Suicide at HMP Foston Hall: Jury finds death contributed to by neglect

Tuesday 27 October 2009

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Inquest touching on the death of Kerry Louise Devereux

Sitting before HM Coroner for Derby and South Derbyshire, Dr. Robert Hunter. On 21 October 2009 a jury concluded that the death of Kerry Devereux on 18 April 2007 was contributed to by neglect by HMP Foston Hall. Kerry was transferred to HMP Foston Hall from HMP Low Newton approximately four months before her death. In the weeks leading up to her death Kerry's behaviour deteriorated and three self-harm ACCT forms were opened in response to acts of self-harm (including cutting her wrist with a razor blade). The day before her death Kerry was transferred to the segregation unit. Once there Kerry told staff that she had attempted to hang herself earlier in the day but that the ligature had snapped. A mark was seen on Kerry's neck. Kerry was assessed by a health care assistant and told her that she wanted to die and that she was hearing voices telling her to kill herself. Kerry was judged be a high-risk of suicide but was not placed on constant observations and potential ligatures were not removed from her room. Kerry remained in the segregation unit and the following morning, following an adjourned adjudication, Kerry was found hanging from her belt. A jury found that Kerry's death was "contributed to by neglect of the failure of systems and procedures". HM Coroner made a recommendation under rule 43 of the Coroners Rules 1984 to the Ministry of Justice that all closed ACCT forms should be part of a prisoners record and ACCT assessors should have access to those ACCT forms.

Kerry's death was the first self-inflicted death at HMP Foston Hall. Following Kerry's death Anne Owers, HM Chief Inspector of Prisons, conducted a routine inspection and raised a number of concerns about HMP Foston Hall's suicide and self-harm practices and procedures.

Kerry's family was represented by Kirsten Heaven of Garden Court Chambers and Fiona Borrill and Amy Nicholson of Lester Morrill Solictors.


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