Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0211, written 2 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 May 2025 |
|---|---|
| Reference | 2025-0211 |
| Deceased | Sarah Boyle |
| Coroner | Victoria Davies |
| Coroner area | Cheshire |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Governor for HMP Styal 2 Minister of State for Prisons, Probation and Reducing Reoffending 3 Ministry of Justice 1 CORONER I am Victoria DAVIES, Area Coroner for the coroner area of Cheshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 24 July 2024 I commenced an investigation into the death of Sarah Frances BOYLE aged 35. The investigation concluded at the end of the inquest on 29 April 2025. The conclusion of the inquest was that: Sarah Boyle died as a result of a self-applied ligature. Her intention at the time of applying the ligature cannot be determined. 4 CIRCUMSTANCES OF THE DEATH Sarah Boyle was detained at HMP Styal between 8 April 2024 and 11 July 2024. She was monitored via the ACCT process for the entirety of that period save for one day (the ACCT was closed on 9 July and re-opened on 10 July following an act of self harm). Sarah suffered from emotionally unstable personality disorder, a condition which is associated with thoughts of self harm and suicide. She was not on the caseload of the mental health team in prison as was not felt to meet the criteria, but was assessed for psychological therapies. A formulation and plan was made from this assessment but it could not start prior to her release on 11 July. On 13 July, Sarah was recalled to prison due to a breach of her licence. It became apparent during her court hearing that she had tried to end her life by ligature whilst released (11-12 July) and again tried to ligature of GeoAmey, prior to transfer back to HMP Styal. On reception screening, Sarah was assessed by a prison officer and, whilst she did not fully engage, responded ‘yes’ to the question of d you have any current thoughts of self harm or suicide. The prison officer did not immediately open an ACCT as she wanted more information, and commented that the vast majority of women in reception will indicate they want to end their life. Sarah was subsequently seen by a nurse for a healthcare screening, who opened an ACCT. whilst in the custody On 14 July, in the morning, Sarah was found to have tied a ligature around her neck in her cell, and this was discovered when the officer attended to carry out the ACCT assessment. She did not require any medical intervention and the ligature was removed. Shortly after (within the hour), the mental health team attended to carry out the well person assessment, as was routine for every new prisoner at that time. The assessment was unable to be completed as Sarah did not engage. Sarah then walked off from the mental health nurses, and tried to get over the railings on the second floor landing. She was Regulation 28 – After Inquest Document Template Updated 30/07/2021 restrained and taken back to her cell. An ACCT case review was attempted by the officer, without healthcare input, but Sarah did not engage. Her observations were increased from hourly to two an hour and she was to remain in her cell due to the risk of her getting at height. At around 5pm that evening, Sarah was discovered in her cell with a ligature around her neck, hospital. She had suffered irreversible brain damage and died on 20 July 2024. . A code blue was called, and paramedics attended, taking her to 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths. My concerns are based on the following points which I heard in evidence: I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the HMP Styal is a women’s prison with a high number of self inflicted deaths, • compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in; • Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting; • women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and It was the evidence of the Head of Safer Prisons and Equality that they also receive Regulation 28 – After Inquest Document Template Updated 30/07/2021 The number of self harm incidents and ACCT documents open appears to have I heard from one witness that a ‘good day’ on one side of the wing would just be where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025); • one incident of self harm, but there would be frequently multiple incidents; • hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem This may lead to key cases being missed; like a lot but it’s not in the context of Styal”. The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed; Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training. The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”. In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which contribute to this, which have been reflected in this inquest. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by June 27, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Regulation 28 – After Inquest Document Template Updated 30/07/2021 , family Greater Manchester Mental Health NHS Foundation Trust Spectrum Community Health CIC I have also sent it to Prisons and probation ombudsman NHS England (on the basis this may require joint working given the health aspect) HM Chief Inspector of Prisons who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 02/05/2025 Victoria DAVIES Area Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: 24 June 2025 Dear Ms Davies, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MS SARAH BOYLE Thank you for your Regulation 28 report of 2 May 2025 following the inquest into the death of Ms Boyle. The report is addressed to the Governor of HMP/YOI Styal, the Minister of State for Prisons, Probation and Reducing Reoffending, and the Ministry of Justice. I am responding as the interim HMPPS Director General of Operations on behalf of all three recipients. I know that you will share a copy of this response with Ms Boyle’s family, and I would first like to express my condolences for her death. