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, after which a nurse intervened. She was granted an initial phone call to her best friend, but 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, loss of control and use of force in prison hard for her to cope with.
Despite 11 self-harm and suicide reviews being conducted in the 19 days Melhuish spent in prison, a mandatory care plan with support actions was never prepared.
On 4 July 2022, less than three weeks after Melhuish arrived at Eastwood Park, she was found unconscious in her cell. Officers had seen her making obvious preparations to end her life that day, but did not consider putting her under constant supervision. She died in hospital three days later, aged 36.
The family says Melhuish's case is a stark reminder of the dangers of criminalising vulnerable women.
In an interview with the Guardian, Melhuish's 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."
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