Celeste Craig

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Independent investigation into
the death of Ms Celeste Craig,
a prisoner at HMP Styal, on 23
October 2016
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Ms Celeste Craig was found hanged in her cell at HMP Styal on 23 October 2016. She
was 26 years old. I offer my condolences to Ms Craig’s family and friends.
Ms Craig was a vulnerable, drug abusing young woman who, sadly, said she felt safer in
prison than in the community. She had returned to Styal some three weeks prior to her
death. During this time, staff missed opportunities to assess her mental health properly. A
fuller consideration of her risk of suicide should have taken place before staff decided that
suicide and self-harm prevention procedures were not necessary. The investigation also
identified that there were some weaknesses in the emergency response.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Nigel Newcomen CBE
Prisons and Probation Ombudsman July 2017
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 14
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Summary
Events
1. Ms Celeste Craig had served numerous short prison sentences at Styal since 2009.
She misused a number of drugs and was often homeless in the community. On 11
July 2016, she was sentenced to 20 weeks custody. Six days later, she tied a belt
around her neck, attached it to the wing railing and said she was going to jump.
She later told staff she had been withdrawing from New Psychoactive Substances,
or NPS. Staff began suicide and self harm monitoring procedures (ACCT) which
they continued until 2 August when Ms Craig was no longer considered a risk to
herself.
2. On 16 September, Ms Craig was released from prison but was later recalled to
custody and was returned to Styal on 4 October. Staff observed her smoking what
they suspected to be NPS and she was moved to the care and separation unit. She
later admitted to NPS use at a disciplinary hearing and was given five days cellular
confinement as a punishment.
3. During this time, staff became worried that Ms Craig was behaving bizarrely. They
contacted the mental health team and a nurse assessed her. Although Ms Craig
seemed paranoid, the nurse had no concerns that she presented a risk to herself
and booked her next appointment for six days later. Ms Craig moved back to the
wing on 10 October. Prisoners told the investigator she was paranoid, behaving
strangely and withdrawing from NPS. On 11 October, an officer contacted the
mental health team as she was concerned about Ms Craig’s behaviour, but no one
was available to assess her at the time.
4. Prisoners told the investigator that they thought that Ms Craig’s mood improved
over her time on the wing. Ms Craig attended regular appointments with substance
misuse workers and disclosed that she was using unprescribed subutex.
5. On 23 October, some prisoners told the investigator that Ms Craig was upset. Staff
had no concerns about her, however, and an officer locked her into her cell around
5.00pm. She shouted to another prisoner through the cell wall at around 8.00pm.
At 9.30pm, another prisoner asked the Operational Support Grade if he could ask
Ms Craig to turn her music down. When he looked through Ms Craig’s observation
panel, he saw her hanging. He radioed for staff assistance and, 70 seconds later,
together with his colleague, unlocked Ms Craig’s cell and cut her down.
6. More staff arrived almost immediately and began cardio-pulmonary resuscitation
(CPR). A custodial manager asked for an ambulance to be called. Nurses
attached a defibrillator to Ms Craig and paramedics took over treatment.
Resuscitation efforts were unsuccessful and Ms Craig was pronounced dead at
10.39pm.
Findings
Assessment of risk
7. Ms Craig had a number of risk factors for suicide and we are concerned that these
were not considered holistically, particularly in light of her continued drug use and
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previous behaviour when withdrawing. The investigation also found that not all staff
had received ACCT training.
Clinical care
8. The clinical reviewer concluded that Ms Craig’s care was not equivalent to that she
could have expected to receive in the community, although some aspects were of
an acceptable standard. Ms Craig received good substance misuse support and
staff appropriately responded to Ms Craig having brought NPS into the prison.
However, healthcare staff missed opportunities to fully assess her mental health,
despite concerns voiced by prison staff that she was behaving bizarrely and
seemed paranoid.
Emergency response
9. When staff found Ms Craig, they did not use an emergency code, thereby delaying
the request for an ambulance. Staff took 70 seconds to go into Ms Craig’s cell due
to staff sharing emergency cell keys and those present obtaining permission to
enter Ms Craig’s cell.