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have expressed a number of concerns about safety at the prison, including the operation of the Assessment, Care in Custody, and Teamwork (ACCT) case management process for those at risk of self-harm or suicide. Your report also touches more broadly on the extent of imported risk amongst the population at Styal, including the presence of women who have been remanded for their own safety on ‘warrants of concern’, and the pressure that this puts on both the prison and the provider of their mental health services. I recognise your concerns that Styal has had a higher number of self-inflicted deaths than other establishments in the women’s estate, and would like to reassure you that following the cluster of self-inflicted deaths, support has been provided to the prison from the national safety team as part of the HMPPS cluster death support process. This has included assistance with delivering a local safety summit and upskilling for staff on a range of issues, including awareness of risks, triggers and protective factors for suicide and self-harm. The purpose of the ACCT process is to provide a person-centred approach for prisoners at risk of suicide and/or self-harm, and I take very seriously your concern that it is not doing so effectively at Styal. The process is designed to ensure that support is responsive to the specific needs and circumstances of the individual, such as mental health concerns, which are discussed during multi-disciplinary case reviews. Care plans are then developed which use a range of support mechanisms, including specific support actions, observations and conversations, to ensure that there is holistic support for the individual to reduce their risk of suicide and/or self-harm. In the light of your concerns and on the basis of other feedback and learning, the Governor of Styal is taking further steps to ensure meaningful support actions are identified at each case review and implemented. Case reviews are subject to quality assurance processes, and any case coordinators identified as needing additional support receive weekly one-to-one upskilling sessions. Furthermore, through the support of the group safety team, learning and best practice identified from other cases within the women’s estate is shared and applied at to facilitate continuous improvement. As you have identified, the primary purpose of an ACCT observation is to ensure the safety and welfare of the prisoner. However, staff are also encouraged to engage with the prisoner during these observations where appropriate, to establish and build relationships. Additionally, the ACCT case co-ordinator sets the expected frequency of meaningful conversations throughout the day, in addition to the observations. These interactions are designed to allow prisoners to raise any concerns and to express how they are feeling, offering a valuable opportunity for emotional support to be provided by staff themselves, or for a referral to be made to other sources of such support, including Listeners. All prisoners at Styal who are subject to ACCT case management and have observation levels set at more than one every two hours are located on the residential wings, as opposed to the dormitories, where there are more staff available to conduct the observations. Additionally, women who are being supported through the ACCT process are discussed during the Senior Management Team morning meeting, and where appropriate more staff are deployed to areas in which more such individuals are located to ensure that there is time for meaningful interactions with them. In support of this the local safety team is being expanded with the introduction of a safety analyst and a second safety hub manager, who will assist in the ACCT quality assurance process and provide any necessary upskilling for staff. You have expressed particular concern about the contribution of mental health staff to the ACCT process. As you are aware, all new prisoners are assessed by healthcare colleagues and any mental health concerns are passed to the mental health team. Additionally, prison staff can contact the daily duty mental health worker during the core day if they have concerns about a prisoner. Every effort is made to ensure mental health colleagues attend the initial ACCT case review if there are concerns about a prisoner’s mental health, and if these continue mental health colleagues will be invited to attend subsequent reviews. In response to your concerns, the Governor of Styal and the mental healthcare provider will be reviewing the current process for involving mental health services in such cases. As you have pointed out the prison currently receives a number of women under what is known as a “warrant of concern”. This term is used to describe any warrants that cite mental health issues, vulnerabilities or own protection as a reason to refuse bail. Currently, any warrants of concern are reported to the Prison Group Director for the women’s estate who is monitoring their prevalence across the estate. As you have noted the presence of prisoners remanded for this reason, who frequently have complex needs, adds to the challenges faced by prison and healthcare staff. I am pleased to report that the Government is committed to ending the use of remand for own protection where the court’s sole concern is a defendant’s mental health through the Mental Health Bill which is currently going through Parliament. Instead, courts will be directed to bail the defendant and work with local health services to put in place appropriate support and care to address risks to their safety. I am aware that both you and the Senior Coroner for Cheshire are intending to visit Styal in September. I am pleased to hear this and hope you will be able to see the benefits of these actions and the broader programme of work to improve safety at HMP/YOI Styal. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters identified. Yours sincerely, Interim HMPPS Director General of Operations
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