Rule 43 report following the death of Rebecca Smith
Coroner announces intention to make a Rule 43 report following
the death of Rebecca Smith at HMP Buckley Hall
21st December 2009
On 17 December 2009, the jury at the inquest
held before HM Coroner for Greater Manchester North, Simon Nelson,
sitting at Tops Business Centre, Heywood, Lancashire, reached a
unanimous verdict that “Rebecca Smith took her own life whilst she
was suffering from an enduring mental health condition.”
Rebecca had a long history of mental health
problems, including several attempts at suicide. Throughout her
life, she found changes to her routine and environment very
difficult. However, she managed to live successfully for long
periods in her own home with the support of her long-standing
Community Psychiatric Nurse and local mental health team.
On 18 September 2003, Rebecca set fire to a
sofa in her flat in a failed suicide attempt. She was charged with
arson with intent to endanger life and remanded into custody at her
local prison, Eastwood Park. Both her Community Psychiatric Nurse
and family visited her regularly in HMP Eastwood Park where she
spent most her time in the in-patient Health Care Centre.
After being sentenced in March 2004, Rebecca
was moved to HMP Buckley Hall, a training prison 200 miles away
from her home in accordance with prison regulations, Prison Service
HMP Buckley Hall had no in-patient Health Care
Centre, despite receiving large numbers of female prisoners with
serious mental health problems. Rebecca’s family and Community
Psychiatric Nurse were no longer able to visit her due to the
distance involved. The upheaval for Rebecca was considerable and
arranged at one day’s notice.
After being transferred to HMP Buckley Hall,
Rebecca had refused to take her anti – psychotic medication. She
had also stated to prison staff that she would end her life by self
-suffocation. Six days before her death Rebecca was moved from the
induction wing to a residential wing. Four days before her death, a
decision was taken to end the additional observations by prison
staff used to safe guard prisoners at risk of self- harm and
suicide known as F2052SH.
Within a month of the transfer, she had ended
her own life by self –suffocation with a plastic bag. She was found
dead in her cell by a prison officer who tried unsuccessfully
(along with other prison staff) to resuscitate her. A pathologist
explained to the inquest that Rebecca was probably dead within four
minutes of placing the bag over her head.
The coroner has indicated that he intends to
write to the Ministry of Justice, further to rule 43 of the
Coroners Rules, asking that:
- The relevant Prison Regulations on the
transfer of prisoners from one prison to another (PSO 0900
(Categorisation & Allocation)) are revisited, to ensure that
greater account is taken of individual’s prisoners’ clinical and
social needs (as well as the receiving prison’s ability to meet
- Review of items, given to a prisoner who
has indicated that she will self harm, in a particular manner, are
undertaken, to ensure that the prisoner does not have access to
objects she may use to self –harm.
- The emergency radio codes used by prison
staff to summon help to an injured prisoner or prison officer are
uniformly applied across all prisons in England Wales, to enable
appropriate help to be given immediately.
- All prison officers are given
resuscitation training as part of their basic first training,
during their induction.
Rebecca’s family hope that the rule 43 letter
will either prevent or at least substantially reduce the risk of
further self-inflicted fatalities within the prison population.
Yet again, an inquest into the death of a
vulnerable woman in prison raises questions about their
imprisonment. INQUEST will continue to work to ensure that such
women are diverted from custody, as recommended by Baroness
Corston's report on Women with Particular Vulnerabilities in
the Criminal Justice System in 2007.
Rebecca Smith’s family was represented by
INQUEST Lawyers Group member
Anna Thwaites from Hodge Jones & Allen Solicitors and
counsel Fiona Paterson from 3 Serjeant’s Inn Chambers.