Reports slams 'troubling' prison suicide of Exeter woman

A report has slammed prison authorities over the death of an Exeter woman in custody. Kayleigh Melhuish died in hospital three days after she was found hanging at HMP Eastwood Park.

In the days leading up to her death the 36-year-old first time prisoner showed signs of being "highly distressed", complained about being bullied and was monitored for self-harming. She had autism, a range of mental health conditions and said she could not cope with the loud noises.

An hour before her death she was handcuffed, carried back to her cell and locked inside. An investigation by the Prisons and Probation Ombudsman has concluded that "staff did not do enough to try to keep Ms Melhuish safe."

It described her death as a "very troubling case". Kimberley Bingham, acting prisons and probation ombudsman, concludes: "The Governor needs to learn the lessons from this investigation and ensure that staff are aware of prisoners’ specific care needs and how best to support them."

The report sets out the timeline from Kayleigh's arrival at the prison in Gloucestershire on June 15, 2022 to her death in hospital on July 7. It says she was remanded in prison custody charged with carrying an offensive weapon, harassment and damage to property.

She arrived with a suicide and self-harm warning form and had tried to strangle herself with a seatbelt in the prison van. Staff started suicide and self-harm monitoring, says the report.

She had autism, post-traumatic stress disorder (PTSD), attention deficit and hyperactivity disorder (ADHD) and a personality disorder. Throughout her time at Eastwood Park, she was highly distressed. Her behaviour included banging her head repeatedly against her cell wall, punching herself in the face and making cuts to her arms.

On June 27 and July 3 she was found with a ligature around her neck and said she was frustrated with her medication.

At around 6.30pm on July 4, staff found her hiding under a table in the association room. She refused to return to her cell. She said she was being bullied by other prisoners and staff were not listening to her or doing anything to help her.

A custodial manager spoke to her and told her that they would try to move her the next day, the report says. When she still refused to return to her cell, more staff arrived. Officers restrained her.

The report says: "They forced her into a lying position on the floor, handcuffed her and then carried her to her cell and locked her in."

An officer carried out two checks, a third at 7.25pm got no response from her. When staff entered her cell they found Kayleigh hanging. She was taken to hospital but never recovered.

The report makes a number of findings. It says the suicide and self-harm procedures, known as ACCT, were "poorly managed".

It adds: "There was no ACCT care plan and little evidence that staff had properly explored Ms Melhuish’s risks and issues of concern, including her options for moving to another wing due to her issues with noise.

"While the prison’s neurodiversity specialist had created a comprehensive communication support plan for Ms Melhuish, it is unclear whether all wing staff were aware of this, particularly the staff involved in the events of July 4."

One significant finding followed an expert review of the use of force. The reports says force was used when "Ms Melhuish posed no risk to staff and that staff should have had continued dialogue with her rather than calling for more staff, which appeared to escalate the situation.

"Use of force should be a last resort in any situation, and we consider that given Ms Melhuish’s issues associated with her autism, it should have been avoided if at all possible. The decision to use force to return Ms Melhuish to her cell had devastating consequences."

The report also criticised an "inadequate" cell check on her welfare and that "staff did not investigate" her allegations of bullying before she died.

The report did praise the good work of the mental health team who saw Kayleigh.

The ombudsman has made a number of recommendations resulting from her case. They include improvements to how prisoners at risk of suicide or self-harm are managed.

"The Governor should commission an investigation into the actions of staff involved in the use of force incident on July 4 and inform the ombudsman of the outcome," it concludes.

It adds: "The Governor should ensure that incidents of violence, bullying or intimidation are taken seriously, investigated, and dealt with in line with local and national policies, and victims are supported and protected."

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