'Serious failings' by prison staff led to suicide of 'deeply caring' mother, jury finds

“Serious failings” by prison staff contributed to the death of a mother who died after she was found hanging in her cell, a jury has found.

Caroline Ann Hunt, 53, was found hanging in her cell at HMP Foston Hall in September 2015, where she had been left alone despite having attempted to suffocate herself the night before, the court heard.

The jury heard that in the two weeks before her death, Ms Hunt was seen to be distressed and anxious and had said she planned to kill herself, while other prisoners had reported that she was expressing suicidal thoughts.

The night before her death, Ms Hunt had attempted to suffocate herself and her cell mate twice expressed serious concerns to prison officers that she would kill herself.

But staff decided to put her in a cell on her own and, while observations were increased from two to three times an hour, the next morning she was found dead having hanged herself.

It comes after the Prison and Probation Ombudsman (PPO) warned in March that the rise in suicides among female prisoners was linked to “inadequate” mental health provision in UK prisons, stating that a “lack of urgency” among prison staff in responding to indications of mental illness was partly to blame.

Following Ms Hunt's death, the overnight custody manger, who was the most senior officer on duty at the prison that night, was immediately suspended for his actions surrounding the assessment and management of her risk.

The jury found serious failings in the way Ms Hunt was managed and cared for, including staff underestimating the risk she posed to herself and failure to refer her for a formal psychiatric assessment.

It concluded that she took her own life in part because the risk of her doing so was not adequately recognised and appropriate precautions were not taken to prevent her doing so.

During the course of the inquest hearing, HM Senior Coroner Dr Hunter issued a Prevention of Future Death report to the governor of HMP Foston Hall, which raised the coroner’s immediate concerns about another member of prison staff.

He stated that he had “grave concerns” about the governor's understanding of safer custody procedures and that “should she remain operational she is endangering the lives of current prisoners.” The Ministry of Justice has indicated that officer has been suspended from operational duties while she undertakes urgent training.

Ms Hunt had no criminal history and had not been in prison before 29 May 2015, when she was remanded in HMP Foston Hall for threatening to kill her daughter during an argument.

Her death was the fourth self-inflicted death at HMP Foston Hall in 2015, and one of a total of five deaths in women’s prisons that year. In 2016, there were two further deaths in Foston Hall, both in November.

Following the hearing, Ms Hunt's daughter said: “My mother was a very kind person, who cared deeply for her friends and family members. I believe she was sadly blighted with various mental health issues throughout her lifetime, which led directly to the circumstances surrounding her committing an offence, the first she ever committed.

"In prison, she felt hopeless and frightened about her future. Tragically for my mother, there were many missed opportunities to protect her from the obvious risk she posed to herself, including concerns raised by other prisoners about her risk to herself, and to provide the support she clearly needed.

"Had the opportunities been taken, my mother would probably be here with us all today.”

Jane Ryan, of Bhatt Murphy solicitors, who represented the family, said: “The fact that a preventing future death report was issued by HM Senior Coroner before these proceedings had even concluded is an indication of the high risk faced by women prisoners at HMP Foston Hall.

“Urgent action is required, including addressing deficits in training on a wider level, to address that risk.”

Deborah Coles, director of the Inquest charity, which provides advice and support around contentious deaths, said following the hearing: “The familiar failings which contributed to Caroline’s death point to the urgent need to stop imprisoning women and invest in women centred community services.

“It is truly shocking that at the point of giving evidence over 18 months on, the coroner found a key member of staff had a lamentable lack of understanding of suicide prevention policies."

Female prisoner suicides have been steadily rising in recent years, with 12 reported last year, compared with seven in 2015 and between one and three each year before that since 2006.

A Ministry of Justice spokeswoman said: “This is a tragic case and our thoughts are with Caroline Ann Hunt’s family and friends.

“We recognise that there were failings in her care, and HMP Foston Hall has already put in place a number of measures to better support offenders following the PPO investigation.

“We will now carefully consider the findings of the inquest.”