26 Oct Kayleigh ‘Kay’ Melhuish: Jury finds neglect led to self-inflicted death of an autistic woman at HMP Eastwood Park
A jury in Bristol has concluded that the self-inflicted death of a vulnerable woman in prison was contributed to by neglect by the prison.
Kayleigh Melhuish, known as Kay, was 36 years old at the time of her death. She had six children. Kay had mental ill health and was diagnosed with autism, ADHD and complex post-traumatic stress disorder. Her autism meant that she was sensorily sensitive, in particular to noise. She had a history of self-harm and suicide attempts.
Kay had never been to prison before but was remanded to Eastwood Park Prison on 15 June 2022. Professionals immediately wrote to Eastwood Park to express their concern about her risk of suicide, and to warn staff about how difficult Kay would find an environment which was unfamiliar, heavily controlled, often arbitrary, and noisy. Her family, her psychologist and her solicitors all warned them.
These messages were passed on, and the prison did move reasonably quickly to have Kay assessed by a specialist neurodiversity practitioner who was working a day a week at the understaffed prison at the time. This person has since left and has not been replaced. However, the jury heard:
- That almost no staff had read the communication support plan that the neurodiversity practitioner had prepared.
- That despite 11 suicide/self-harm case reviews in 19 days, the mandatory care plan with support actions was never prepared. Support actions are the bedrock of the process designed to keep prisoners safe from suicide and self-harm, known as Assessment, Care in Custody and Teamwork (‘ACCT’). As it happened, Kay’s care under this process had been allocated to the prison’s safety custodial manager with responsibility its quality assurance. 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.
- The lack of support actions meant that no action was taken on the key issues that were distressing Kay the most, including ensuring that staff read and acted on her communication support plan; that she be able to make calls on a prison phone so she could call her family for support; that action be taken to try to mitigate the noise of the prison; that allegations she was being bullied be investigate; and that action be taken in respect of things like food and underwear. The jury heard that for her first ten days in the prison, and until a nurse intervened, Kay had only a single pair of knickers.
- That Kay’s prescription of diazepam was reduced much faster than her community psychiatrist thought was probably appropriate. He told the court that this was something that needed to be done carefully, particularly in the early days of prison when Kay was already very distressed and did not have her family around her, and when she was a remand prisoner and so might be returning to the community soon anyway. He said a reduction at the speed that appeared to have occurred would have been another driver of Kay’s anxiety and distress.
Throughout her time in prison Kay self-harmed by headbanging, punching herself in the face, cutting and ligaturing. She was only able to have two short phone calls to her family.
On the morning of 4 July 2022, Kay had self-harmed again and made her second ligature in 24 hours. She again explained how much she was struggling with the noise, and she was seen lying on her bed with her hands over her ears, trying to block out the noise of the wing. Kay was told that she was not going to be returning to the induction wing where she had felt more supported and which she found less noisy.
That afternoon, Kay told staff that she felt bullied, they had still not resolved the issues with the phone, and she was also still struggling with her medication. In the late afternoon, Kay could not be found by officers. She had gone to hide under a table in a quieter communal room. Staff shortages meant that officers on the wing that day did not know her, and did not know about her autism. They described her as “childlike”, but did not take further steps which would have shown them that they were overwhelming her and driving her response to them. Instead, six of them restrained her forcibly for 13 minutes, and carried her upstairs to her cell. Before and during the restraint, Kay was headbanging and told staff that she did not want to breathe and that there was plenty left in her cell to harm herself with.
Once left in her cell Kay was seen ripping up clothes by at least two officers and a nurse, but she was left alone without increasing her level of observations. Staff did not consider putting her under constant supervision, even for a short period, and pending a formal suicide/self-harm review. When officers looked through the cell door window on over the next half an hour, Kay was behind a screen and they got no response. By the time the review came to be carried out, Kay was found behind the screen, ligatured.
Kay never regained consciousness and died in hospital three days later, on 7 July 2022.
The inquest conclusion
After listening to often harrowing evidence over the course of four weeks, the jury concluded on 17 October 2024 that Kay’s death was contributed to by neglect: there were gross failings in Kay’s basic care at a time when she was less able to look after herself, that caused or contributed to her death. Such a conclusion is reserved for the most serious failings and is a damning indictment of the prison.
The jury found that the prison had adequate information about Kay from day one but throughout her time at Eastwood Park she was inadequately supported; that staff shortages were no excuse for failing to provide a duty of care to her; and that the prison failed to follow processes for vulnerable prisoners such as Kay that could have resulted in a different outcome. They were particularly critical about the underwear and phone calls, saying that it was “incomprehensible” that these “basic human needs” were not met, as well as about the use of force on 4 July 2022 and the failure to keep Kay safe thereafter.
Prevention of Future Death Report (PFD)
HM Senior Coroner Maria Voisin will send PFD reports to the prison service, Eastwood Park prison and the healthcare provider at the prison. Such reports are sent when an inquest gives rise to concerns that future deaths will occur and the coroner considers that action should be taken to reduce the risk of death.
In Kay’s case, these reports will cover:
- Training across the prison estate on neurodiversity (including considering making this mandatory);
- Training for prison and healthcare staff on important aspects of the suicide/self-harm (ACCT) process; and
- A review of the ligature points
Cathy Goldsmith, Kay’s best friend and the person described throughout the prison documents as Kay’s sister, said: “No woman who presents like Kay should be in prison. 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.”
Ceri Lloyd-Hughes, solicitor for Kay’s family added: “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 family is grateful for the attention which the coroner and jury has given to this case over the last four weeks. It has illuminated very real problems, from which real learning is required. This is not the only case arising from Eastwood Park at around the same time, and it is not the only case where there are clusters of death in a particular prison. Prisons need to be reminded that when it is used properly, the ACCT process in place to manage the risk of suicide and self-harm works. This case shows too that much more work is needed on neurodiversity in the prison estate. The awareness is insufficient, and even where, as here, there were clear instructions, almost no-one read them. The combination of those two things – ACCT process failures and a significantly neurodiverse woman – proved quickly fatal.
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.”
Jodie Anderson, Senior Caseworker at INQUEST, said: “The difference between what prisons represent in the public imagination and how they exist in reality, is stark. 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.”
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Ceri Lloyd-Hughes of Deighton Pierce Glynn Solicitors, solicitor for the family: clhughes@dpglaw.co.uk, 020 7407 0007
The family is represented by Ceri Lloyd-Hughes of Deighton Pierce Glynn Solicitors and Nick Armstrong KC of Matrix Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.
Other Interested Persons represented are HMP Eastwood Park, a custodial manager and an officer at the prison, Avon and Wiltshire Mental Health Partnership NHS Trust, and Practice Plus Group.
A photo of Kay for media use is available here.
The Guardian report is here.
HMIP Report:
The Chief Inspector of Prisons Charlie Taylor said, following an inspection in October 2022: “We have given Eastwood Park our 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.” One of his priority concerns was self-inflicted deaths and self-harm: “There had been four self-inflicted deaths since our last inspection and rates of self-harm were very high and increasing. Many women told us they did not feel well cared for.” (Report on an unannounced inspection of HMP/YOI Eastwood Park by HM Chief Inspector of Prisons, 17–28 October 2022)
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