The daughter of a vulnerable woman who took her own life in prison after being left without clean underwear for 10 days and denied phone calls with loved ones has called for urgent reform of England’s justice system.
A jury at Avon coroner’s court concluded last week that Eastwood Park prison in Gloucestershire failed to provide for Kay Melhuish’s “basic human needs” and that neglect contributed to her death in July 2022 after “gross failings” in her care.
Melhuish waited 10 days to get clean underwear until a nurse intervened. After being granted an initial phone call to her best friend, it took 16 days before she was allowed another call.
Melhuish was taken into custody during an acute mental health crisis and was being held on remand. In a state of despair over access to her children, she had been arrested holding a knife to her own throat outside the place where two of her children were living with her ex-partner.
The prison was aware of her history of suicide attempts and self-harm. It had also been warned that her autism coupled with complex PTSD from violence inflicted on her since childhood made the noise, use of force and loss of control in prison hard for her to cope with.
Despite 11 self-harm and suicide reviews being conducted in the 19 days Melhuish spent there, a mandatory care plan with support actions was never prepared.
On 4 July 2022, less than three weeks after Melhuish arrived at the prison, she was found unconscious in her cell, and she died in hospital three days later, aged 36.
Officers had seen her making obvious preparations to end her life that day but did not consider putting her under constant supervision.
The family say Melhuish’s case is a stark reminder of the dangers of a justice system that criminalises vulnerable women.
In an interview with the Guardian, her daughter Oceana, 20, a care worker from Exeter, said: “Mum was ill, not bad. She had harmed herself and that’s a big enough red flag. She wasn’t a criminal, she was just someone that was really unwell.”
A government review of sentencing is expected to consider ways to reduce the number of women in prison and will look at scrapping shorter sentences and treating more offenders in the community.
Deborah Coles, the director of the charity Inquest, said: “If ever a death is to prompt a radical change in the way we treat women in conflict with the law, it should be this one. I urge the prisons minister to respond to the shocking circumstances of Kay Melhuish’s case. Yet again we ask why she was ever imprisoned in the first place.”
Eastwood Park was given the lowest grade for safety in a 2022 inspection, which warned about concerning gaps in care for the most vulnerable and distressed women.
During her time at Eastwood Park, Melhuish was repeatedly seen cowering with her hands over her ears trying to block out noise, running into walls, punching herself and creating the means to end her own life.
A communication support plan was produced by a neurodiversity specialist, who has since left and not been replaced, but the court heard that almost nobody even read it.
Oceana said: “The prison did not try hard enough. They are the reason I lost my mum just before I turned 18 and I’m going to have to go through all my now adult life without my mum – all five of us kids will have to. All professionals that could have done something, made a change – literally, just given her a pair of pants or given her a phone – it just wasn’t even looked at.”
Before Melhuish had even entered Eastwood Park there were warnings. She had to be cut from the Serco van having made a credible suicide attempt, and there was a letter from her psychiatrist saying prison would endanger her life.
Her best friend, Cathy Goldsmith, had called ahead from court to tell the prison that Melhuish’s neurodiversity and mental health meant it was a dangerous environment for her.
Melhuish arrived with none of her medication and when she was given the diazepam she relied on, the dosage was dangerously reduced.
In her last call to Goldsmith she was distressed, telling her friend that she “looked like Batman” after punching herself and that her medications were all wrong.
Goldsmith believes that if Melhuish had been given proper access to a phone, “she would still be here today”. The records show Melhuish trying repeatedly to call her from the prison phone but that it failed to add her number.
Goldsmith said of the prison: “They’ve got blood on their hands. They were warned by professionals and by me. Kay should never have been in prison. Just shut it down and build some therapy units for these poor women.”
Ceri Lloyd-Hughes, a solicitor for Melhuish’s family said: “The tragedy of Kay’s death is that it was avoidable. Two more vulnerable prisoners at Eastwood Park died self-inflicted deaths within six months of Kay. There must now be swift action to address the coroner’s concerns that similar future deaths will occur at Eastwood Park or at other prisons if things do not change.”
The story of Melhuish’s eventual imprisonment is also one of missed opportunities to intervene. Her family say that when she was threatening to end her life two years earlier, police used a stun gun against her and she was sectioned. They were expecting her to be treated for 28 days, but two days later she arrived home again, still desperately unwell.
Oceana said: “My mum isn’t the first and she won’t be the last if there is no change. And change obviously won’t bring back Mum, but if we can save lives in the future and save families from going through the grief that we went through, that’s as good as it can be.”
A Ministry of Justice spokesperson said: “Our thoughts remain with the family and friends of Kay Melhuish. The circumstances of her tragic death are why the new government is ending the designation of prison as a ‘place of safety’ and will soon form a women’s justice board, tasked with reducing the number of women going to prison.
“At HMP Eastwood Park, improvements and training have been carried out so women, especially those in the early days of custody, are better supported. More psychologists are also being recruited to help those with complex needs.”
