 February 2008.
  • The inquest into the death of Sarah Burke at HMP Drake Hall is also expected to conclude today. Similar issues including delays in finding her body, and undertaking suicide and self-harm procedures have been part of the inquest. More information here. See inquest.org.uk and follow @INQUEST_ORG for updates.
  • 2016 was the deadliest year in women’s prisons for over a decade. There were 22 deaths, at least 12 of which were self-inflicted deaths. More info here.
  • Deaths in women’s prisons are a priority area of work for INQUEST. More information and recent reports available here.

*ACCT stands for Assessment, Care in Custody & Teamwork (ACCT) and is the name of suicide and self-harm monitoring forms and procedures used in prisons.