Before HM Senior Coroner Peter Nieto
Derby Coroner’s Court
25 September – 3 October 2024
Saria Hart, 26, died in hospital on 13 October 2019 after ligaturing at HMP Foston Hall nine days earlier. She had been remanded to custody only seven weeks before. Now an inquest found that serious failings by prison staff contributed to her death.
Saria was born in Tamworth, the third of seven children. Her family describe her as a sociable person with a big heart who loved being around people.
She had a long history of anxiety, depression and self-harm.
On 14 August 2019, Saria was arrested. During her arrest, she threatened to self-harm and take her own life whilst holding a knife. Saria was subsequently remanded to Foston Hall on 16 August 2019.
Before Saria arrived at the prison, the prison was informed that there was a self-harm alert for Saria. Her medical record, available to the prison, also detailed her history of self-harm and ligaturing in prison previously, including at HMP Foston Hall.
Despite this, following an initial screening and health assessment, no safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place.
On 3 October, Saria was restrained by a number of prison officers following an incident on the wing in which she was allegedly abusive towards staff.
As a result of this, she was suspended from her job as a wing cleaner, was placed on a basic regime losing access to certain privileges, and was placed in segregation pending an adjudication.
The Custodial Manager involved in this incident gave evidence at the inquest and stated that “there was absolutely no need to segregate Saria”.
Later that day, Saria passed a handwritten note to a prison officer detailing her intent to take her own life if she lost her job. In response to this note, an ACCT was put in place which detailed that Saria was to be observed twice an hour by prison staff.
On 4 October, during Saria’s ACCT assessment she disclosed that she wanted to die and that she had plans to end her life and refused to hand over razor blades in her room to staff. This information was not passed on to staff responsible for reviewing the assessment and devising a plan to manage Saria’s risk.
At the inquest, none of the staff conducting the ACCT assessment or review could be sure that they had seen Saria’s note, which had prompted the opening of the ACCT in the first place.
No steps were taken to remove high risk items from Saria’s room, no referral was made to the mental health team, and her observation level remained at two per hour.
Giving evidence at the inquest, one member of staff suggested that there was a blasé attitude towards notes from prisoners “threatening” self-harm or suicide, and that these notes were not taken as seriously as they should be.
Saria was taken straight from the review to an adjudication for the altercation which took place on the previous day. She was found guilty and was further punished, including by losing 50% of her earnings.
At 3.40pm, Saria passed a second note to staff expressing her distress and further detailing her intent to take her own life. No action was taken in relation to this note.
Shortly afterwards, at 4.45pm, Saria was found ligatured in her cell by the same member of staff that she had passed her second note to. An emergency ‘Code Blue’ was called and Saria was taken to Royal Derby Hospital where she passed away nine days later, on 13 October 2019.
The jury concluded that Saria died by suicide. They found a number of serious failings by the prison staff contributed to her death, including that:
- All relevant information / previous history was not available to be considered in the first ACCT review;
- After the adjudication, no further ACCT case reviews was implemented and no adequate immediate response was given to Saria’s note;
- All previous self-harm / suicide attempt history attempt history was not considered at the first ACCT assessment review;
- ACCT assessment interview did not appropriately identify Saria’s triggers and risks.
The jury also considered that the absence of Saria’s suicide note and ACCT document during the ACCT review and adjudication on 4 October meant that key information regarding her mental health and her risks was not considered and missed by staff.
Karen Brown, Saria’s mother said:“Saria, our riri, was a bubbly, cheeky girl who loved being around people. We had our good days and our bad days like any other family, but she meant so much to all of us. We all miss her dearly and still think about her every day.
We are still so hurt and angry that Saria died in circumstances where she was clearly begging for help and nobody took any notice.
Five years on from Saria’s passing, the jury has confirmed what we have always known – that more should have been done to prevent Saria’s death.”
Erica San, of Bhatt Murphy Solicitors, said: “A number of preventative and risk reducing measures were available to the prison staff to manage Saria’s risk: a safer cell with fewer ligature points, constant observations, removal of certain dangerous items from her cell. Instead, prison staff ignored and dismissed Saria’s cries for help.
The most recent HMIP inspection found that the response to women in crisis was ‘too reactive, uncaring and often punitive’. This was all too clear from the evidence heard at Saria’s inquest, and there is no evidence that the attitudes of the prison officers who remain at HMP Foston Hall have changed.”
Selen Cavcav, Senior Caseworker at INQUEST, said: “Saria’s last words to prison staff in a written note were: “I am done not being listened to anymore”. Will her words which were ignored during her last hours be heard now by the government, parliamentarians and policy makers?
Too many women like Saria have been ignored, disciplined, segregated and punished instead of being given the care they need and deserve.
Since Saria’s death, 38 people have died in women’s prisons in the UK. Yet despite the long catalogue of failures and warnings from inquests and investigations, we continue to lock women up to die.
How many more women need to die before we finally dismantle prisons and redirect resources to holistic, gender responsive community services?”
ENDS
NOTES TO EDITORS
For further information or to note your interest, please contact Leila Hagmann on [email protected].
Saria’s family are represented by Inquest Lawyers Group members Erica San of Bhatt Murphy Solicitors and Matthew Turner of Doughty Street Chambers.
