Emily’s Hartley's Successful Inquest Case Study

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Gavel Books

Diane Coulson's daughter Emily Hartley, was the youngest woman to die in prison custody in recent years. Emily took her own life at New Hall Prison in April 2016, at 21 years old. Emily had a long history of mental health issues; which she believed began at the age of 9, after grieving the death of her grandmother, whom she was very close too. Emily was under the care of the Child and Adolescent Mental Health Service in Leeds from early adolescence.

The jury at inquest into Emily’s death was critical of the poor professionalism of prison staff, in particular the failure to act on Emily’s own fears regarding her mental health: several incidents of self-harm, as well as the discovery of a suicide file. Emily reported in seven occasions’ allegations of bullying by prison staff including a formal complaint. The prison education manager filed a report a about the way she was treated.

Despite warnings, the prison was found to have neglected the ACCT process, which is designed to care for vulnerable prisoners at high risk. Particularly there was a failure to realise that Emily was absent from the prison for over two hours; and had suspended herself from an external gate, despite the fact she was required to be monitored and checked on a half hourly basis.

Diane stated that Ruth Bundey worked tirelessly to achieve a just outcome to the inquest: “Ruth asked all the right questions, making sure things were not ignored. As result, she brought to light things that may have been swept under the carpet.”

Gareth Naylor Head of our Personal Injury department, successfully secured compensation for Diane, as a claim under the Human Rights Act.

This case was referred to our team at Harrison Bundey Solicitors, by the National Organisation Inquest.  

Ruth Bundey comments:

“Emily’s struggle to cope with prison and her mental health issues which led to self-harm, escalated dramatically 8 days before her death. She used a ligature and showed a mental health nurse a ‘suicide file’ with an accompanying letter for ‘who finds her.’ This development, showed a dangerous move from impulsive actions to planning for death, was insufficiently shared with staff responsible for her care.”

National Organisation Inquest comments:

Deborah Coles, Director of Inquest stated: “This inquest is a damning indictment of a justice system that criminalises women for being mentally ill. For decades, recommendations from investigations, inquests and the Corston review have not been acted upon.”

“This inquest adds to the plethora of evidence about the dangers of imprisonment for women, and the need to invest in community services that can address mental ill health and addiction.”

“Emily Hartley, was the youngest of 22 women to die in prison in 2016, the year that saw the highest annual number of deaths in women’s prisons on record.”

“Emily was imprisoned for arson, having set fire to herself, her bed and curtains. She had a history of serious mental ill-health including self-harm, suicide attempts and drug addiction. This was Emily’s first time in prison. A prison that could not keep her safe.”

Read more at https://www.inquest.org.uk/emily-hartley-closing

Justice Week Justice in Focus Photography Exhibition

The Law Society are currently holding a Photography Exhibition, Justice in Focus, depicting individuals in times of crisis with difficult legal issues. The story of Ruth Bundey’s client Diane’s Daughter- Emily Hartley, is being exhibited in London, on Chancery Lane.

The exhibition celebrates the tenacity and resilience of people during crisis,  as well as the solicitors and advisors who help them. The exhibition shows the significance of access to the justice system for those with challenging difficulties.

Justice Week is a new initiative setup by the three legal professional bodies; the Law Society, the Bar Council and the Chartered Institute of Legal Executives.

More information can be found here:

If you have been affected by any of the following information discussed, or wish to seek clarity; contact myself Ruth Bundy directly on 0113 284 5000 or alternatively email ruth.bundey@harrisonbundey.co.uk. We do not charge for initial inquiries or consultations. Before we give advice we make sure we listen carefully and understand your situation.  Do not hesitate to get in touch if you need advice. 

  • ​ Why did this happen?

    Prison Officers resigning in first year rising amid levels of self-harm, violence and suicide

    An analysis of figures by Labour show that a third of prison officers who quit leave within the first year of starting. 33% of outgoing officers in the past 12 months resign service within months.

