Full list of serious failings by prison after Tamworth woman's suicide notes 'ignored'

Ministry of Justice says it has now improved training on suicide and self-harm to support vulnerable prisoners

A string of serious failings at a prison contributed to the death of 'bubbly' daughter, an inquest heard. Tamworth-born Saria Hart was found unresponsive in her cell at HMP Foston Hall in Derbyshire after her suicide notes 'fell on deaf ears.'

The 26-year-old 'begged for help' by passing staff hand-written notes, expressing her plans to take her own life. She died in hospital on October 13, 2019, with her death recorded as suicide by a coroner last week.

Her inquest found there had been no immediate response to her notes, despite her last words to prison staff: "I am done not being listened to anymore." The Ministry of Justice expressed its condolences to Saria's family - who described her as "bubbly and cheeky."

READ MORE: Tragic final words of 'bubbly' daughter who died after 'begging prison staff for help'

The MoJ said it had since improved training on suicide and self-harm in prisons, with staff working to provide "further support to vulnerable prisoners". A spokesperson for the MoJ said: "Our thoughts remain with Saria Hart’s friends and family.

"All staff now receive improved training on suicide and self-harm and we’re working with charities to provide further support to vulnerable prisoners.”

Saria's inquest had outlined the following failures in her care at the prison:

• 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.

Why journalists cover inquests

Journalists are always allowed to go to inquests and are allowed to report anything which is said in court. Many journalists report inquests as part of the principle of ‘open justice’.

The purpose of open justice and reporting from inquests is to: make sure that the public understands the reasons why someone has died, make sure that deaths are not kept secret, draw attention to circumstances which may lead to more deaths or injuries and to prevent this from happening and clear up any rumours or suspicion about the death.

Saria was arrested on August 14, 2019. During her arrest, she threatened to self-harm and take her own life while holding a knife. She was remanded to Foston Hall on August 16.

Before Saria arrived, the prison was informed of a self-harm alert for Saria. Her medical record, available to the prison, also detailed her history of self-harm in prison previously, including at 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 October 3, Saria was restrained by a number of prison officers following an incident on the wing in which she was allegedly abusive towards staff.

She was suspended from her job as a wing cleaner, placed on a basic regime losing access to certain privileges, and segregated pending an adjudication. The custodial manager involved in the incident told the inquest "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 - including plans to observe her twice an hour.

On October 4, during Saria’s ACCT assessment, she disclosed she wanted to die and had plans to end her life. She 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, the inquest heard. None of the staff conducting the ACCT assessment or review could be sure they had seen Saria’s note, which had prompted the opening of the ACCT, the court was told.

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 there was a blasé attitude towards notes from prisoners “threatening” self-harm or suicide, and that such 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 per cent 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. At 4.45pm, Saria was found unresponsive in her cell by the same member of staff she had passed her second note to.

An emergency ‘Code Blue’ was called and Saria was taken to Royal Derby Hospital, where she died nine days later. The jury concluded Saria died by suicide.