11th April 2013

Thursday 11 April 2013 at 10am
Before HM Coroner for Surrey Richard Travers
Sitting at HG Wells Conference Centre, Church Street East, Woking, Surrey, GU21 6HJ

Melanie Beswick was 34 years old when she died on 21 August 2010.  She was found hanging from a ligature made from shoelaces attached to the window of her cell in HMP Send.

In March 2009 Melanie was given a nine month prison sentence for fraud. This was her first offence. Melanie had a long history of depression and self harm, and self harmed on several occasions during her first period of imprisonment. Confiscation proceedings were brought and following her release Melanie was ordered to repay the money she took within 6 months or serve a further 12 month prison sentence in default. Short of selling the family home and making her husband and two young children homeless Melanie could not repay the money in time and was sent back to prison by the court.

She self-harmed on several occasions during her imprisonment and was subject to an ACCT (Assessment, Care in Custody, and Teamwork – the system used for prisoners who are at risk of self harm) on three occasions.  She had also reported bullying on several occasions, and expressed fear that she would not be able to repay the money and so face further imprisonment.  On the day of her death, she had been found unresponsive and motionless in her cell and, despite no obviously signs of physical ill health, was taken to hospital, where she became agitated and tried to harm herself several times.  The doctor eventually discharged her but instructed that she was at high risk of self harm and needed constant observation and mental health input.

Despite this, on Melanie’s return from hospital that afternoon the duty governor decided that she did not need an ACCT or monitoring. Apparently unknown to him another officer had already begun the process but she was only placed on hourly observations.  At about 7.45pm Melanie asked to speak to a Listener (prisoners trained by the Samaritans to support other prisoners in distress) but was told to wait because the on-duty Listeners were busy with other prisoners.  At 8.35pm, she was found hanging in her cell and despite attempts to resuscitate her was pronounced dead at 10.02pm at hospital.

Her family hopes the inquest will address the following issues:

• What HMP Send should have known about Melanie’s medical history
• The ACCT process
• The medical care Melanie received in HMP Send and her undiagnosed underlying mental health condition
• How the prison dealt with Melanie’s allegations of bullying
• Information Melanie was given about her sentence
• The care she received at hospital on the morning of the day of her death
• Information breakdown between the hospital and the prison
• The decision of the Deputy Governor not to instigate ACCT monitoring
• The Listener scheme
• The provision of first aid by prison staff

Melanie’s husband, two young daughters, mother and step-father are represented by INQUEST Lawyers Group members Jo Eggleton of Deighton Pierce Glynn and Jesse Nicholls of Tooks Chambers.

Ends