The report, ‘Preventing the deaths of women in prison: the need for an alternative approach’, was written in response to the large number of suicides of incarcerated women in the last decade. They believe these deaths could have been prevented with the right support.

In suicides or “self-inflicted” deaths in particular, the report found that in some cases previous documents evidencing past attempts at suicide and self-harming behaviour were either ignored or were not presented to staff opening new assessments.

In the instance of Kerry Devereux, a case study for Inquest, previous self-harming documents failed to come to light during her incarceration and three new documents made during her time in prison were never collated together, meaning there was often no visible record of former self-harming behavior.

Mental health issues were also cited as a precursor to self-harm and suicide. One of the case studies involved a female prisoner who had suffered from post natal depression and had a history of self-harm. Despite prison authorities being told by the judge during sentencing that she was a “serious suicide risk”, and later by hospital staff that she was “at high risk of self-harm and needed constant observation”, the staff made the decision to check in on her just once every hour based on an assessment meeting. After her body was discovered an inquest found “failures in communication between the prison and the hospital, and internally within the prison”.