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Inquests Farleys Solicitors LLP

Lisa Marley – Death at HMP Styal, Cheshire

The jury found that Miss Marley’s death was caused by a “failure to ensure awareness of accurately reporting and act on all events which could be significant for a prisoner at high risk of self harm”.

The jury criticised the prison for failing to provide adequate mental health training for staff working on the Keller Unit – a clear breach of the unit’s own policy. The Coroner also noted that despite her complex needs, Miss Marley only had ‘fleeting contact’ with a mental health professional during her time at HMP Styal, and also that the Keller Unit “fell far short of its operating philosophy of providing a multi disciplinary approach”.

The Coroner intends to make a rule 43 recommendation for HMP Styal to carry out regular inspections of cells on the Keller for ligature points; to devise an electronic system to record ACCT observations; to require staff to have mental health awareness training; to provide a Registered Mental Health Nurse seven days a week; and to ensure that ACCT reviews are multidisciplinary.

The Coroner noted that :

“At any one time, the Keller unit is likely to hold some of the most damaged members of HMP Styal’s prison population, most if not all suffering from one form of mental illness or another. A sense of injustice and resentment fostered through an unequal operation of the system is likely to prove counter productive. Urgent steps need to be taken to ensure a universal understanding and consistent application thereof”.

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