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INQUEST PRESS RELEASE – For immediate release 22 February 2010

The inquest into the death of a young woman with severe borderline personality disorder in HMP Styal has concluded, with the jury highlighting a number of significant failings by prison officers that contributed to her death. The coroner also identified various shortcomings in relation to the care of Lisa Marley in his rule 43 report made to the Prison Service and Central and Eastern Cheshire Primary Health Care Trust.

The inquest opened on 1 February 2010, two years after her death in January 2008, and was heard at Macclesfield Town Hall before HM Coroner for the County of Cheshire, Nicholas Rheinberg

Lisa Marley suffered from mental health problems and drug dependency from a young age. She made repeated attempts of self-harm throughout her life. Within 48 hours of her first remand to HMP Styal in October 2007 she had made a serious attempt at hanging herself with a bed sheet. Although she stopped breathing, she was later revived in hospital. Her family noted that the incident left her with a permanent impairment to her speech.

When she was arrested by police in January 2008 she told her sister "you won’t see me again," before being remanded again to HMP Styal on 17 January 2008.

Lisa was placed in what HMP Styal termed a "reduced risk" cell on the Keller Unit. Despite its name, a gap around the casing which surrounded the television in her cell provided a ligature point above the toilet in the only part of the cell that could not be observed by prison officers looking through the observation hatch. Lisa was also provided with ordinary bedding. On 19 January she hanged herself using the bedding which she had ripped to make a ligature, and was found suspended from the casing around the television set.

The coroner noted that he found it "sadly ironic that an individual identified as at acute risk of self-harm and for that reason housed on the Keller Unit should find the physical means to end her life, less than 48 hours after being sent there."

The jury found that "inappropriate cell design with a clear ligature point" contributed to Lisa’s death. During the inquest they heard evidence from Dr Leslie Klein, who conducted a clinical review on behalf of the Prisons and Probation Ombudsman, concluding that the Keller Unit was "not fit for purpose."

On visiting the Keller Unit on 9 January 2010, Lisa’s family were shown the cell where she died, and were shocked to see that improvements had been made to the cell only weeks before the inquest was due to start. Her family said, “In the two years since Lisa’s death, nothing seems to have changed.”

At the inquest, Prison Officers failed to offer any real explanation why Lisa, who should have been observed five times every hour, was not observed at all through her door between 11:15-12:15 on the day she died. The coroner also noted that "one of the two officers responsible for checks was mistaken as to the number of checks required and neither officer appeared to have any precise idea of what the other was doing."

During one of the checks that did take place less than two hours before her death, prison officers had noted a red mark on Lisa’s neck. Officer Jackie Brown was shown on CCTV footage gesturing to her colleague Leslie Allcock by making a gesture across her throat. During this exchange, Lisa Marley was told by Officer Allcock that she would not be allowed to associate with other prisoners that evening because of her failure to clean her cell when asked. Lisa replied"I won’t be here for that." Neither the red mark nor Lisa’s comment were recorded or reported to anyone by either officer. Officer Brown stated that she didn’t feel it was "significant" to do so, despite being aware of Lisa’s previous hanging attempt.

Officer Allcock told the jury that at 14:05 she saw Lisa sitting on the floor under her mattress, looking furtive and behaving in way suggestive of doing something that she didn’t want officers to see. When it was put to her that Lisa might have been making a ligature, Officer Allcock accepted it was possible. Despite this, Officer Allcock did not return to Lisa’s cell for another 20 minutes, at which point she was found hanging.

The jury found that Lisa’s death was caused by a "failure to ensure awareness of, accurately report and act on all events which could be significant for a prisoner at high risk of self-harm."

The jury also criticised the prison for failing to provide adequate mental health training for staff working on the Keller Unit, a clear breach of the Unit’s own policy. The coroner noted that despite her complex needs, Lisa Marley only had �fleeting contact� with a mental health professional during her period at HMP Styal, and that the Keller Unit "fell far short of its operating philosophy of providing a multi-disciplinary approach."

Most shocking to the family, however, was the coroner’s ruling during the inquest which disallowed the jury from seeing CCTV footage showing Officer Allcock laughing and joking outside Lisa’s cell whilst she was receiving CPR inside. The coroner acceded to the Prison Service’s objection that the footage was "too prejudicial" to show to the jury. The family continue to demand an explanation for the officer’s behaviour and will be making a complaint to the governor of HMP Styal about the incident.

In response to the jury’s verdict, Lisa’s step-father Terry Schofield said:

It is there in black and white, the prison have failed. The only way that something good can come of today is if something changes; it is just words until action takes place.

Deborah Coles, Co-Director of INQUEST, said:

Despite the high-level scrutiny of HMP Styal in recent years, the death of Lisa Marley once again illustrates the serious concerns that remain about the safety and quality of treatment of vulnerable prisoners held there. It is particularly difficult to understand why Lisa was remanded to Styal Prison, given her acute mental vulnerability and previous attempts at self-harm, especially in light of the report carried out after the death of six women at Styal within a twelve month period that raised grave concerns about the treatment afforded in particular to women who are vulnerable to drug use and/or mental illness.

Lisa Marley’s family was represented at the inquest by INQUEST Lawyers Group members Gemma Vine of Farleys Solicitors and counsel Anna Morris of Garden Court Chambers.

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