29 April 2021

Before HM Assistant Coroner Anna Crawford
Surrey Coroner’s Court, address, postcode

Inquest hearing 20-27 April 2021

An inquest into the death of Serena Maria Nicolle has concluded. She was 52 when she died at the Sodexo run prison HMP Bronzefield on 3 September 2018. The inquest heard concerning evidence about Serena’s treatment at the prison, whilst she was in a deeply distressed state.

Though concluding her death was from ‘natural causes’, the coroner found the stress of her imprisonment contributed. HM Assistant Coroner Anna Crawford has also indicated that she will make a report to prevent future deaths with national recommendations on safety in prisons.

Serena suffered from profound and chronic physical and mental ill health, including diabetes, sleep apnoea and bipolar disorder. She had been remanded into the custody of the prison on 31 August 2018, just three and a half days before her death. This was Serena’s first time in prison and she was deemed to be so unwell that she was detained directly on the healthcare wing.

Serena was a mother of two and a grandmother, born in Hampshire. She was a warehouse worker. In her home life she was very crafty. She loved activities like crocheting blankets and often planted flowers, especially in her favourite colours pink and lilacs.

The inquest heard distressing evidence that, during her time in custody, Serena was in a highly vulnerable state and exhibited bizarre and volatile behaviour. For example, Serena flooded her cell with water and subsequently lay on the wet cell floor and refused dry clothing. A woman who was imprisoned at the same time described hearing Serena shouting and banging on the cell door.

Serena also suffered violent outbursts against prison and healthcare staff. She appeared to have limited comprehension, yet a full mental capacity assessment was not deemed necessary by attending staff. Due to concerns about the risk that Serena was perceived to pose to others, she was not assessed face-to-face by a doctor during her three days of incarceration.

Serena was admitted to prison healthcare on a Friday and presented with multiple and complex needs, yet no multi-disciplinary meeting to discuss her care took place until the following Monday afternoon. Tragically, during the course of that meeting, Serena was discovered unresponsive in the cell.

Safety observations of Serena were unstructured and took place from outside her cell, and the coroner determined cardiac arrest must have taken place between 12.11 and 16.11, before her cell door was eventually opened at 16.35. There was a significant delay in raising the alarm when staff found her and it was some time before it was appreciated that she had suffered cardiac arrest.

Questions remain on why a woman with Serena’s vulnerabilities and presentation came to be incarcerated in a prison. Pre-inquest reviews looked at evidence on the time Serena spent in Hampshire police custody and court, where she displayed distress and lashed out yet was assessed as fit to detain. However, the coroner ruled possible diversion from the criminal justice system was not within the scope of the inquest.

After four days of evidence, the inquest into Serena’s death concluded on 27 April 2021. The coroner determined that Serena “died suddenly due to Hypersensitive Heart Disease, contributed to by chronic conditions of Diabetes, Sleep Apnoea and Obesity.” The coroner also found that stress in the days leading up to her death contributed to her heart suffering. This ultimately led to cardiac arrest.

The coroner was unconvinced that the circumstances in which Serena died could be characterised as a “one off mistake”, stating that there is a clear risk of future deaths. This was particularly around the issue of Serena’s breathing not being checked for several hours before she was found to be unresponsive. The coroner will soon be making a Prevention of Future Deaths report for this matter to be addressed nationally.

Teresa Samuel, sister of Serena said: It was horrifying to hear of the lack of basic care that my sister Serena received in prison. I was absolutely shocked to hear the staff who were meant to look after her talking about her desperate and distressing situation as if it was normal behaviour for a woman in prison. I cannot bring my sister back but I will continue to fight on her behalf against the systems that let her down.

I hope the multiple agencies who were supposed to support and safeguard my sister, before and after she was in prison, will look back and realise they let her down. While she is no longer here, I will be her voice and I will do what I can to educate people about mental health and to campaign for proper mental health services. No matter how mentally unwell someone is, they and their family are entitled to receive care and respect.”

Clare Hayes of Deighton Pierce Glynn Solicitors said: “It is an alarming indictment of women’s imprisonment that Serena’s extreme vulnerabilities and distress appear to have been responded to with little urgency or care. Urgent action will be needed at national level to respond to the coroner’s forthcoming Prevention of Future Deaths report and to address the circumstances that allowed a woman in Serena’s state to be left in a prison cell and to suffer the indignities that she experienced in the final days and hours of her life.”’

Selen Cavcav, Senior Caseworker at INQUEST, said: “This inquest showed the shocking, and yet common, dehumanisation of a woman in prison in extreme distress. She was left to die in a cell when she needed care and support far from the walls of a prison.

To prevent further deaths and harm, Government must work across health, social care and justice departments to dismantle failing women’s prisons and invest in specialist community led women’s services. Not continue their plans to build 500 new prison places for women."

Dr Kate Paradine, CEO of Women in Prison said: “Serena suffered from both chronic physical and mental ill health yet tragically she was isolated in a cell and left without the medical care she so clearly needed. In the past five years 61 women* have died in prison. How many more families need to face the loss of a loved one before the Government acts?  

“There is another way. The government can and must halt its plans to build 500 new prison places and instead support women in the community -  replacing a system of cruelty with one of care.”  


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

Teresa Samuel, Serena’s sister, is represented by INQUEST Lawyers Group member, Clare Hayes of Deighton Pierce Glynn Solicitors and, due to the constraints of the Legal Aid funding regime for bereaved families, was unrepresented by Counsel at the inquest. Another family member was represented separately. The family were supported by INQUEST Caseworker Selen Cavcav.

Other interested persons represented were Sodexo Justice Services who run the prison, Central and North West London NHS Foundation Trust whose care she had been under in the community, Cimmaron UK who run healthcare at HMP Bronzefield, and a doctor involved in her care.

Interested persons in the pre-inquest review stages also included the Chief Constable for Hampshire Police, and Mitie Care and Custody (Health) Ltd who run healthcare in Hampshire police custody.

HMP Bronzefield

  • Serena is one of ten women to die at HMP Bronzefield since 2010. All but one have been deaths of women between the ages of 30 and 56 from non-self-inflicted deaths, often relating to issues in healthcare.
  • In 2018 the inquest into the death of Natasha Chin, who died at HMP Bronzefield on 19 July 2016, concluded finding neglect and serious medical failures contributed to her death. See media release
  • Also see information on the conclusions of inquests into the deaths of Helen Waight and Sarah Higgins in press releases from 2013.

Women’s Prisons

INQUEST is calling for urgent action to save lives by ending the inappropriate use of imprisonment for women, closing women's prisons and redirecting resources from criminal justice into community-based services. Learn more about our recent reports and campaigns on women’s prisons.

The charity Women in Prison are campaigning to prevent the government’s plan to build 500 new prison places for women. INQUEST is a supporter of the campaign. Learn more and support the campaign here.

Since 2016, 61 women have died in prison. 

See the latest statistics on deaths in women’s prisons here.