Sarah Reed Inquest: Prison failures contributed to mum’s death, jury finds
Jury criticises delays in getting a medical report from prison
20 July, 2017 — By Emily Finch
Sarah Reed who died at Holloway Prison
AN inquest jury today censured the prison system over a series of failings that contributed to the death of a vulnerable woman at Holloway Prison.
Mother-of-one Sarah Reed was found dead on her cell bed with a ligature on her neck on January 11 last year after spending 90 days in prison while on remand.
The 32-year-old was held in prison awaiting “fitness to plead” reports for the Inner London Crown Court, two of which concluded she was in no fit mental state to stand trial – but arrived after her death.
In a damning verdict marking the end of a three-week inquest, the jury at the City of London Coroner’s Court identified a series of failings at the Camden Road prison that it said contributed to Ms Reed’s death.
In its narrative conclusion, the jury said an assessment by psychiatrists on Ms Reed’s “fitness to plead” medical report for the court was not “sufficiently timely” and should have been made available sooner. It was “particularly difficult” for them to understand the delay given Ms Reed was placed in C1, the prison’s mental health unit, for almost a month.
“If a timely fitness to plead assessment had been performed in compliance with the court notice [by December 15], then Sarah Reed would not still have been incarcerated in HMP Holloway at the time of her subsequent mental deterioration but in the hands of her community mental health team,” the jury said.
The number of days a person can remain on remand is open-ended. Jurors pointed to a lack of psychological care for Ms Reed in prison, where she had only one group counselling session.
The jury said: “She was not receiving adequate treatment for her deteriorating mental state to alleviate her distress.”
They also pointed to a “lack of any contingency plan” in Holloway to manage her psychosis which “contributed greatly to the levels of Sarah’s distress”.
During her time in prison, checks on Ms Reed’s cell were altered from half-hourly to hourly. The jury criticised the reduction in her observations, describing it as “inappropriate”, as her mental
deterioration had been well documented. The jury also described as “detrimental” the lack of sharing of information between the staff who recorded Ms Reed’s observations.
Ms Reed took her own life “while the balance of her mind was disturbed”, the jury concluded, adding: “We are not sure she intended to do so, and to which a failure in management of her medication contributed.”
Speaking after the hearing, Lee Jasper, a former adviser to ex-London Mayor Ken Livingstone who acted as a spokesman for Ms Reed’s family, said: “It’s a cumulative effect of catastrophic failure. It’s usually one in an inquest, but here there is a range.”
Mr Jasper said Ms Reed, as a young black woman, suffered a “degree of oppression and discrimination”, adding: “The court doesn’t push [for the psychiatric report] and make it clear that they want the psychiatric evaluation [and] when it comes to court, there’s delay and confusion and it happened during the middle of Christmas.
“I can’t believe people wanted to dump Sarah and enjoy their Christmas turkey, come back in the new year and [thought] it would be all right.”
Ms Reed had suffered from serious mental health issues since the death of her infant daughter in 2003. She had previously caught the attention of the national media after she was brutality beaten by a Metropolitan police officer, PC James Kiddie, five years ago, in an incident which her family said worsened her mental health.
In a statement at the start of the inquest, which heard from more than 40 witnesses, Ms Reed’s mother Marylin Goldring had paid tribute to her daughter.
“Sarah was adored and loved by the whole of her family,” she said. “Her death has been devastating for us. Before she was remanded she had started to turn her life around. Sarah was in a good relationship. She was my first daughter and was very much treasured.”
Coroner Peter Thornton said he would be writing a Prevention of Future Deaths report.
A Ministry of Justice spokeswoman said: “This is a tragic case and our thoughts are with Sarah Reed’s family and friends. “We await the full recommendations from HM coroner and these findings will be carefully considered by the departments and agencies involved.”