The family are supported by INQUEST Senior Caseworker Selen Cavcav.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Saria Hart: Jury Finds Serious Failings By Staff At Hmp Foston Hall Contributed To Self-inflicted Death
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
Before HM Senior Coroner Peter Nieto
Derby Coroner’s Court
25 September – 3 October 2024
Saria Hart, 26, died in hospital on 13 October 2019 after ligaturing at HMP Foston Hall nine days earlier. She had been remanded to custody only seven weeks before. Now an inquest found that serious failings by prison staff contributed to her death.
Saria was born in Tamworth, the third of seven children. Her family describe her as a sociable person with a big heart who loved being around people.
She had a long history of anxiety, depression and self-harm.
On 14 August 2019, Saria was arrested. During her arrest, she threatened to self-harm and take her own life whilst holding a knife. Saria was subsequently remanded to Foston Hall on 16 August 2019.
Before Saria arrived at the prison, the prison was informed that there was a self-harm alert for Saria. Her medical record, available to the prison, also detailed her history of self-harm and ligaturing in prison previously, including at HMP Foston Hall.
Despite this, following an initial screening and health assessment, no safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place.
On 3 October, Saria was restrained by a number of prison officers following an incident on the wing in which she was allegedly abusive towards staff.
As a result of this, she was suspended from her job as a wing cleaner, was placed on a basic regime losing access to certain privileges, and was placed in segregation pending an adjudication.
The Custodial Manager involved in this incident gave evidence at the inquest and stated that “there was absolutely no need to segregate Saria”.
Later that day, Saria passed a handwritten note to a prison officer detailing her intent to take her own life if she lost her job. In response to this note, an ACCT was put in place which detailed that Saria was to be observed twice an hour by prison staff.
On 4 October, during Saria’s ACCT assessment she disclosed that she wanted to die and that she had plans to end her life and refused to hand over razor blades in her room to staff. This information was not passed on to staff responsible for reviewing the assessment and devising a plan to manage Saria’s risk.
At the inquest, none of the staff conducting the ACCT assessment or review could be sure that they had seen Saria’s note, which had prompted the opening of the ACCT in the first place.
No steps were taken to remove high risk items from Saria’s room, no referral was made to the mental health team, and her observation level remained at two per hour.
Giving evidence at the inquest, one member of staff suggested that there was a blasé attitude towards notes from prisoners “threatening” self-harm or suicide, and that these notes were not taken as seriously as they should be.
Saria was taken straight from the review to an adjudication for the altercation which took place on the previous day. She was found guilty and was further punished, including by losing 50% of her earnings.
At 3.40pm, Saria passed a second note to staff expressing her distress and further detailing her intent to take her own life. No action was taken in relation to this note.
Shortly afterwards, at 4.45pm, Saria was found ligatured in her cell by the same member of staff that she had passed her second note to. An emergency ‘Code Blue’ was called and Saria was taken to Royal Derby Hospital where she passed away nine days later, on 13 October 2019.
The jury concluded that Saria died by suicide. They found a number of serious failings by the prison staff contributed to her death, including that:
The jury also considered that the absence of Saria’s suicide note and ACCT document during the ACCT review and adjudication on 4 October meant that key information regarding her mental health and her risks was not considered and missed by staff.
Karen Brown, Saria’s mother said:“Saria, our riri, was a bubbly, cheeky girl who loved being around people. We had our good days and our bad days like any other family, but she meant so much to all of us. We all miss her dearly and still think about her every day.
We are still so hurt and angry that Saria died in circumstances where she was clearly begging for help and nobody took any notice.
Five years on from Saria’s passing, the jury has confirmed what we have always known – that more should have been done to prevent Saria’s death.”
Erica San, of Bhatt Murphy Solicitors, said: “A number of preventative and risk reducing measures were available to the prison staff to manage Saria’s risk: a safer cell with fewer ligature points, constant observations, removal of certain dangerous items from her cell. Instead, prison staff ignored and dismissed Saria’s cries for help.
The most recent HMIP inspection found that the response to women in crisis was ‘too reactive, uncaring and often punitive’. This was all too clear from the evidence heard at Saria’s inquest, and there is no evidence that the attitudes of the prison officers who remain at HMP Foston Hall have changed.”
Selen Cavcav, Senior Caseworker at INQUEST, said: “Saria’s last words to prison staff in a written note were: “I am done not being listened to anymore”. Will her words which were ignored during her last hours be heard now by the government, parliamentarians and policy makers?
Too many women like Saria have been ignored, disciplined, segregated and punished instead of being given the care they need and deserve.
Since Saria’s death, 38 people have died in women’s prisons in the UK. Yet despite the long catalogue of failures and warnings from inquests and investigations, we continue to lock women up to die.
How many more women need to die before we finally dismantle prisons and redirect resources to holistic, gender responsive community services?”
ENDS
NOTES TO EDITORS
For further information or to note your interest, please contact Leila Hagmann on [email protected].
Saria’s family are represented by Inquest Lawyers Group members Erica San of Bhatt Murphy Solicitors and Matthew Turner of Doughty Street Chambers.
The family are supported by INQUEST Senior Caseworker Selen Cavcav.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
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