Recommendations
• The Governor and Head of Healthcare should ensure that all staff working with
prisoners have an understanding of risk factors for suicide and self-harm and are
vigilant about any changes that might indicate an increased risk.
• The Governor and Head of Healthcare should ensure that:
• The mental health team assesses all prisoners on the day of their arrival.
• A dual diagnosis team is established to ensure prisoners with related mental
health and substance misuse issues are managed appropriately.
• The Governor should ensure that all prison staff are made aware of and understand
their responsibilities during medical emergencies, including that:
• Staff efficiently communicate the nature of a medical emergency using the
appropriate code.
• All night staff carry individual emergency cell keys and enter cells as quickly
as possible in a life threatening situation.
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The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Styal informing them
of the investigation The investigator issued notices to staff and prisoners at HMP
Styal informing them of the investigation and asking anyone with relevant
information to contact her. No one responded.
11. The investigator visited HMP Styal on 31 October. She obtained copies of relevant
extracts from Ms Craig’s prison and medical records.
12. The investigator interviewed nine members of staff and three prisoners at HMP
Styal in December. She also interviewed five members of staff and four prisoners
by telephone. She interviewed a researcher at the PPO office and the clinical
reviewer interviewed a further member of staff by telephone. The investigator wrote
to a recently released prisoner, but she did not respond.
13. NHS England commissioned a clinical reviewer to review Ms Craig’s clinical care at
the prison. She conducted some interviews jointly with the investigator.
14. We informed HM Coroner for Cheshire of the investigation. We have sent the
coroner a copy of this report.
15. One of the Ombudsman’s family liaison officers contacted Ms Craig’s mother, to
explain the investigation and to ask whether she had any matters she wanted the
investigation to consider. She asked how Ms Craig had managed to hang herself
as when she visited Ms Craig’s cell there was nothing for her to attach a ligature to.
16. Ms Craig’s mother received a copy of the initial report. The solicitor representing
Ms Craig’s mother wrote to us pointing out some factual inaccuracies. The report
has been amended accordingly. They also raised a number of questions that do
not impact on the factual accuracy of this report. We have provided clarification by
way of separate correspondence to the solicitor.
17. HM Prison and Probation Service (HMPPS) also received a copy of the report.
They accepted all the recommendations. They also pointed out some factual
inaccuracies which have been amended accordingly.
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Background Information
HMP Styal
18. HMP Styal is a prison in Wilmslow, Cheshire holding up to 460 women. There are a
variety of residential units, with 16 separate houses holding about 20 women, and a
mother and baby unit. There is also a wing holding up to 134 women where Ms
Craig was mainly located.
19. Spectrum Community Health runs healthcare services at the prison. Lifeline
delivers psychosocial intervention to substance users. Greater Manchester West
Mental Health NHS Foundation Trust provides mental health services. There are
nurses on duty at all times with one registered nurse and a health support worker
available at night. GP sessions are held every day except Sundays, when there is
an out of hours service. There is no in-patient facility.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Styal was conducted in November 2014.
Inspectors reported that Styal was a very good prison and they were impressed with
efforts to give prisoners responsibility for themselves. They noted that most
prisoners felt safe and there were good relationships between staff and prisoners.
Prisoners subject to suicide prevention monitoring procedures generally received
good support and were offered a wide range of interventions. Most assessments
were considered good, well-coordinated and multidisciplinary.
21. Inspectors noted that substance misuse support had improved and was now good
overall. The supply reduction action plan had been reviewed to reflect the
challenges presented, and proactive steps taken to address these challenges,
including trading in prescribed medications. Inspectors reported that the Drug and
Alcohol Recovery Service (DARS) delivered an impressive range of psychosocial
interventions and prisoners were positive about the support available.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to April 2016, the IMB reported that
the mental health team at Styal continued to provide a good service. Prisoners
often self-referred to be seen by a mental health nurse, at twice-weekly clinics.
Operational staff also assisted this referral process.
