How the State failed Sarah Reed

Statement by the NGO INQUEST

The jury at the inquest of Sarah Reed, 32 have concluded unacceptable delays in psychiatric assessment and failures in care contributed to her death. She was found dead with a ligature round her neck on 11 January 2016, while a prisoner at HMP Holloway. She was on remand for over three months solely for the purpose of obtaining two psychiatric reports to confirm whether she was fit to plead, for an alleged offence which took place whilst she was a sectioned inpatient at a mental health unit

The jury concluded that:

Sarah’s death was self-inflicted at a time when the balance of her mind was disturbed, however they were not convinced that she intended to take her life.

Sarah did not receive adequate treatment for her high levels of distress, and the failure of prison psychiatrists to manage Sarah’s medication contributed to her death.

The failure to complete the fitness to plead assessment in a timely manner contributed to her death.

After three months in prison the two fitness to plead reports were eventually completed. The second of which was due to be finalised on the 15th of January, four days after Sarah’s death. The jury concluded that “clearly there were internal staff available who could have performed this assessment in a more timely manner” and concluded that “the failure to conclude the fitness to plead assessment contributed to her subsequent death”. They went on to say, “the fact that key members of Sarah’s mental health team were unaware of the sole purpose of Sarah’s remand was for the purposes of a fitness to plead assessment appears incomprehensible”.

The inquest heard that Sarah spent her last days either chanting, screaming, banging and spitting, or in a trance like state. This deterioration followed her being taken off anti-psychotic medication. Sarah had been taken off this due to concerns about her heart. However expert evidence was given which said, directly contrary to the claims of the lead psychiatrist at Holloway, alternative cardiac safe anti-psychotic medication was available.

The psychiatrists responsible for her care treated her solely on the basis of a diagnosis of emotionally unstable personality disorder and dismissed her history of diagnosis of clear psychotic disorder, including paranoid schizophrenia. Consequently on behalf of the family it was suggested that Sarah’s psychotic illness remained untreated with her dealt with primarily as a discipline issue.

Sarah had been suffering from serious mental ill health since the death of her six-month old baby in 2003. In 2012 Sarah was assaulted by a police officer James Kiddie, an experience which aggravated her mental health issues. The first fitness to plead assessment on the 22 December by a visiting psychiatrist confirmed that Sarah was suffering from psychosis and was not fit to plead. He recommended that an anti-psychotic should be considered, however it took the lead psychiatrist eight days to respond to this, and until the 4th of January to discuss this matter with the team at Holloway. Over this period Sarah’s mental health deteriorated rapidly. The jury concluded that that the failure to manage Sarah’s medication contributed to her death.

Deborah Coles, Director of INQUEST said:
“Sarah Reed was a woman in torment, imprisoned for the sake of two medical assessments to confirm what was resoundingly clear, that she needed specialist care not prison. Her death was a result of multi-agency failures to protect a woman in crisis. Instead of providing her with adequate support, the prison treated her mental ill health as a discipline, control and containment issue. Serious mental health problems are endemic in women’s prisons, with deaths last year at an all-time high. They continue because of the failure of the governments to act.