Her inquest reveals systemic failings in the care for people in prison with mental illnesses, writes ZITA HOLBOURNE
SARAH REED, a young black woman with a history of mental illness, was detained on remand in a single occupancy cell in the healthcare unit of Holloway women’s prison. She was found dead on January 11 2016. The prison has since been closed.
Her illness was precipitated by the premature death of her six-month-old daughter in 2003, when she and her partner were dispatched from a children’s hospice with their deceased baby wrapped in a quilt to find an undertaker.
Reed’s mental health deteriorated as a consequence of this trauma. She was also the victim of a vicious assault by a Metropolitan Police officer, PC James Kiddie, in 2012. He was subsequently charged, convicted and dismissed from the police force.
This incident further exacerbated her condition, as did her arrest for an alleged assault while defending herself against a sexual attacker in a secure mental health unit.
The inquest into Reed’s sudden death was held at City of London Coroner’s Court. It started on July 4 and concluded on July 20.
The jury’s damning verdict was highly critical and found that the Inner London Crown Court’s processes of obtaining psychiatric medical reports were not sufficiently timely. The jury found the delay “particularly difficult to understand.”
If a timely fitness to plead assessment had been performed as requested by the court, then Reed would not have suffered a mental health crisis in HMP Holloway and would have received appropriate treatment within a mental health hospital.
The jury concluded this delay significantly contributed to her subsequent death.
The jury also found that the Assessment, Care in Custody and Teamwork (ACCT) review delays and failures were contributory factors to Reed’s death, in particular the reduction of observations despite her worsening psychotic condition.
They found the reduction of Sarah’s anti-psychotic medication to have been appropriate initially but strongly criticised the subsequent failure to consider safer alternatives.
The jury also found that HMP Holloway staff failed to respond to a request from Dr Timms to review her anti-psychotic medication in a timely manner.
These failures left Reed in a distressed state without appropriate treatment. Finally, the jury considered HMP Holloway’s inexplicable decision to cancel Reed’s visits with family and friends especially detrimental.
Some of the evidence heard during the inquest has led to more questions than answers.
Reed was experiencing a mental health crisis and as such should have been treated with compassion and care. Instead she was punished — isolated from other prisoners; not allowed to bathe or watch TV and placed in a cell with a screen around it, cutting off human contact.
She was on suicide watch and therefore officers were supposed to check her every 30 minutes. However, these were pushed to hourly.
There are questions about how prison officers could claim that Reed was alive and shouting from her cell only 10 minutes before she was discovered dead and alleged to have taken her own life.
The neglect Reed experienced in her last days alive contributed to her death. Even though the prison confirmed she was top of the list to be transferred to hospital, a prison officer stated that it could take hours, days or weeks to get her transferred.
When prisoners experience a physical medical emergency, surely they should be transferred to hospital for urgent medical attention. So why was Reed treated so differently? Was it because her condition was mental not physical health?
Reed’s legal team was exceptional. The search for the truth is often frustrated by a lack of resources for families in terms of legal and evidential expertise.
The inquest evidence presented, outlining the ways in which Reed’s behaviour was assessed and managed, the withdrawing of her medication, and the punishments and segregation to which she was subjected are highly disturbing.
It paints a distressing picture of the inhumane way a black woman with mental illness was treated in prison. Reed’s case, like the cases of Dean Saunders and David “Rocky” Bennett before her, have highlighted systemic failings in the care for people with mental illness and institutional racism within prisons.
The Sarah Reed Campaign for Justice has been supported by a number of individuals, groups and organisations, in particular the social movement Blaksox, Women in Prison, my organisation Black Activists Rising Against Cuts (BARAC) UK, Gender and Education and Enterprise Development for Africa.
In addition Reed’s death has been of great concern to the trade union and labour movement with four emergency motions passed at TUC Black Workers’ Conference, Women’s Conference and Disabled Workers’ Conferences and three fringe meetings hosted by BARAC UK and sponsored by PCS, GMB and the FBU at Black Workers’ and Women’s conferences. Sarah’s mother, Marilyn Reed, also addressed the TUC Black Workers’ Conference this year.
As far as the campaign and her family are concerned, the facts relating to Reed’s death remain largely unexplained.
The Sarah Reed Campaign for Justice makes the following urgent demands:
- The government should commit to ensuring nobody with severe mental illness should be placed in a police or prison cells.
- Urgent modernisation and reform of coroner’s courts processes to give greater equity and justice to victims’ relatives.
- That coroner’s inquests recommendations need to be mandatory and enforced by law.
- In the event a prisoner is identified as having a mental health crisis requiring transfer to hospital, this takes place within two hours and treated as an emergency, as is the case with a physical medical crisis.
- That no prisoner identified as mentally ill and/or on suicide watch is screened off as punishment, isolating them from human contact and cutting off visibility when they most need it.
But as mentioned above this inquest has left serious questions unanswered.
How did Sarah, a woman in poor physical health, commit suicide by strangling herself and maintain the pressure past the point of unconsciousness while lying face up on a bed, within a 10-minute window?
Why were key reports such as fitness to plead and important psychiatric assessment reports delayed, causing significant harm to Reed?
Why did Holloway prison psychiatrist Dr Darren Bull determine that Reed was not psychotic, despite overwhelming evidence to the contrary?
Why was there a substantive and critical delay in transferring Reed from Holloway to hospital once a decision was made that she was in need of urgent medical treatment?
Nobody deserved the gross injustices Reed was subjected to which ultimately led to her unexpected death.
She died because she was black, a woman and mentally ill. Her family deserves to know the truth. She was failed by multiple public authorities when she was vulnerable and needed care and support — if they had honoured their duties of care towards her she would be alive now.
Recently myself and others signed a letter published in the Guardian calling on Home Secretary Amber Rudd to immediately publish the long overdue report into black deaths in custody.
Nobody should have to die as Reed did — alone, isolated, distressed and neglected.
Zita Holbourne is the Sarah Reed Campaign trade union liaison officer, national chair of BARAC UK and national vice-president of PCS.