23. The IMB noted that drugs were a major concern at Styal. On a few occasions, NPS
had entered the prison in significant amounts, but for the most part opiates, opiate-
substitutes and cannabis were the substances most usually identified following finds
and drug testing. The prison's prime security objective for 2016-17 was to reduce
substance use, demand and supply within the prison. They concluded that Styal
used good intelligence and observation of women in the first days of their sentence
to identify those bringing illegal substances into the prison.
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Previous deaths at HMP Styal
24. Since 2011, we have investigated the deaths of five prisoners at Styal, including
that of Ms Craig. The other four deaths were all due to natural causes. We have
identified an issue in both this, and an earlier investigation, concerning delays in
requesting an ambulance in an emergency.
Assessment, Care in Custody and Teamwork
25. ACCT is the care planning system the Prison Service uses to support prisoners at
risk of suicide or self-harm. The purpose of the ACCT is to try to determine the
level of risk posed, the steps that staff might take to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Checks should be made at
irregular intervals to prevent the prisoner anticipating when they will occur. Part of
the ACCT process involves assessing immediate needs and drawing up a caremap
to identify the prisoner’s most urgent issues and how they will be met. Staff should
hold regular multidisciplinary reviews and should not close the ACCT plan until all
the actions of the caremap are completed. Guidance on ACCT procedures is set
out in Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of
harm to self, to others and from others (Safer Custody).
Segregation Units
26. Segregation units are used to keep prisoners apart from other prisoners. This can
be because they feel vulnerable or under threat from other prisoners or if they
behave in a way that prison staff think would put people in danger or cause
problems for the rest of the prison. They also hold prisoners serving punishments
of cellular confinement after disciplinary hearings. Segregation is authorised by an
operational manager at the prison who has to be satisfied that the prisoner is fit for
segregation after an assessment by a member of healthcare staff. Segregation unit
regimes are usually restricted and prisoners are permitted to leave their cells only to
collect meals, wash, make phone calls and have a daily period in the open air. The
unit at Styal is known as the care and separation unit and comprises nine cells.
Incentives and Earned Privileges (IEP) Scheme
27. Each prison has an Incentives and Earned Privileges (IEP) scheme, which aims to
encourage and reward responsible behaviour, encourage sentenced prisoners to
engage in activities designed to reduce the risk of re-offending and to help create a
disciplined and safer environment for prisoners and staff. Under the scheme,
prisoners can earn additional privileges such as extra visits, more time out of cell,
the ability to earn more money in prison jobs and to wear their own clothes. There
are four levels, entry, basic, standard and enhanced.
New Psychoactive Substances (NPS)
28. New psychoactive substances, previously known as ‘legal highs’ are an increasing
problem across the prison estate. They are difficult to detect and can affect people
in a number of ways including increasing heart rate, raising blood pressure,
reducing blood supply to the heart and vomiting. Prisoners under the influence of
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NPS can present with marked levels of disinhibition, heightened energy levels, a
high tolerance of pain and a potential for violence. Besides emerging evidence of
such dangers to physical health, there is potential for precipitating or exacerbating
the deterioration of mental health with links to suicide or self-harm.
29. In July 2015, we published a Learning Lessons Bulletin about the use of NPS and
its dangers, including its close association with debt, bullying and violence. The
bulletin identified the need for better awareness among staff and prisoners of the
dangers of NPS; the need for more effective drug supply reduction strategies; better
monitoring by drug treatment services; and effective violence reduction strategies.
30. HMPPS now has in place provisions that enable prisoners to be tested for specified
non-controlled psychoactive substances as part of established mandatory drugs
testing arrangements. Testing has begun, and HMPPS continue to analyse data
about drug use in prison to ensure new versions of NPS are included in the testing
process.
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Key Events
31. Ms Celeste Craig had served numerous short prison sentences since 2009, usually
at HMP Styal. She was sometimes homeless in the community and had a history of
offending to fund her drug misuse. Prison documentation indicates that she had
attempted suicide twice in the community: in 2007 by taking an overdose and in
2014 by jumping off a bridge. She told staff and prisoners that she felt safer and
more comfortable in prison than in the community.
