20th July 2017

Before HM Assistant Coroner Peter Thornton QC
City of London Coroner's Court
4– 20 July 2017

The jury at the inquest of Sarah Reed, 32 have concluded unacceptable delays in psychiatric assessment and failures in care contributed to her death. She was found dead with a ligature round her neck on 11 January 2016, while a prisoner at HMP Holloway. She was on remand for over three months solely for the purpose of obtaining two psychiatric reports to confirm whether she was fit to plead, for an alleged offence which took place whilst she was a sectioned inpatient at a mental health unit.

The jury concluded that:
• Sarah’s death was self-inflicted at a time when the balance of her mind was disturbed, however they were not convinced that she intended to take her life. 
• Sarah did not receive adequate treatment for her high levels of distress, and the failure of prison psychiatrists to manage Sarah’s medication contributed to her death.
• The failure to complete the fitness to plead assessment in a timely manner contributed to her death.

After three months in prison the two fitness to plead reports were eventually completed. The second of which was due to be finalised on the 15th of January, four days after Sarah’s death. The jury concluded that “clearly there were internal staff available who could have performed this assessment in a more timely manner” and concluded that “the failure to conclude the fitness to plead assessment contributed to her subsequent death”. They went on to say, “the fact that key members of Sarah’s mental health team were unaware of the sole purpose of Sarah’s remand was for the purposes of a fitness to plead assessment appears incomprehensible”.

The inquest heard that Sarah spent her last days either chanting, screaming, banging and spitting, or in a trance like state. This deterioration followed her being taken off anti-psychotic medication. Sarah had been taken off this due to concerns about her heart. However expert evidence was given which said, directly contrary to the claims of the lead psychiatrist at Holloway, alternative cardiac safe anti-psychotic medication was available.

The psychiatrists responsible for her care treated her solely on the basis of a diagnosis of emotionally unstable personality disorder and dismissed her history of diagnosis of clear psychotic disorder, including paranoid schizophrenia. Consequently on behalf of the family it was suggested that Sarah’s psychotic illness remained untreated with her dealt with primarily as a discipline issue. 

Sarah had been suffering from serious mental ill health since the death of her six-month old baby in 2003.  In 2012 Sarah was assaulted by a police officer James Kiddie, an experience which aggravated her mental health issues. The first fitness to plead assessment on the 22 December by a visiting psychiatrist confirmed that Sarah was suffering from psychosis and was not fit to plead. He recommended that an anti-psychotic should be considered, however it took the lead psychiatrist eight days to respond to this, and until the 4th of January to discuss this matter with the team at Holloway. Over this period Sarah’s mental health deteriorated rapidly. The jury concluded that that the failure to manage Sarah’s medication contributed to her death.

Sarah was being monitored on suicide and self-harm processes known as ACCT documents from 28 December to her death, but despite her clearly worsening condition staff reduced the twice hourly checks, to a single hourly check. The jury concluded this reduction was inappropriate given the clear evidence of mental deterioration.

Throughout this period Sarah’s condition deteriorated to such an extent that she was deemed such a risk to staff that she was on a ‘four man unlock’, where four prison officers must be present before opening her cell door. A screen was placed in front of her cell to block the hatch, and agency staff on the wing were warned not to engage with her as she had been acting aggressively.

During her last weeks multiple visits from Sarah’s family and lawyer were cancelled, often with no reason recorded, despite her status as a remand prisoner entitled to daily visits. From January 7 through to her death Sarah’s filthy cell was not cleaned, she was not permitted a shower and was kept in virtual isolation. An increasingly agitated and unwell Sarah spent her last tormented days locked in a cell towards the end of a corridor, behind a screen, with no visits or telephone calls to family, friends and no proper interaction with staff.

Deborah Coles, Director of INQUEST said:
“Sarah Reed was a woman in torment, imprisoned for the sake of two medical assessments to confirm what was resoundingly clear, that she needed specialist care not prison. Her death was a result of multi-agency failures to protect a woman in crisis. Instead of providing her with adequate support, the prison treated her mental ill health as a discipline, control and containment issue.  Serious mental health problems are endemic in women’s prisons, with deaths last year at an all-time high. They continue because of the failure of the governments to act. 

The legacy of Sarah's death and the inhumane and degrading treatment she was subjected to must result in an end to the use of prison for women. The state’s responsibility for these deaths goes beyond the prison walls and extends to the failure to implement the Corston review, tackle sentencing policy and invest in alternatives to custody and specialist mental health services for women.”



For further information, please contact Lucy McKay on [email protected] or 020 7263 1111

INQUEST have been working with the family of Sarah Reed since her death. The family is represented by INQUEST Lawyers Group members Irene Nembhard of Birnberg Peirce & Partners Solicitors and Sean Horstead of Garden Court Chambers.

The press release issued at the opening, which has further background information, can be found here.

A campaign for justice began following Sarah’s death. Details can be found on their Twitter or Facebook. Their statement on the conclusion of the inquest can be found here

Women in prison
• In 2016 there were a total of 22 deaths in women’s prisons in England and Wales. This is the highest total number of deaths on the female estate since INQUEST started recording statistics in 1990. Three of those who died were women of colour, including Sarah. Of these deaths at least 12 were self-inflicted, the highest number since 2004.
• According to Ministry of Justice statistics (March 2016-March 2017), within the female prison estate there were 10 self-inflicted deaths at a rate of 2.6 per 1,000 prisoners. This is compared to 1.3 per 1,000 prisoners across both the male and female estates.
• More information on the deaths of women in prison can be found here, with reports from a number of oversight bodies.
• The Corston Report can be found here. Recommendations included:
- Custodial sentences for women must be reserved for serious and violent offenders who pose a threat to the public.
- Women unlikely to receive a custodial sentence should not be remanded in custody.

Sarah Reed
• Sarah was assaulted by police officer James Kiddie in November 2012. Kiddie was convicted of common assault in March 2014 and sentenced to a community order
• Evidence was heard at the inquest which confirmed since the death of her baby in 2003, Sarah had been diagnosed variously as suffering from Schizophrenia, psychotic illness, bipolar disorder, bulimia nervosa, as well as emotionally unstable personality disorder.
• She spent many years in and out of mental health institutions and prisons. When not in institutions, she relied on her family for support, who desperately tried to get the right help for her but felt that she was constantly being failed by the system.

HMP Holloway
• HMP Holloway closed in July 2016, with prisoners being moved to HMP Downview and HMP Bronzefield. George Osborne, announced the closure on 25 November 2015, saying prison would close and would be sold for housing.
• Local campaigners are asking that some of the site of the prison is retained for “urgently needed community facilities and women’s support services, such as domestic violence and mental health” (see Women in Prison). The campaign page can be found here.