A woman serving a prison sentence for arson after setting herself on fire killed herself following a failure by staff to monitor her properly, an inquest jury has ruled.

Emily Hartley, 21, died in the grounds of HMP New Hall, a women’s prison in Wakefield, on 23 April 2016. She had been allowed into the prison’s exercise yard at about 2.30pm and was found hanged around two and a half hours later.



Wakefield coroner’s court heard claims Hartley was bullied by prison officers who were alleged to have spoken of their desire to attack her physically. After hearing the evidence the jury said there were “concerns for the professionalism” of the staff at New Hall.

Hartley, who was diagnosed with emotionally unstable personality disorder, had been remanded in custody in May 2015 after setting fire to herself, her bed and curtains in the multiple occupancy building she was living in.

Following her arrest a court decided to bail Hartley to a bail hostel rather than transfer her to a secure hospital. After breaking her bail conditions, she was sentenced to two years and eight months’ imprisonment for arson and sent to New Hall in November 2015.

In a narrative verdict, the jury found staff at the prison had failed to properly implement policies for monitoring suicide and self-harm (known as ACCT) and “did not have sufficient training and therefore understanding of [her] condition”.

“Whilst we can empathise with the difficult and demanding job prison staff have, rigorous adherence to the ACCT process should be paramount,” they said. “The failure to apply the ACCT process as intended was a key contributing factor to Emily’s death.”

The jury said that while New Hall prison was the best place for Hartley at the time of her detention the deterioration of her mental state from January 2016 meant her situation should have been reviewed “and a move to a therapeutic unit would have been more appropriate”.

In a statement, Hartley’s family said: “Whilst we were shocked to find Emily sent to prison, the one consolation was that we believed she would be kept safe.”



Giving evidence to the inquest, Hartley’s mother, Diane Coulson, said her daughter, who had previously made multiple suicide attempts, had complained that nobody was checking on her for hours at a time, when she was supposed to be being checked twice an hour.

The jury heard Hartley had self-harmed in the weeks before her death, cutting herself and taking an overdose of another patient’s antibiotics. She spoke of feeling the lowest she had ever felt and asked 13 times to be put on antipsychotic medication, but was told it would not help her.

On 15 April, eight days before her death, she was found with a ligature and showed a mental health nurse a suicide file with a letter “for who finds me”. The jury found that knowledge of the existence of this file had not been shared adequately among staff.

Hartley complained of being bullied by prison officers. Her complaints were supported and an internal investigation launched after one member of staff claimed to have heard two prison officers using dismissive and abusive language about her.

The inquest was told that one had been heard to say: “I hope she calls me a fucking cunt again, so I can slap her around the face” and: “I hope she kicks off again. It’s an excuse to take her down and she’ll go down with some speed.” The officers denied speaking in this way and there were no disciplinary proceedings.

The jury expressed “concerns for the professionalism” of prison officers, saying evidence to the inquest had been contradictory and that it was “logically clear that fictional accounts were given under oath as the accounts are mutually exclusive”.

On the day Hartley died she had been allowed out to exercise at 2.27pm. Prison officers were distracted by searching two prisoners suspected of dealing drugs, which allowed Hartley to slip out of sight before the number of women in the yard was counted.

“[We] believe that the exercise area used for Oak inmates was inadequate and not fit for purpose,” the jury said. “A risk assessment should easily have identified that inmates had the potential to disappear from view.”



Despite Hartley leaving the building half an hour earlier, an entry was made in her records claiming she had been checked on at about 3pm, something described to the inquest as being a result of “pure laziness” by prison officers. Summing up the case for the jury, the senior coroner, David Hinchliff, said: “If the observation had been done correctly, the disappearance would have been noticed sooner.”

Hartley’s was one of four deaths at HMP New Hall in 2016, three of which were self-inflicted and one not yet classified. She was the youngest of 12 women to take their own lives in prisons in England and Wales that year, which represented a sharp spike after a decade where the numbers had declined. There were two suicides in women’s prisons in 2017.

While women still only make up 5% of the prison population, they account for some 21% of all incidents of self-harm across the prison estate.

Deborah Coles, director of the charity Inquest, said the outcome of the inquest was a “damning indictment of a justice system that criminalises women for being mentally ill”. She said the verdict added to “the plethora of evidence” about the dangers of imprisonment for women.



A Prison Service spokesperson said: “The welfare of those in our custody is our absolute priority. HMP New Hall has taken urgent action to address the concerns raised, including reviewing care procedures for those most at risk and new suicide and self-harm training for staff.

“We will carefully consider the inquest findings to see what further lessons can be learned alongside the ombudsman’s investigation.”



• In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here