Despite telephoned and written warnings that Claire Bosley, 34, was an "exceptional" suicide risk, prison reception staff decided to leave her alone in a holding room. She was dead within minutes - although her body was not discovered for an hour-and-a-half, when staff realised she was missing.
In an exact repeat of an earlier attempt on her life hours earlier while in police custody, she had stuffed toilet tissue down the back of her throat blocking her airways. Mrs Bosley, who had a nine-year-old son, had been arrested and charged last November after confessing to stabbing to death her husband, Barry. She was diagnosed as suffering paranoid depression following a second ectopic pregnancy which left her unable to have any more children, the City of London coroner's court was told.
The unusual verdict is the first to criticise the authorities over a death in custody following a 1994 Court of Appeal ruling which limited inquest juries' powers to make lack of care or neglect findings in suicide cases. It amounts to the latest in a series of damning indictments in the way the Prison Service has been treating prisoners in the country's largest women's jail.
The first came a week after Mrs Bosley's death, with the unprecedented walk-out by the Chief Inspector of Prisons in protest at the infestation of rats, cockroaches and lice and the "overzealous" security at the north London jail. There followed an equally damning report from the jail's Board of Visitors, pointing to a complete management breakdown within the jail and highlighting concerns over the "degrading" treatment of women.
The Board of Visitors had also raised concerns about suicide awareness, saying that despite Mrs Bosley's death and that of another women in the jail earlier in the year - training remained inadequate.
The inquest into Mrs Bosley's death heard that the senior officer in reception who decided that she was not a "major risk" was a suicide awareness trainer. Further, the senior officer, Pauline Martindale, admitted she had not fully read the police warning "Pol 1" form, before making her own assessment. She said her priority had been to deal with two other "disruptive" prisoners, but the inquest jury heard that staff "processed" three other non-disruptive prisoners - admitted after Mrs Bosley - before noticing the dead woman's absence.
Tim Owen, barrister for Mrs Bosley's family, said the police, through constant supervision had struggled to keep her alive for more than 48 hours, whereas the Prison Service failed to manage an hour. Inquest, the body which monitors deaths in custody, called for the Chief Inspector to investigate suicide prevention within the jail.
After the hearing, Michael Ainsworth, Holloway's deputy governor, said that changes to reception and suicide prevention procedures had been introduced.Reuse content