    According to official figures, the number of officers leaving the role surged from 596 in 2015/16 to 1,244 in the 12 months to March 2018 – an increase of 109%. There are a variety of reasons reported for early resignation; absence of support from management and chaos in wings.

    Self-harm and violent attacks have hit record level highs; with self-harm being recorded every 12 minutes on average, violent assault at 18 minute intervals, with 23 attacks on staff daily. Ministry of Justice statistics for safety in custody record more than 11,600 prisoners harmed themselves in 2017. Self-harm reached a record high of 42,837 incidents in the 12 months to September 2017. The Statistical bulletin also revealed that inmates needing hospital treatment from self-inflicted cuts, overdoses, and strangulation had risen.

  • ​ Safety in Custody 2017 stats:

    • There were 295 deaths in prison custody in the 12 months
    • Assaults have continued to increase, reaching a record high of 28,165 incidents in the 12 months
    • There were 20,346 prisoner-on-prisoner assaults, up 9% from the previous year
    • There were 7,828 assaults on staff, up 22% from the previous year.

    Despite the drive to recruit more officers, the surge of resignations prompts concerns around the lack of experience within the sector.

    Joe Simpson Deputy General Secretary for the Prison Officers Associations stated; “there is more violence, more psychoactive substances, and more murders. Officers have to cut people down who decide to take their own life, and have to deal with prisoners who are extremely violent and strong.” 

    The rise of resignations puts dangerous conditions in jails. The exposure to self-harm and a lack of support from management lead new officers into a downward spiral of ill health. “They leave because they receive no support from senior management. There is no assistance if they do get mentally ill. Line managers are not trained to notice signs of mental health. Officers end up falling into a downward spiral.”

    Shadow Justice Minister Richard Burgon stated cuts to prison budgets and officer numbers has derived a crisis. “The government must end the exodus of experienced officers which is creating a dangerous cocktail of inexperienced officers and experienced prisoners.”

    Joe Simpson describes the increase of resignation is a result of low pay and a poor remuneration package for officers, who are not considered as professionals.  He states “the government hasn’t kept up with comparable wage outside, because they don’t treat us as professionals. The remuneration package for our members is a disgrace. People leave and say this job is not worth my mental health.”

  • Inhumane Conditions

    The chief inspector of prisons Peter Clark comments in a recent report that many prisons are short of staff and investments and struggle to maintain basic standards of safety and decency.

    The report describes situations where prisoners are forced to share cells designed to hold only one person, using the space as a bedroom, dining room and lavatories without lids and inadequately screened.

    Peter Dawson director of Prison Reform Trust, backed the report: “thousands of prisoners are forced to share cells designed for one, eating meals next to unscreened toilets; violence and self-harm have risen exponentially; and a fifth of prisoners spend less than two hours a day out of their cell.”

    Peter Clark states; “some fail to tackle basic problems of violence, drugs, and disgraceful living conditions.” Clark states there is an obvious correlation between the increase of violence and the large reductions of stuff numbers and resources. “There is a clear link between cell call bells and self-harm, and suicide.”

    Inmate Osvaldas Pagirys, 18, hanged himself at HMP Wandsworth after staff failed to respond to his call for help. The teenager was previously found on five different occasions with a ligature around his neck during his time in prison. Investigators found that Pagirys rang a cell call bell at lunchtime in his cell, but was not responded too for 37 minutes. Officers found Pagirys hanging in his cell, dying three days later after never regaining consciousness. The jury found the cause of death accidental, with numerous failings by healthcare and prison staff contributing to the death.

    The Prison watchdog has issued urgent notification official warnings to the government regarding four UK jails; Nottingham, Exeter, Birmingham and Bedford. The deterioration of jails has been abundantly clear; the Independent Monitoring Board IMB described HMP Bedford as a “dungeon, with infestations of rats, cockroaches, disgusting amounts of rubbishing, alongside rising levels of violence. The struggle to keep the prison clean is lost, these conditions are not appropriate in which to detain prisoners in the 21st century.”

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