A jury concluded that the death of a vulnerable young woman who took her own life in prison on Christmas Eve was contributed to by neglect. Alex Davies, 25, from Liverpool, who suffered severe borderline personality disorder and post-traumatic stress disorder from sexual abuse, was found dead in her segregation cell at Styal Prison, an inquest heard.
A jury at the 11-day inquest at Cheshire Coroner’s Court in Warrington, found that neglect contributed to her death – an extremely rare conclusion which can only be used where there has been a gross failure to provide basic medical attention and that this caused an individual’s death.
Alex’s mum Stacie, 44, from Liverpool, was represented by specialist civil liberties lawyers from Broudie Jackson Canter at the inquest which concluded on Monday 3 November. She said:
“Alex was my little girl and my best friend. All she wanted was help but her situation in prison made her feel like she had no other option but to take her own life. I would like to see Styal Prison condemned as I wouldn’t wish what happened to my daughter on my worst enemy.”
The jury heard how psychiatrists said Alex should have been placed in a mental health hospital rather than prison. She was kept on the Care and Separation Unit (CSU), which is effectively a segregation unit, for 27 days from 9 November to 6 December. For 14 of those days, Alex was placed on constant observation because the risk to her life had substantially increased. National guidelines state that prisoners who are at risk of suicide should not be kept in CSU apart from in exceptional circumstances, as it is well documented that a person’s mental health will likely decline while they are there. Numerous witnesses to the inquest reasoned that Alex was kept on the CSU for so long as there was nowhere else, she could go that could safely manage her risk to self.
Additionally, Alex had been discharged from the Integrated Mental Health Team’s (IMHT) caseload following an assault on staff. It became apparent that concerns were being raised about some of the IMHT nurses’ interactions with Alex. It was reported that one of the nurses had told Alex that she would not be getting medication for depression and epilepsy “until she behaves” and prison staff reported uncaring and unprofessional attitudes by IMHT staff towards Alex.
On Christmas Eve 2024, Alex was on her way back to her cell following a treasure hunt when a prison officer told her to ‘stop perving’ when she tried to speak to another prisoner. Alex became upset, ran off and was forcibly restrained before being taken to the CSU. In distressing footage shown of the restraint and relocation to the segregation unit, Alex is repeatedly telling officers “she called me a perv”.
Alex screamed “I don’t want to go to this hell cell” and begged staff not to take her there over Christmas. A Prison & Probation Ombudsman (‘PPO’) stated that force was not necessary and attempts were not made to de-escalate the situation by talking with her.
A male nurse, who walked away after Alex put a mattress against the observation window when he asked her if she would like to talk, admitted at the inquest that he incorrectly filled out a healthcare algorithm which should have raised a red flag about Alex being kept in CSU. Within about 5 minutes of the door to Alex’s cell being closed, she attempted to self-harm and officers had to force their way into her cell because she had blocked the door. Items of clothing and bedding were removed from Alex’s cell while the Governor in charge of the decision to segregate stood outside.
After repeated attempts at self-harm Alex was left wearing nothing but a pair of boxer shorts while under observation by male prison officers. Despite the persistent attempts at self-harm she was not put on constant watch. There were five occasions in which officers entered her cell in order to remove ligature material from her cell, however these incidents were not escalated to Senior Officers or the Duty Governor.
Although an IMHT nurse told the inquest that she had approached Alex’s cell on the CSU and asked if she wanted to be reviewed by the mental health team, there was no evidence of any interaction between Alex and the IMHT on any of the CCTV or body worn footage that captured Alex’s movements on the CSU on 24th December 2024. During the inquest proceedings, it was disclosed that prison staff reported unprofessional attitudes towards Alex by members of the mental health team that occurred on the day of her death; for example, one member of IMHT is said to have used a derogatory phrase in the unit office to describe Alex whilst visiting the Valentina Unit that morning.
Stacie added:
“Alex suffered from age regression so for her the thought of being on her own in that cell at Christmas would have been torture. Instead of caring for her the nurse just walked away and didn’t raise the fact that she might be at risk. My girl wanted help when she was arrested and I know she wouldn’t have wanted to kill herself. The neglectful actions of the prison staff contributed towards her death.”
Alex’s dad Allan, 45, said:
“This conclusion is bittersweet justice. Dying through neglect in a prison in the 21st century is truly appalling, and I hope that changes are made to prevent this from happening to somebody else. Alex was such a joyful child and we will always miss her.”
Alex, who had been in and out of mental health hospitals since the age of 14, saw her mental health deteriorate after she was taken off the antipsychotic drug, Clozapine, and was arrested in October last year after threatening her psychiatrist and possession of a knife.
The jury found that the ‘stop perving’ comment probably contributed to the decline in Alex’s mental state, among other factors, and that the completion of the healthcare algorithm was inappropriate.
The fact that Alex was taken to the CSU on 24 December probably contributed to her death and was a failing of care. The decision not to place Alex on constant observations when she first self-harmed on the CSU, only 5-minutes after she was last seen by staff, at a time when governors were present and able to make this decision was also a failing in care and probably contributed to her death.
Overall, the jury concluded that there was a gross failure to place Alex on constant observations whilst on the CSU and as such her death was contributed to by neglect. The family were represented by Nicola Miller, specialist civil liberties solicitor at Broudie Jackson Canter, and Ciara Bartlam from Garden Court North. In response to the conclusion, Nicola Miller said:
“For a young vulnerable woman to be neglected in this way in a state prison that allowed her to take her own life is truly abominable. Alex should never have been sent to the wholly inappropriate surroundings of a prison where she was wrongly placed in effective solitary confinement as they didn’t know what else to do with her or know how to deal with her needs.
Moreover, the treatment of Alex by some staff was cruel. She was desperate for help, but instead was neglected. HMP Styal is a women’s prison with a high number of self-inflicted deaths, compared to the rest of the female estate. Significant changes need to be made to ensure the women are getting the help and support they need, and lessons need to be learnt to prevent more young lives being lost.”