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Sarah Reed inquest: Should cell death inmate have been moved sooner?

Jury to consider seven "central issues" in deciding what contributed to Ms Reed's death at Holloway Prison

19 July, 2017 — By Emily Finch

Sarah Reed, who died in her Holloway Prison cell last year

THE coroner in the inquest of a seriously mentally ill woman who died at Holloway Prison last year has told the jury to consider whether prison staff should have put her up for transfer to a mental health hospital sooner.

Sarah Reed, 32, was found dead on her bed at the Camden Road women’s jail with a ligature on her neck made from a bed sheet in January 11 last year.

She was top of a list of inmates waiting to be transferred to hospital. A letter to the Central and North West London Healthcare NHS trust to start the process of getting her transferred to hospital was sent three days before her death, the inquest at City of London Coroner’s Court heard.

The jury in the three-week hearing, which has turned the spotlight on the care Ms Reed received at Holloway, starts to consider its conclusion later today (Wednesday).

Among seven “central issues” assistant coroner Peter Thornton QC asked jurors to consider when deciding which factors contributed to her death, is whether the transfer from prison to hospital “should have been considered earlier than the 7th to 8th of January”.

He also asked the jury to consider whether delays providing psychiatric reports to the judge in her case at Inner London Crown Court on Ms Reed’s “fitness to plead” played a role in her demise.

The court heard Ms Reed was on remand for 90 days after she was charged with assault on a psychiatric nurse in October 2015. One psychiatric evaluation report was finalised on the day she was found dead, while another was completed after her death. Both found her unfit to be tried.

Mr Thornton asked the jury to consider if there was an unnecessary delay in the court receiving the report, the reason for the delay and what could have been done to speed up the process.

In his other questions for the jury, the coroner asked them to look at the care Ms Reed received at Holloway, in particular whether prison officers correctly judged the risks she posed to herself.

He said: “In general terms, was the risk of self harm and suicide correctly assessed and managed by the prison officers and members of staff?”

The jury previously heard Ms Reed was continuously deemed “low risk” in her care plan, documents outlining concerns about an inmate deemed to be at risk of suicide or self-harm.

Prison officers and medical staff in C1, the prison’s mental health wing, maintained her “low risk” rating despite writing in her records that day: “She is completely psychotic, aggressive towards staff, making comments about god and the devil. She started rolling around in the bed and screaming.”

Mr Thornton pointed to three dates the jury should examine in particular. The first was January 5, when Ms Reed was transferred from segregation to C1, the prison’s mental health unit, where her observations were reduced from twice an hour to hourly.

The second was January 8 – three days before her death – when her observations were reviewed and remained hourly.

The coroner also asked the jury to consider whether the decision to stop prescribing Ms Reed her anti-psychotic drugs on November 16 was “reasonable”.

He also asked if it was “acceptable” and “reasonable” that a care plan meeting organised by the Central North West London NHS Trust to assess Ms Reed’s mental health needs only took place once – and two months after she came to Holloway.

The final aspect for jurors to consider is whether more should have been done to facilitate family visits for Ms Reed.

The court heard the 32-year-old suffered from a long list of mental health issues including schizophrenia and emotionally unstable personality disorder following the death of her infant daughter in 2003.

Ms Reed was the last inmate to die in custody at the Camden Road prison before its closure last year.

The jury could reach a conclusion as early as tomorrow (Thursday).

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