19th May 2017

Before HM Coroner Jonathan Leach
Wakefield Coroner’s Court
2 – 19 May 2017

Today a jury unanimously concluded that Vikki Thompson, 21 did not intend to take her own life; they found her treatment in HMP Leeds was inadequate and lacked in professionalism. She had been on remand in HMP Leeds for less than a month when she died on 13 November 2015. Vikki was the first of three transgender women to die in men’s prisons in the last 18 months. HMP Leeds has the second highest rate of deaths in prison since 2013.

The jury concluded that:
• Throughout her life Vikki was let down by various departments including the NHS, Leeds Community Healthcare NHS trust and the prison;
• The co-ordination and management of Vikki’s risk of self-harm in prison and the community by the NHS made more than minimal contribution to her death;
• The management of ACCT (1) procedures for Vikki was inadequate and observations of Vikki’s cell paid only ‘lip service’ to the standard and frequency required;
• The mandatory actions required by the (now replaced) PSI on “the care and management of transsexual offenders” were not complied with.

The jury also recognised the day to day pressures on all services involved, which were under immense pressure, understaffed and working in extremely difficult situations.

Dr. Mitchell, the Clinical Reviewer for the Prison and Probation Ombudsman told the inquest that Vikki’s health and mental health care was not sufficient and “scant regard was given to her mental health and her transgender issues by healthcare staff.” Evidence of several issues with ACCT procedures included that no member of health care, mental health or equalities staff ever attended any of the ACCT meetings.

The jury heard that in reception at Leeds, Vikki told the first healthcare assistant she spoke to that she didn’t want to be in a men’s prison, yet this comment was neither recorded or raised with other prison or healthcare staff. As part of the Case Management plan, Vikki agreed with the prison that she would not add excessive padding to her bra and only wear make-up in moderation.

Multiple times both in prison and before she was transferred from police custody, Vikki had told staff she would “be carried out in a box”. Whilst in Leeds prison she was subject to multiple incidents of sexual harassment, transphobic abuse and bullying.

Lisa Harrison, mother of Vikki Thompson said:
“Words cannot describe the upset of losing my daughter Vikki. She was such a bubbly personality and so full of life. As a transgender woman, she experienced a number of difficulties throughout her life. She was the victim of a rape and was going through the process of dealing with this not long before she was sent back to HMP Leeds. Vikki was anxious to be back in prison and repeatedly expressed her concerns.  I do not feel that the prison fully appreciated Vikki’s vulnerabilities and I believe their lack of insight has resulted in her death.”

Deborah Coles, Director of INQUEST said:
“This was a death waiting to happen. A vulnerable, young transgender woman was sent to a men’s prison despite the risks of abuse and mistreatment. There was little consideration of the gender she had openly identified with for half her life. Leeds prison has the second highest rate of self-inflicted deaths in the country. It was also a prison in which Vikki said she had previously been sexually assaulted, and where she was a victim of transphobic abuse and harassment.

Following the death of Vikki and Joanne Latham (both trans women in men’s prisons) the government implemented a new PSI which significantly improves the policy on the care and management of transgender prisoners. However, it remains to be seen how much of a difference this will make in practice.

We are not convinced that the new PSI could have prevented Vikki’s death, given the range of failures uncovered at this inquest. Vikki’s treatment by the prison and healthcare trust was at best incompetent and at worst inhumane. Recent inquests at HMP Leeds and other prisons have shown staff are unable to implement even the most basic training and policies intended to protect vulnerable prisoners. The incoming Government needs to address the unacceptable death toll in prisons and the high numbers of people in prison who should not be there at all.”

The family is represented by INQUEST Lawyers Group members Gemma Vine and Komal Hussain of Minton Morrill Solicitors and Anna Morris of Garden Court Chambers.



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

1. Assessment, Care in Custody and Teamwork (ACCT) is the mechanism in prisons for managing prisoners at risk of self-harm or suicide.

2. There have been two further deaths of transgender women in men’s prisons since Vikki died. Joanne Latham died in HMP Woodhill on 27 November 2015 (only weeks after Vikki). Jenny Swift died in HMP Doncaster on 30 December 2016.

3. HMP Leeds has the second highest current death rate of any prison in England and Wales. Since December 2013 there have been 10 self-inflicted deaths in HMP Leeds. Recent Leeds inquests include those of Chris Beardshaw and Matthew Stubbs. The highest rate and number of deaths is at HMP Woodhill.

4. Ministry of Justice (MOJ) stats show the rate of self-inflicted deaths in prisons has more than doubled since 2013.

5. The MOJ estimated that “there are 70 prisoners currently living in, or presenting in, a gender different to their sex assigned at birth and who have had a case conference” in a statistical release. There is no data on which estate the identified people are held in.

6. The Prison and Probation Ombudsman published a learning lessons bulletin focusing on transgender prisoners in January 2017 which contains detail on experiences and deaths of transgender people in prison.

7. Vikki’s death, as well as a number of high profile battles for trans women to be transferred to women’s prisons, prompted an MOJ review of the ‘Care and Management of Transgender offenders’. This led to the creation of a new Prison Service Instruction, which became active in January 2017.

8. An article with an overview of the new Prison Service Instruction on ‘the care and management of transgender offenders’ can be found here. A briefing on the review by Clinks can be found here


INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths. Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.