Built to Harm: how women's prisons take lives

Women who died in prison might still be alive today if government had listened to evidence, new INQUEST report highlights

Women who died in prison could still be alive today if the government had listened to calls from campaigners and years of evidence to end the imprisonment of women. Instead, a new report shows how the government prioritised tweaks to women’s prisons that have failed to prevent deaths and harm.

Published during the UN’s 16 days of Activism against gender-based violence, INQUEST’s report Built to Harm: how women’s prisons take lives, uncovers successive government failures to safeguard the lives of people in women’s prisons.

Between 2018 and 2024, 59 people died in women’s prisons in England and Wales, more than a third (39%) of these deaths were self-inflicted. There has been at least a further 10 deaths this year in women’s prisons. In the next four years, self-inflicted deaths across all prisons in England and Wales are expected to rise by 21%.

By analysing the stories of seven of these deaths, including that of a baby, and official statistics, deaths and self-harm, the report uncovers recurring systemic issues. It finds repeated failures to believe women in distress, malfunctioning prison processes, and the routine use of imprisonment as the response to social inequality and trauma.

To prevent further deaths, the report calls on the government to dismantle the women’s prison estate and halt all prison expansion, and to invest urgently in housing, mental health and domestic abuse services that would prevent women coming into contact with the criminal justice system in the first place.

Deborah Coles, Executive Director of INQUEST, said: “For decades, INQUEST has documented the stories of women who have died in prison, after being repeatedly failed and neglected. This report adds to the undeniable evidence that the imprisonment of women is excessive and that women’s prisons are built to harm.

If successive governments had acted on decades of evidence from reviews, bereaved families, research, and inquests to end the imprisonment of women, many of those who died might still be alive today. Promises of action have failed to effect change and needless deaths continue.

Lives can only be safeguarded when the government dismantles women’s prisons, and tackles the poverty, inequality and trauma that push women into contact with the criminal justice system. They must invest in women and community-based services and support, that prioritises care over punishment.”

Oceana, daughter of Kay Melhuish who died following neglect in HMP Eastwood Park, said: “Every day I pass the mental health hospital where I wish mum had been treated. Mum should never have been sent to prison in the first place.

Mum was neurodiverse, sensitive to noise and in need of care. Prison was the worst possible place for her. When we visited her cell after her death, it was worse than we could have ever imagined.

Prison failed mum and me, and it’s failing so many others. No one should be sent there, not least women who are mentally unwell. People should be cared for and supported, not trapped in cells and forgotten about.”

Cathy, friend of Kay Melhuish: “Kay and I lived next to each other, we called each other sisters.

After Kay was arrested in a mental health crisis, she said that if she went to prison, she would take her own life. No one listened to her - not the judge, nor the prison staff. She was dead 19 days later.

Sentencers must know the harmful consequences of sending people to prison. They have a duty of care to people like Kay and their families.”

An executive summary of the report is available here

People featured in the report

-          Ann-Marie Roberts, 51, died of a serious complication of diabetes only two weeks after arriving at HMP Eastwood Park. She was remanded to custody during a mental health crisis. An inquest found she died of natural causes. Media release.

-          Saria Hart, 26, died in hospital on 13 October 2019 after ligaturing at HMP Foston Hall nine days earlier. She had been remanded to custody only seven weeks before. An inquest found that serious failings by prison staff contributed to her death. Media release.

-          Annelise Sanderson, 18, died after ligaturing at HMP Styal only five days after being discharged from mental health services. An inquest found a lack of record keeping and communication failures at the prison. Media release.

-          Luisa Boultbee, 49, died in HMP Foston Hall. Despite the prison being aware that Luisa had epilepsy, access to her prescribed medication was delayed and she was given paracetamol when she complained of a bitten tongue, a strong indicator of epileptic seizures. An inquest found that she died of Sudden Unexpected Death in an Epileptic Patient (SUDEP).

-          Kay Melhuish, a 36 year old autistic woman, died a self-inflicted death at HMP Eastwood Park in 2022. An inquest found neglect led to her death. Media release.

-          Christine McDonald, 55, died a self-inflicted death at HMP Styal in March 2019, just days after a traumatic arrest. An inquest found that neglect led to Christine’s death. Media release.

-          Baby Aisha Cleary was born and died in HMP Bronzefield during the night of 26 September 2019, and was not found until the following morning. A coroner found serious operational and systemic failings contributed to her death. Media release.

Built to harm: how women’s prisons take lives follows decades of monitoring and research by INQUEST into deaths in women’s prisons.