Tragic final words of 'bubbly' daughter who died after 'begging prison staff for help'

Inquest finds serious failings by HMP Foston Hall prison staff after Tamworth-born Saria Hart found unresponsive in cell

A 'bubbly' daughter who 'begged for help' died after prison staff failed to take enough action over her suicide threat, an inquest found. Tamworth-born Saria Hart was 26 when she died in hospital on October 13, 2019.

Nine days earlier, she was found unresponsive in her cell at HMP Foston Hall in Derbyshire - where she had hand-written notes expressing plans to take her own life. Now, an inquest has identified serious failings by prison staff contributed to her death - recorded as suicide.

She had passed on two notes to staff expressing concerns for her wellbeing, Derby Coroners' Court heard. But no immediate response was given to the notes, which included her last words to prison staff: "I am done not being listened to anymore."

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Saria, described as a sociable person with a 'big heart', had a long history of anxiety, depression and self-harm. Her mother, Karen Brown said the inquest had confirmed what they had "always known."

She said: "Saria, our riri, was a bubbly, cheeky girl who loved being around people. We had our good days and our bad days like any other family, but she meant so much to all of us. We all miss her dearly and still think about her every day.

"We are still so hurt and angry that Saria died in circumstances where she was clearly begging for help and nobody took any notice. Five years on from Saria’s passing, the jury has confirmed what we have always known – that more should have been done to prevent Saria’s death.”

Where to get help if you're feeling suicidal

Samaritans (116 123) samaritans.org operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org , write to Freepost RSRB-KKBY-CYJK, PO Box 9090, STIRLING, FK8 2SA and visit www.samaritans.org/branches to find your nearest branch.

Childline (0800 1111) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.
PAPYRUS (0800 068 41 41) is a voluntary organisation supporting teenagers and young adults who are feeling suicidal.

Other depression charities

Mind is a mental health charity that offers information, support and resources for those that are struggling. They also offer help for young people and those supporting someone in their life with mental health struggles. Call Mind info line on 0300 123 3393.

Shout 85258 is a free, confidential, anonymous mental health text support service. Texting the word 'SHOUT' to 85258 will start a conversation with a trained Shout volunteer, who will text you back and forth.

Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts. Bullying UK is a website for both children and adults affected by bullying studentsagainstdepression.org

There are other depression charities and support you can access. If you are seriously concerned, please call 999.

Saria was arrested on August 14, 2019. During her arrest, she threatened to self-harm and take her own life whilst holding a knife. She was remanded to Foston Hall on August 16.

Before Saria arrived, the prison was informed of a self-harm alert for Saria. Her medical record, available to the prison, also detailed her history of self-harm in prison previously, including at Foston Hall.

Despite this, following an initial screening and health assessment, no safety plan for prisoners at risk of suicide or self-harm - known as an ACCT - was put in place. On October 3, Saria was restrained by a number of prison officers following an incident on the wing in which she was allegedly abusive towards staff.

She was suspended from her job as a wing cleaner, placed on a basic regime losing access to certain privileges, and segregated pending an adjudication. The custodial manager involved in the incident told the inquest "there was absolutely no need to segregate Saria."

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Later that day, Saria passed a handwritten note to a prison officer detailing her intent to take her own life if she lost her job. In response to this note, an ACCT was put in place - including plans to observe her twice an hour.

On October 4, during Saria’s ACCT assessment, she disclosed she wanted to die and had plans to end her life. She refused to hand over razor blades in her room to staff.

This information was not passed on to staff responsible for reviewing the assessment and devising a plan to manage Saria’s risk, the inquest heard. None of the staff conducting the ACCT assessment or review could be sure they had seen Saria’s note, which had prompted the opening of the ACCT, the court was told.

No steps were taken to remove high-risk items from Saria’s room, no referral was made to the mental health team, and her observation level remained at two per hour. Giving evidence at the inquest, one member of staff suggested there was a blasé attitude towards notes from prisoners “threatening” self-harm or suicide, and that such notes were not taken as seriously as they should be.

Saria was taken straight from the review to an adjudication for the altercation which took place on the previous day. She was found guilty and was further punished, including by losing 50 per cent of her earnings.

Why journalists cover inquests

Journalists are always allowed to go to inquests and are allowed to report anything which is said in court. Many journalists report inquests as part of the principle of ‘open justice’.

The purpose of open justice and reporting from inquests is to: make sure that the public understands the reasons why someone has died, make sure that deaths are not kept secret, draw attention to circumstances which may lead to more deaths or injuries and to prevent this from happening and clear up any rumours or suspicion about the death.

At 3.40pm, Saria passed a second note to staff expressing her distress and further detailing her intent to take her own life. No action was taken in relation to this note. At 4.45pm, Saria was found unresponsive in her cell by the same member of staff she had passed her second note to.

An emergency ‘Code Blue’ was called and Saria was taken to Royal Derby Hospital, where she died nine days later. The jury concluded Saria died by suicide. The panel found a number of serious failings by the prison staff contributed to her death, including:

• All relevant information/ previous history was not available to be considered in the first ACCT review;
• After the adjudication, no further ACCT case reviews was implemented and no adequate immediate response was given to Saria’s note
• All previous self-harm / suicide attempt history attempt history was not considered at the first ACCT assessment review;
• ACCT assessment interview did not appropriately identify Saria’s triggers and risks.

The jury also considered the absence of Saria’s suicide note and ACCT document during the review and adjudication on October 4 meant key information regarding her mental health and her risks was not considered and missed by staff.

Selen Cavcav, senior caseworker at charity Inquest, said: “Saria’s last words to prison staff in a written note were: 'I am done not being listened to anymore.' Will her words which were ignored during her last hours be heard now by the government, parliamentarians and policy makers?

"Too many women like Saria have been ignored, disciplined, segregated and punished instead of being given the care they need and deserve." Prison staff now receive "improved training" on suicide and self-harm, the Ministry of Justice said.

A spokesperson for the MoJ said: "Our thoughts remain with Saria Hart’s friends and family. All staff now receive improved training on suicide and self-harm and we’re working with charities to provide further support to vulnerable prisoners.”