Saria Hart died by suicide in 2019

Saria twice threatened to end her life in prison but nobody was listening

Saria Hart was an inmate at HMP Foston Hall in Derbyshire when she died by suicide

by · Derbyshire Live

A jury has found that a number of serious failings by staff at a Derbyshire prison contributed to an inmate's death. Saria Hart died at the Royal Derby Hospital on October 13, 2019, after being found in her cell at HMP Foston Hall, Foston, nine days earlier.

She had been remanded to custody only seven weeks before and on Friday (October 4, 2024) an inquest concluded that more could have been done to prevent the 26-year-old's death. Saria was born in Tamworth, the third of seven children, and her family described her as a "sociable person" with a "big heart" who "loved being around people".

She had a long history of anxiety, depression and self-harm. On August 14, 2019, Saria was arrested. During her arrest, she threatened to self-harm and take her own life whilst holding a knife - Saria was subsequently remanded to Foston Hall on August 16.

Before Saria arrived at HMP Foston Hall, the prison was informed that there was 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 HMP 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.

As a result of this, she was suspended from her job as a wing cleaner, was placed on a basic regime, lost access to certain privileges, and was placed in segregation pending an adjudication. The custodial manager involved in this incident gave evidence at the inquest and stated: “There was absolutely no need to segregate Saria”.

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 which detailed that Saria was to be observed twice an hour by prison staff.

On October 4, during Saria’s ACCT assessment, she disclosed that she wanted to die and that she had plans to end her life and refused to hand over razor blades in her room to staff. This information was not passed on to the staff responsible for reviewing the assessment and devising a plan to manage Saria’s risk.

At the inquest, which opened on Wednesday, September 25, none of the staff conducting the ACCT assessment or review could be sure that they had seen Saria’s note, which had prompted the opening of the ACCT in the first place. 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 that there was a blasé attitude towards notes from prisoners “threatening” self-harm or suicide and that these 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% of her earnings.

At 3.40pm on October 4, 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. Shortly afterwards, at 4.45pm, Saria was found ligatured in her cell by the same member of staff that she had passed her second note to. An emergency ‘Code Blue’ was called and Saria was taken to Royal Derby Hospital where she passed away nine days later, on October 13, 2019.

The jury concluded that Saria died by suicide. They found a number of serious failings by the prison staff contributed to her death, including that:

  • All relevant information / previous history was not available to be considered in the first ACCT review;
  • After the adjudication, no further ACCT case reviews were implemented and no adequate immediate response was given to Saria’s note;
  • All previous self-harm/suicide 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 that the absence of Saria’s suicide note and ACCT document during the ACCT review and adjudication on October 4 meant that key information regarding her mental health and her risks was not considered and missed by staff. Karen Brown, Saria’s mother, 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.”

Erica San, of Bhatt Murphy Solicitors, said: “A number of preventative and risk-reducing measures were available to the prison staff to manage Saria’s risk: a safer cell with fewer ligature points, constant observations, removal of certain dangerous items from her cell. Instead, prison staff ignored and dismissed Saria’s cries for help.

"The most recent HMIP inspection found that the response to women in crisis was ‘too reactive, uncaring and often punitive’. This was all too clear from the evidence heard at Saria’s inquest, and there is no evidence that the attitudes of the prison officers who remain at HMP Foston Hall have changed.”

Selen Cavcav, Senior Caseworker at 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 policymakers?"

A Prison Service spokesperson 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.”

Where to get help if you're struggling

You don't have to suffer in silence if you're struggling with your mental health. Here are some groups you can contact when you need help.