“Deeply insufficient” jail procedures contributed to the dying of a younger lady who was left alone in her cell after being discovered with ligatures round her neck, an inquest has discovered.



Jessica Whitchurch died after on 20 Could 2016 in HMP Eastwood Park. She was one in every of 12 self-inflicted deaths in ladies’s prisons that yr – the very best annual dying toll on report.



The jury discovered that there was “inadequate observational” effort by jail officers through the 31-year-old’s closing hour in her cell.



After discovering her in a state of misery with ligatures round her neck, jail employees had positioned her on twice hourly observations over the lunchtime interval.



Lower than two hours after the primary incident, she was discovered unconscious with ligatures round her neck. Her coronary heart had stopped and he or she died in hospital two days later.



The coroner’s professional advised the jury that the final verify on Ms Whitchurch when she was alive had been “insufficient” and that she ought to have been topic to steady commentary till her situation stabilised.



The jury additionally heard proof about bullying directed on the 31-year-old over that interval, together with goading by different prisoners to ligature herself once more, which “went unchallenged” by employees.



Ms Whitchurch, from Nailsea close to Bristol, was from a close-knit household who described her as “probably the most caring individual we have now been fortunate sufficient to know”, a enjoyable and optimistic one who liked life however struggled together with her demons.



The jury discovered that open bullying of Ms Whitchurch by different prisoners – which a psychological well being employee within the jail described as a “marketing campaign” in opposition to her – exacerbated her inherent vulnerability.



She had a historical past of psychological sick well being and dependancy in addition to repeated self-harm and suicidality. However opposite to necessary nationwide steerage, there was no healthcare involvement within the jail suicide and self-harm (ACCT) procedures.



This, an professional witness advised the courtroom, “considerably compromised” the administration of Ms Whitchurch’s threat to herself.



Following the inquest, Emma Gardiner, Ms Whitchurch’s sister mentioned: “After a painful two and a half yr wait and 7 days of extraordinarily distressing proof the jury has lastly confirmed what we have now recognized all alongside, that Jess’ care within the hours earlier than her dying was insufficient and that her dying was avoidable.



“All we will hope now’s that classes may be learnt in order that the lives of different weak ladies may be spared, and no household has to endure as we have now. We wish to thank the jury for his or her arduous work and cautious consideration of the proof.”



Selen Cavcav, caseworker at charity INQUEST mentioned: “A jury member at this inquest requested the pertinent query: ‘Given her presentation, ought to Jessica have been incarcerated in jail in any respect?’ This vital conclusion clearly solutions that. 



“This nation criminalises ladies for their very own struggling, imprisoning them in locations that can’t presumably finish the cycle of hurt or hold them secure.



“Jess died within the yr which noticed the very best variety of deaths in ladies’s prisons on report. Preventable deaths like hers proceed, but the present motion from the federal government is inadequate. 



“What’s urgently wanted is concentrated work throughout well being, social care and justice departments to dismantle failing ladies’s prisons and put money into specialist providers for girls locally.”



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