The failure of a prison to heed warnings contributed to the self-inflicted death of a vulnerable autistic mother of six, according to a jury at Avon coroner’s court. Kayleigh ‘Kay’ Melhuish, who had never been to prison before, had a history of suicide attempts and been diagnosed with post-traumatic stress disorder and autism which led to noise sensitivity, when she was remanded to Eastwood Park Prison in June 2022. Professionals immediately wrote to the prison about her risk of suicide and how difficult she would find an unfamiliar and noisy environment.
Melhuish self-harmed by headbanging, punching herself in the face, cutting and ligaturing throughout her short time in prison before losing consciousness and dying in hospital on July 7. After listening to evidence for four weeks, the inquest jury concluded earlier this month that problems at the understaffed prison contributed to Melhuish’s death finding gross failings on behalf of the prison in meeting her basic needs. The jury found that it was ‘incomprehensible’ that her ‘basic needs’ was not met – she was only allowed two short calls with family and for her first ten days had no change of underwear – and concluded staff shortages were no excuse.
Two years ago in October 2022, the Chief Inspector of Prisons Charlie Taylor ranked Eastwood Park the lowest grade for safety. ‘This is very unusual for a women’s prison, but the gaps in care and the lack of support for the most vulnerable and distressed women were concerning,’ he said; adding a particular concern was self-inflicted deaths and self-harm: There had been four self-inflicted deaths since their last inspection and rates of self-harm were ‘very high and increasing’.
‘No woman who presents like Kay should be in prison,’ said Cathy Goldsmith, Melhuish’s best friend. ‘Those who sent her there need to know what they are sending her to. This prison failed in every way. The fact that a care plan with support actions was never produced is heartbreaking, because that is what might have saved her. More immediately, however, she needed a phone. In particular, she needed one after the restraint on 4 July. I have to live with the fact that I know, if Kay had been able to call me, either before that happened or immediately afterwards, she would be alive today.’
The inquest heard that despite 11 suicide/self-harm case reviews in 19 days, a mandatory care plan with support actions was never prepared. Such actions known as ACCT (Assessment, Care in Custody and Teamwork) are ‘the bedrock’ of the process designed to keep prisoners safe from suicide and self-harm, commented INQUEST. ‘The prison was already aware that its ACCT processes were “poor”. Despite this, this fundamental part of the system to manage risk of suicide and self-harm was left blank throughout Kay’s time at Eastwood Park.’
Ceri Lloyd-Hughes, solicitor with Deighton Pierce Glynn Solicitors, said: ‘No woman in Kay’s position should be sent to prison in the first place; this is starkly demonstrated by the evidence heard in Kay’s inquest and the jury’s conclusion of neglect… . The tragedy of Kay’s death is that it was avoidable. Two more vulnerable prisoners at Eastwood Park died self-inflicted deaths within six months of Kay. There must now be swift action to address the coroner’s concerns that similar future deaths will occur at Eastwood Park or at other prisons if things do not change. However, such changes cannot go far enough alone, as our prison system is fundamentally not fit for purpose, especially for vulnerable women on remand or serving short sentences who are ripped away from their support systems. The family call on the government to act urgently to follow through with their proposals to review the sentencing and imprisonment of women, and to close women’s prisons.’
‘The difference between what prisons represent in the public imagination and how they exist in reality, is stark,’ commented Jodie Anderson, senior caseworker at INQUEST. ‘The evidence from this inquest lays bare the cruel and dark reality of prisons as harmful, violent, dehumanising and degrading places. Kay should never have been sent to prison in the first place. The fact that so many processes exist to keep vulnerable prisoners safe and yet they continue to fail demonstrates that the prison project is beyond reform. We must urgently divert the billions spent on a failed prison estate into tackling the root causes of crime and redirect resources to holistic, gender responsive community services. Only then will we see an end to the deaths of women in prison.’
The coroner Maria Voisin will send a report to the prison service setting out concerns over the risk of future deaths concerning training on neurodiversity, the ACCT process and a review of the ligature points
