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Ombudsman in attack on prison over Sarah Reed cell death

Mother-of-one was ‘tragic case of seriously unwell woman’ at Holloway Prison

28 July, 2017 — By Emily Finch

Sarah Reed: ‘Her risk was assessed to be low’

A TWIN attack on staff at Holloway Prison over the death of a mother in her cell was made this week by her family and the Prisons Ombudsman.

In a special report, following an investigation by his department, ombudsman Nigel Newcomen said prison staff failed to correctly assess the suicide risk level of 32-year-old Sarah Reed and ignored national guidelines.

Ms Reed’s family maintain her death was “absolutely avoidable” and that she would still be alive if the governor, prison staff, psychiatrists and mental health team had acted differently, according to their spokes­man, Lee Jasper, a former advisor to ex-London Mayor Ken Livingstone.

He said that, though she was only 5ft 7in and weighed 8st, she was treated as if she was the “head of a criminal organisation”.

An inquest into her death, which ended last Thursday, heard that during her three months in prison visits by her mother, partner and solicitors were cancelled 11 times.

Mr Jasper says that the family are demanding that “those accountable do not walk away with their reputation intact”.

In his report, Mr Newcomen criticised procedures at the now-closed Camden Road prison.

Ms Reed was found dead on her cell bed with a ligature around her neck in January last year.

The mother-of-one was on remand for 90 days awaiting a “fitness to plead” medical report for Inner London Crown Court.

She suffered from a series of illnesses, including schizophrenia and emotionally unstable personality disorder.

Mr Newcomen said: “This is a particularly troubling case of a seriously unwell woman being held in a prison setting which, despite commendable efforts by some staff, proved incapable of keeping her safe.

“It is essential that lessons are learned from Ms Reed’s tragic case. Accordingly, although Holloway Prison has now closed, I make a number of generic recommendations to the National Offender Management Service.”

Mr Newcomen said staff failed to note their observations in care plans immediately after visiting an inmate’s cell and observations were not “appropriately adjusted” even after prisoners posed a greater risk of self harm.

Prison officers monitor at-risk inmates through an assessment, care in custody and teamwork (ACCT) care plan, where observations are recorded in a bright orange folder.

He said: “On December 12, Ms Reed wrote a letter stating an intention to cut her throat. Notes of the ACCT case review held on January 1, 2016, showed that Ms Reed’s behaviour remained volatile and unpredictable.

“Despite this, and her recorded history of suicidal thoughts, her risk was assessed to be low.”

Similar concerns were raised by a jury during the inquest into Ms Reed’s death. In their conclusion, they said it was “inappropriate” that Ms Reed’s observations remained hourly because she was deemed “low risk”. Ms Reed was previously under half-hourly observations when she was in the prison’s segregation unit.

Another prisoner in C1, the mental health unit where Ms Reed died, was under constant observation.

Mr Newcomen recommended “recording ACCT observations immediately or as soon as possible after they are made” and “setting levels of observations which are appropriately adjusted as the perceived risk changes”.

He also recommended that mental health staff should help decide an inmate’s risk of self-harm after Ms Reed’s care review six days before she died deemed her “low risk” and featured no medical staff.

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