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Sarah Reed inquest: cell death inmate was “completely psychotic”

Inquest told prison officers knew woman slit her throat before being sent to Holloway Prison

10 July, 2017 — By Emily Finch

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

A HOLLOWAY prison inmate who was found dead in her cell last year was deemed “low risk” – despite staff describing her as “completely psychotic” and knowing she had slit her neck weeks before going to prison, an inquest has heard.

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.

At the time of her death, she was held in C1, the prison’s mental health unit, where she was checked upon every hour. She had previously been in the segregation unit, where staff checked on her every half hour.

The inquest at City of London Coroner’s Court, which started last week, has turned the spotlight on the care Ms Reed received at the prison. In a series of revelations on Friday, the jury heard:

● Prison officers knew the 32-year-old had severe mental health issues and had slit her throat weeks before coming to Holloway;

● She was described as “completely psychotic” by a prison officer three days before she was found dead – but staff did not consider her to be at high risk of self-harm;

● The last record of her having a shower was four days before she died – when she was also threatened with the removal of privileges because she kept ringing her cell bell;

● A letter requesting her transfer to a mental health hospital was sent from the prison on January 8 but Ms Reed was not moved because there were not enough beds;

● She only received three visits from family and friends out of a possible 19 between November and her death;

● Her mother was notified by phone that her daughter had died, while the normal protocol was a personal visit from the prison governor.

Ms Reed, described by her family as “much treasured”, started to suffer from mental health issues following the death of her nine-month-old daughter from muscular atrophy in 2003, the court heard.

She had been sent to Holloway in October 2015 after being charged with the serious assault of a psychiatric nurse. She was remanded while the court obtained a “fitness to plead” report on her mental state.

On Friday, Simon Chittenden, a supervising officer in C1, told the jury that the 32-year-old had said she had slit her neck eight weeks before coming to prison in an apparent suicide attempt.

He said a care plan – a series of forms used by prison staff to document concerns about an inmate at risk of suicide or self-harm – was started at the end of December after staff read Ms Reed’s letter to a friend which said: “I might cut my throat on the weekend. I am beaten up by this stinking demon in my room every time I try to sleep.”

Mr Chittenden wrote in Ms Reed’s file records three days before her death: “She is completely psychotic, aggressive towards staff, making comments about god and the devil. She started rolling around in the bed and screaming.” She was, however, deemed a  “low risk” on the care plan and her observations remained hourly, he told the jury.

A second officer, Lesley Stuckey, who worked at Holloway for 21 years before it closed down in June last year, told the jury she did not think Ms Reed was at high risk of suicide when she was transferred from segregation to C1.

She said she believed hourly observations were appropriate at C1 because it was somewhere Ms Reed wanted to go and there was more staff, adding: “There was no indication that Sarah was going to take her own life.”

The court heard that on the eve of Ms Reed’s death, another inmate was under constant observation by an agency nurse, who remained by her cell through the night.

Meanwhile, a screen had been placed in front of Ms Reed’s cell, which was at the end of the corridor, the previous day. Four prison officers, including a senior officer, were required to be present to open her cell door.

Ms Reed was top of a list of inmates waiting to be transferred to a hospital mental health unit, the court heard. A letter to the London Central and North West Healthcare NHS trust was sent on January 8 to start the process of getting her transferred to hospital.

But prison governor Emily Thomas, who joined Holloway in November 2015, told the jury “too much demand and too few beds” meant it could have taken weeks for Ms Reed to be moved, especially because prisoners suffering mental health crises in Holloway were considered safer there than those in the community.

The inquest heard that out of 19 scheduled visits by family and friends to see Ms Reed between November 19, 2016 and her death, only three were recorded as “accepted”.

The jury also heard a doctor had decided to stop Ms Reed’s anti-psychotic drugs on November 16.

Governor Ms Thomas apologised to Ms Reed’s mother, Marylin Goldring, for notifying her of her daughter’s death in a phone call and not in person, as was prison policy.

The inquest will hear evidence from at least 40 witnesses, including senior prison staff, police at the scene and former inmates at HMP Holloway.

The hearing continues and is expected to last another two weeks.

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