Claire Bosley, 34, killed herself by stuffing toilet tissue down her throat and blocking her airways - a successful repeat of one of three earlier attempts she had made on her life in the previous 72 hours in police custody.
But despite both a telephoned and written warning from police that Mrs Bosley posed an "exceptional risk" of suicide, the senior reception officer at Holloway reached a different conclusion. Yesterday Pauline Martindale, told a London inquest into Mrs Bosley's death: "My assessment was that although she was distressed she did not pose a major suicide risk. She did not give the impression she was in crisis."
Mrs Bosley - who apparently unknown to prison staff had been diagnosed as suffering paranoid depression - was placed alone in a holding room in the prison reception area. She went in to an adjacent lavatory and thrust five sheets of toilet tissue down the back of her throat. Professor David Bowen, the pathologist, said she would have had to have been determined in order to overcome a natural impulse to gag.
Her absence went unnoticed for 90 minutes as prison staff checked in and processed three other prisoners admitted to the jail after her.
Mrs Bosley had been arrested and charged last November after confessing to stabbing her husband, Barry, to death.
A police psychiatrist, who had been called to see if Mrs Bosley was fit to be questioned, had decided she had been depressed since May, when she suffered her second ectopic pregnancy, leaving her unable to have any more children. He believed she had developed a morbid jealousy of her husband and decided that because of the nature of her offence - and her mental state - the best place for her to be was in a prison hospital.
She was remanded to Holloway on 25 November, last year.
Her death, the second in the country's largest women's jail last year, occurred just one week before the Chief Inspector of Prisons walked out of the troubled prison in protest at the conditions.
Yesterday an inquest jury at the City of London coroner's court was told that since Mrs Bosley's death - the first to occur in the jail's reception area - those prisoners arriving with the red-ringed "Pol 1" written warnings from police are now held near an office where they can be supervised.
But Michael Ainsworth, Holloway's deputy governor, admitted that although staff were trained in suicide awareness there were neither national nor local written protocols on what should be done, when "risk" prisoners arrive.
Pauline Martindale, who said she had worked at Holloway for 12 years, estimated that about 30 per cent of all women sent to Holloway arrive with a risk warning. On the Saturday of Mrs Bosley's reception there were only five staff on duty and three of those were dealing with two disruptive inmates.
Earlier, David Rummins, Mrs Bosley's brother had told the inquest how his sister, a secretary, had driven with her son to her parents' house and told them she had killed her husband in the bedroom of their home in Basingstoke, Hampshire.
The hearing continues today.Reuse content