Staff blamed for death of prison inmate

A women's prison where six inmates died within a year has come under renewed criticism after an inquest jury concluded that its staff were to blame for one of the deaths.

A women's prison where six inmates died within a year has come under renewed criticism after an inquest jury concluded that its staff were to blame for one of the deaths.

The jury said that the failure of a nurse to secure a medication trolley containing anti-depressants contributed to the death of Julie Walsh, 39, at Styal prison in Cheshire.

Walsh died in August 2003, after drinking 500ml of dothiepin thinking it would help her sleep through the acute discomfort of a heroin withdrawal programme. Four other women who also drank the medication survived.

Nicholas Rheinberg, the Cheshire coroner, sitting at Macclesfield, censured the prison for its peremptory treatment of Walsh's grieving family after her death. He said the family was "not welcomed" at the prison, where her belongings were handed over in a black bin bag, and not notified of a memorial service for her until it was under way. The coroner will be drawing the prison's actions to the attention of Paul Goggins, the Prisons minister.

Mr Rheinberg, who has presided over the inquests of all six women to die at Styal over a 12-month period, said he lacked the powers to order a public inquiry into sentencing policies which have seen the female prison population in England increase from 2,600 to 4,000 since 1997 and the number of women's self-inflicted deaths reach record numbers.

But he indicated his "private view" that there is a "disproportionality of sentencing practices in respect of the women who are sent to Styal".

Walsh, like the other five women whose inquests Mr Rheinberg has presided over, was drug-dependent when sent to Styal. A call in 2001 for a proper detoxification unit at Styal had not been acted upon and the programme was not set up until after a public furore surrounding Walsh's death.

Mr Rheinberg's doubts about whether prison is the right place for mentally ill, drug-dependent women are repeated in a report into the six Styal deaths by Stephen Shaw, the prisons ombudsman. The report, which the Home Office has refused to publish but which has been seen by The Independent, declares the "current use of imprisonment" of mentally ill and drug dependent women to be "disproportionate, ineffective and unkind".

All six of the Styal women shared a "vulnerability" borne of drug dependency, according to Mr Shaw, who notes that three of the six also had a history of mental illness. He concludes that "sentencing should be reduced" and that the prison service has a "duty to protect life and apply lessons from adverse incidents".

The report reveals that other grieving relatives were also treated poorly. The family of Hayley Williams, who hanged herself in her cell, were not invited to a memorial service and the families of Nissa Ann Smith and Anna Baker were not sent a report into deaths, as was promised.

Walsh's inquest heard that a nurse left the drugs trolley unattended for several minutes after handing out medicines.

Dr Rupert Evans, a consultant in A&E at University College, Cardiff, said that the dothiepin, which Walsh and her four fellow inmates took and drank in a nearby shower facility, might not have killed her had she been taken to an intensive care ward quickly enough: "I would hope to save as many [patients who overdosed on it] as I lost."

Frances Kelly Jones, who also took the anti-depressant, claimed a fellow prisoner had screamed for help for five minutes.

After the verdict, Deborah Coles, co-director of Inquest, renewed her call for a public inquiry. "Inquests into deaths in prison are subject to delay, can only examine individual deaths in isolation and have a limited remit - all of which frustrate the opportunity to learn the lessons," she said. "Since Julie's death another 25 women have died in prisons around the country. There needs to be a wide-ranging independent public inquiry that examines the wider issues outside the scope of inquests: sentencing, allocation and whether prison can ever be an appropriate place for vulnerable women."

Grief led to a spiral of drugs, theft and jail

Julie Walsh and the other victims

Julie Walsh found she was to become a mother at the age of 19, but the child, Natalie, was born prematurely, had breathing difficulties and died after six days. Her grief cast her into a spiral of heavy drinking, drug-taking and petty theft to pay for her growing heroin addiction. She was not a violent offender but after many court appearances she was sent to prison in 1987.

The threat of incarceration was nothing compared with Walsh's need to pay for drugs and she was sent to prison 16 times between February 1987 and August 1998. In 2001 Walsh was once again parted from the two children who followed Natalie - Keith, now 16, and Natasha, 14 - after a probation request was denied. Walsh was struggling with her latest heroin withdrawal programme when a prison medication trolley was left unattended one evening in August 2003. She took drugs and within hours she was dead, aged 39.

Nissa Ann Smith, 20. Arrived at Styal with paperwork suggesting she was at risk, but not put on relevant register after an assessment by a locum GP. Found hanging from a ligature made from a curtain strip within two days.

Anna Baker, 29. Ballet dancer and athlete. Had trouble accepting she was adopted and, being of mixed race, looked different to her family. Seen as a risk for self harm, but assessed as safe to be left alone in a cell, where she was found hanged.

Sarah Campbell, 18, made superb pencil drawings. Had a history of mental health problems and took an overdose while on suicide watch.

Jolene Willis, 25. On a spiral of drug-taking. A suicide risk note was pinned to her file. Hanged herself.

Hayley Williams, 41. Drifted into life on streets as heroin habit reached eight bags a day. Hanged herself within a day.