29th October 2013

The inquest into the death of Sarah Higgins at HMP Bronzefield concluded on 28 October 2013 with the jury finding that serious procedural failings and inadequate formal training contributed to Sarah’s death.

Sarah died on 8 May 2010 aged 30.  At the time of her death, Sarah had three children aged 5, 6 and 11.  Sarah was discovered unresponsive on the floor of her cell shortly before 4.30 am by a Prison Custody Officer.  Emergency resuscitation was unsuccessful and she was pronounced dead at 4.48 am. A Kinder Egg containing various drugs was found in her clothing.

Before arriving at HMP Bronzefield, Sarah had been in the custody of Sussex Police following her arrest on 5 May 2010.  Whilst in police custody she was on constant watch due to police officers having witnessed what they suspected to be Sarah secreting drugs.  On 7 May 2010, Sarah was taken by SERCO escort officers to Brighton Magistrates Court where she was remanded into custody at HMP Bronzefield, a private prison run by Sodexo. Sarah was accompanied by a Prisoner Escort Record (PER) that had recorded on it risk indicators, including the real concern that she may have secreted drugs, the fact that she had been on a constant watch at the police station and details about medications that had been given.

The jury at Sarah’s inquest heard damning evidence concerning the failures to communicate and act upon the risk information contained in the PER form, in particular the risk that she may have secreted drugs.  Serious concerns were also raised in respect of the failure to provide prison healthcare staff with medical information accompanying the PER.  Alarmingly, healthcare staff gave evidence that they did not routinely receive medical documents arriving with new prisoners and some were unaware that prisoners arriving at HMP Bronzefield were accompanied with a PER form that could contain health information.

The jury heard evidence from the GP who prescribed methadone to Sarah in reception.  The GP accepted that had he been aware of the risk that Sarah may have secreted drugs, as contained in the PER form, his prescribing decisions, including in respect of methadone, may have been different.

The inquest also heard about the findings from the NOMS Review into Unclassified Prison Deaths between 2010-2011.  This Review found that methadone was particularly toxic at night, and that in 13 out of the 17 methadone-related deaths investigated the person was found dead first thing in the morning or could not be roused.

The jury concluded that serious procedural failings and inadequate formal training led to important details on the PER not being passed to healthcare staff and that this would likely have impacted on the medication prescribed and administered to Sarah.  The jury also concluded that in view of the suspicion of secreted drugs and the prescription of methadone and other medications, Sarah should have been admitted to healthcare where she could have been closely monitored and observed.

Sarah’s death was the first of two deaths in worryingly similar circumstances at HMP Bronzefield within ten months of each other.

Sarah’s mother, Deborah Higgins said:

“I feel very angry about what happened to my daughter Sarah.  The evidence I heard during the course of the inquest showed me how horrific the last few days of her life had been.  Witnesses told us one after another how it was an ‘oversight’ that they did not read and act upon the information contained in the PER that accompanied Sarah to the prison.  The word ‘oversight’ should not exclude them from any accountability.  These serious failures subsequently led to Sarah being prescribed methadone and several other medications.  The inquest heard evidence from an expert that methadone is very toxic especially when given at night, as happened to Sarah, and that individuals need to be closely observed.  The prison failed to recognise this risk and did not monitor Sarah’s health appropriately.  As a consequence, I have lost my daughter and her three children have lost a loving mother.”

Deborah Coles, co-director of INQUEST said:

“On the night of Sarah’s death there were only two nurses looking after 527 women in this privately run prison. If proper procedures had been followed this death could and should been prevented.

“It was Sarah’s drug dependency that resulted in her being imprisoned in an environment that could not keep her safe. Rather than send her to prison which is expensive damaging and dangerous, it should have been possible to address the reasons behind her offending through community based alternatives. This tragic death of a young mother is a tragic reminder of the urgent need for a new approach to the treatment of women in conflict with the law.”

INQUEST has been working with Sarah’s family since 2011.  Sarah’s family is represented by INQUEST Lawyers Group members Jasmine Chadha and Megan Phillips of Bhatt Murphy Solicitors and Alison Gerry of Doughty Street Chambers.

Ends

Notes to editors:

1. Further information and statistics on deaths of women in prison can be found in INQUEST’s report ‘Preventing the deaths of women in prison: the need for an alternative approach’ published earlier this year. Sarah Higgins’ case features in the report.