The daughter of a vulnerable woman who committed suicide in prison after spending 10 days without clean underwear and being unable to make phone calls to loved ones has called for urgent reform of the English justice system.
A jury at Avon coroner's court concluded last week that Eastwood Park prison in Gloucestershire failed to meet Kay Melhuish's "basic human needs" and that neglect contributed to her death in July 2022 after "gross failings" in her care.
Melhuish waited ten days to get clean underwear, until a nurse intervened. After receiving an initial call to her best friend, it took 16 days before she was allowed to call again.
Melhuish was taken into custody during an acute mental health crisis and was on remand. In a state of desperation over access to her children, she had been arrested with a knife to her throat outside where two of her children lived 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, combined with complex PTSD resulting from violence inflicted on her since childhood, made it difficult for her to cope with the noise, use of force and loss of control in prison. to go.
Despite eleven self-harm and suicide assessments being carried out in the nineteen days Melhuish spent there, no mandatory care plan with supportive actions was ever put in place.
On July 4, 2022, less than three weeks after Melhuish arrived in prison, she was found unconscious in her cell and died in hospital three days later, at the age of 36.
Officers had seen her making obvious preparations to end her life that day, but did not consider placing her under constant surveillance.
The family says Melhuish's case is a stark reminder of the dangers of a justice system that criminalizes vulnerable women.
In an interview with the Guardian, her daughter Oceana, 20, a care worker from Exeter, said: "Mum was sick, not bad. She had hurt herself and that is a big enough warning. She wasn't a criminal, she was just someone who was very sick."
A government review of sentencing is expected to consider ways to reduce the number of women in prison, as well as looking at eliminating shorter sentences and treating more offenders in the community.
Deborah Coles, director of the charity Inquest, said: "If ever a death will bring about 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. Once again we wonder why she was ever imprisoned in the first place."
Eastwood Park was given the lowest grade for safety in a 2022 inspection, which warned of gaps in care for the most vulnerable and needy women.
During her time at Eastwood Park, Melhuish was seen repeatedly cowering with her hands over her ears as she tried to block out noise, bumped into walls, hit herself and created the means to end her own life.
A communications support plan was drawn up by a neurodiversity specialist, who has since left and not been replaced, but the court heard almost no one even read it.
Oceana said: "The prison did not try hard enough. They are the reason I lost my mother just before I turned 18 and will have to live my entire adult life without my mother - all five of us children will have to do that. All the professionals who could have done something, could have changed something - literally, just given her a pair of pants or given her a phone - just weren't even considered."
Before Melhuish had even entered Eastwood Park, there were warnings. She had to be removed from the Serco van after making 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 from court to tell the prison that Melhuish's neurodiversity and mental health meant it was a dangerous environment for her.
Melhuish arrived without her medication and when she was given the diazepam she relied on, the dosage was dangerously reduced.
During her last phone call to Goldsmith, she was upset and told her friend that she "looked like Batman" after punching herself and that her medication was all wrong.
Goldsmith believes that if Melhuish had been given proper access to a phone, "she would still be here today." Records show Melhuish repeatedly tried to call her from the jail phone, but her number was not added.
Goldsmith said of the prison: "They have blood on their hands. They were warned by professionals and by me. Kay should never have been in prison. Just close it down and build some therapy units for these poor women."
Ceri Lloyd-Hughes, a lawyer for Melhuish's family, said: "The tragedy of Kay's death is that it was avoidable. Two more vulnerable prisoners at Eastwood Park died of themselves within six months of Kay. "Swift action must now be taken to address the coroner's concerns that similar future deaths will occur at Eastwood Park or other prisons if things do not change."
The story of Melhuish's eventual imprisonment is also a story of missed opportunities to intervene. Her family says that when she threatened to end her life two years earlier, police used a stun gun on her and she was sectioned. They expected her to be treated for 28 days, but two days later she returned home, still desperately unwell.
Oceana said: "My mother is not the first and she won't be the last if things don't change. And change obviously won't bring Mom back, but if we can save lives in the future and save families from the heartache we've experienced, that's the best we can do."
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 council, tasked with reducing the number of women going to prison .
"Improvements and training have been made at HMP Eastwood Park to ensure women, especially those in the early stages of detention, are better supported. More psychologists are also being recruited to help people with complex needs."