2 February 2018

Before South Staffordshire Senior Coroner: Andrew Haigh
County Building, Martin Street, Stafford, ST16 2LH
29 January – 2 February 2018

The inquest into the death of Sarah Marie Burke, known as Maria, has concluded today. Maria, 48, was found hanging on 11 November 2016, just 8 days after she had arrived at Drake Hall from Peterborough prison. The jury identified a failure to monitor and assess suicide and self-harm risk at both prisons, and failure in responding to bullying at Drake Hall. There had not been a self-inflicted death in Drake Hall since 1996, and evidence was heard about the negative impact of the recent closure of Holloway on the prison.

Maria was a mother of four, from Wood End in Coventry. She had suffered a series of close bereavements; she self-harmed, was alcohol dependant and struggled to cope. She was remanded to HMP Peterborough in September 2016, and sentenced for three years the next month. This was Maria’s first time in prison. On 3 November she was transferred to HMP Drake Hall where she died.

Despite signals of distress, no suicide and self-harm procedures (known as ACCT) were started at either prison. Maria experienced bullying at Drake Hall, and repeatedly spoke to staff about her distress but no plan was implemented to address this. On the day of her death, Maria was missing from 8:30am. CCTV showed her to poke her head out of her cell, and see the prisoner who was bullying her on her wing without authority, despite it being specifically for vulnerable prisoners newly entering the prison. Searches did not commence for several hours, and she was not found until 1.24pm when a prison officer saw her hanging in her cell. It took a further 4 minutes for officers to cut her down and start an emergency response.

The inquest jury concluded Maria’s death was a result of suicide, and a possible causative factor was the considerable delay in locating her. The jury also identified the following failings:

  • Failure to subject Maria to suicide and self-harm monitoring (ACCT) at HMP Peterborough;
  • Failure to refer Maria for a mental health assessment at HMP Drake Hall;
  • Improper operation of violence reduction policies at HMP Drake Hall following Maria reporting bullying;
  • Failure to prevent Maria’s bully from entering her accommodation block unauthorised; and
  • A lack of adherence to proper standards of written recording information at both prisons, meaning that those working with Maria did not have a full picture of all relevant information about her.

The inquest also heard evidence that the closure of Holloway women’s prison in July 2016 had made procedures around bullying or violence more challenging for staff. Lee Stedman, Head of Security at Drake Hall at the time, told the inquest, “We saw a significant impact. We were getting a lot more challenging prisoners with complex issues, with 78% having had some form of mental health issue. There were higher levels of physical violence. It meant the process for reporting issues became very time-consuming and very difficult.”  He also accepted that the anti-bullying policy at Drake Hall accepted was “not fit for purpose” at the time of Maria’s death.  

Maria’s family said: “We miss Maria every day. Her death has been devastating for the whole family, especially our mum. We were upset that none of the officers who came to the inquest offered condolences or showed remorse. We hope lessons are going to be learned so no family has to go through this trauma again.”

Deborah Coles, Director of INQUEST said: “The catalogue of failings identified by this inquest are all too familiar. There had not been a self-inflicted death in HMP Drake Hall since 1996. Yet five months after the closure of Holloway it’s clear the prison was unable to cope with the sudden change in their population, leaving many women at risk.

What is urgently needed to stop yet more preventable deaths is investment in community services for women, to properly and humanely address mental ill health and addiction. This would not only reduce vulnerability and deaths in prisons but also mean fewer victims in the community.”



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

INQUEST began working with the family of Sarah Burke shortly after her death. The family is represented by INQUEST Lawyers Group members Karen Rogers from Tuckers solicitors and Tom Stoate from Garden Court Chambers.

  • Yesterday, an inquest closed into the death of Emily Hartley, which presented similar circumstances surrounding the death. For Emily:
    • it was also her first time in prison;
    • she was being bullied, but by prison staff rather than other prisoners;
    • issues were raised around suicide and self-harm management processes;
    • she was not discovered in the prison grounds until hours after her death.
    • See the full press release here.
  • The inquest of Charlotte Nokes, who died in HMP Peterborough on 23 July 2016, is due to open at the end of February.
  • 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.
  • For further background, see the opening to Sarah Marie Burke’s inquest available here.