Another inquest jury has returned a damning verdict following the tragic, and unavoidable, death of a young woman in prison.

Emily Hartley was just 21 when she died at HMP New Hall, Wakefield, in April 2016. She had been sentenced to two years and eight months imprisonment after setting fire to herself, her bed and curtains. Her first time in prison, Emily’s remand was against a background of serious mental ill health, including self-harm, suicide attempts and drug addiction.

Although the provisions of the suicide and self-harm management processes referred to as ACCT applied, and Emily was meant to be observed at regular intervals, she had continued to self-harm.

On 23 April 2016, Emily took her own life, behind the building where exercise took place. It took two and a half hours for Emily to be found- despite the fact that staff were meant to check on her twice every hour.

Ruth Bundey, a Partner at Harrison Bundey represented Emily’s mother at the inquest held at Wakefield Coroners’ Court from 15 January – 1 February 2018, overseen by David Hinchliff, the Senior Coroner for West Yorkshire, and with a jury sitting.

The jury returned a narrative verdict, and its findings included:-

  • Whilst New Hall was an appropriate place for Emily to be detained, the deterioration in her mental state should have prompted a review, and she should have been moved to a therapeutic unit;
  • There were failures in the implementation of the ACCT process, which was a contributing factor in Emily’s death;
  • The lack of professionalism shown by some staff could have been interpreted by Emily as bullying. The staff in question gave contradictory evidence at the inquest, which led to an observation by the jury that it was ‘logically clear that fictional accounts were given under oath’
  • The exercise yard (where Emily died) was not fit for purpose. Risk assessments should have readily identified that prisoners could disappear from view.

Ruth noted Emily’s continuous struggle to cope with both prison and her mental health issues. She also highlighted that Emily’s behaviour had dramatically escalated eight days prior to her death, when she used a ligature as well as showing a mental health nurse a ‘suicide file’ with a letter for ‘who finds me.’ The jury found that knowledge of this file had not been properly shared amongst staff.

As Ruth pointed out, this development showed an evidently dangerous transition from ‘impulsive’ actions on Emily’s part, to her planning for her death. This was insufficiently shared with the staff responsible for her care- a point with which the jury agreed.

The Guardian reports that Emily’s death was one of four at New Hall in 2016, at least three of which were self-inflicted. She was the youngest of 12 women who took their own lives in prisons across England and Wales in the same year- which the paper describes as a ‘sharp spike’ compared with the previous decade.

The jury’s assessment of Emily’s case, and its findings, are clear. Emily was failed by an inadequate system and a distinct lack of competence.

At the very least, it is to be hoped that the jury’s findings are properly and thoroughly considered, leading to change not just at New Hall but across the entire prison estate. It is easy to pledge that lessons will be learned, but this must translate into tangible measures.

If you have any queries relating to the content of this article, please contact Ruth Bundey on 0113 200 7400 or at

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