32. During the first half of 2016, Ms Craig returned to Styal three times to serve
sentences of up to six weeks. She told prison staff that she used drugs including
heroin, crack cocaine, benzodiazepines (medicine used to assist sleep) and NPS.
She also drank alcohol excessively. On 22 February, Ms Craig said she had
thoughts of suicide and staff began ACCT suicide and self-harm prevention
procedures. These were closed the next day when Ms Craig was assessed as no
longer posing a risk to herself. She told staff she had made the statement due to
frustration and did not feel suicidal.
33. Staff and prisoners described Ms Craig as a very likeable prisoner but who did not
always conform to the regime. Staff submitted 45 security information reports about
her conduct between 2014 and 2016. These were largely related to suspected drug
possession and supply in prison, and issues with other prisoners.
34. The investigator was approached by a PhD student, who interviewed Ms Craig
twice at Styal, in March and April 2016. Se informed the investigator that Ms Craig
had told her that she had gender dysphoria and that Ms Craig believed this was
partly responsible for her substance misuse issues. There is no evidence that Ms
Craig had ever told any staff or prisoners that she identified as a man or how this
impacted on her behaviour. We therefore make no further reference to this in the
report.
35. On 11 July, Ms Craig was sentenced to 20 weeks custody for theft offences and
was taken to Styal. Her conditional release date was 18 September and her
sentence expiry date was 27 November. Ms Craig told staff that she had been
using crack cocaine, heroin, NPS and diazepam in the community. On 17 July, Ms
Craig tied a belt around her neck, attached it to the wing railings, climbed onto the
other side of the railing and said she was going to jump. She said she wanted to kill
herself as she had nothing to live for. After an hour of negotiations, she climbed
back over the railings and was taken to the care and separation unit (CSU). Staff
noted that Ms Craig might have been under the influence of NPS and began ACCT
monitoring procedures.
36. Ms Craig told staff that she was angry about not receiving adequate medication to
minimise her withdrawal symptoms from NPS and wanted methadone or diazepam.
Ms Craig said she had wanted to die as she had had enough of going in and out of
prison and it was the anniversary of her father committing suicide. She said she
had taken an overdose of diazepam on 8 July while in the community and had been
hospitalised.
37. Over the next few weeks, Ms Craig engaged with the Drug and Alcohol Recovery
Service (DARS) and discussed her use of NPS. On 2 August, staff closed her
ACCT and Ms Craig moved back to the general residential wing. Over the following
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weeks, after warnings about her behaviour, Ms Craig was reduced to the lowest
level of the Incentives and Earned Privileges (IEP) scheme. Staff suspected she
was involved in the supply of drugs in the prison, distributing drugs for other
prisoners who paid her with small amounts of NPS. On 5 September, Ms Craig told
a nurse that she had been taking subutex every two days.
38. On 16 September, Ms Craig was released, subject to licence, the terms of which
included attending appointments with her offender manager. She did not attend
these appointments and her offender manager applied to have her licence revoked.
Ms Craig was recalled to custody and returned to Styal on 4 October. She was due
for release on 1 December.
39. Staff observed Ms Craig smoking a green leafy substance in the first night centre.
As a result, staff moved her to the CSU with the intention of minimising the
distribution of drugs around the prison. Ms Craig was placed on a disciplinary
charge (adjudication) because of her behaviour. Ms Craig told a nurse that she had
been using heroin, crack cocaine, NPS and diazepam since she was last in prison.
The nurse noted that Ms Craig seemed under the influence of NPS and had been
homeless since she was last released. A drug test was positive for opiates,
cannabinoids (including NPS and cannabis), cocaine and benzodiazepines. Ms
Craig did not appear to be suffering any withdrawal symptoms and the nurse
referred her to a doctor. Ms Craig said she had no thoughts of suicide and self-
harm.
40. At 7.30pm, a prison GP assessed Ms Craig through the observation panel in her
cell door as there were insufficient staff available to unlock her. He noted that she
had no thoughts of suicide or self-harm, looked well, alert and comfortable. He
prescribed her trazodone (an antidepressant). On 5 October, a mental health nurse
tried to assess Ms Craig. She was unable to do so, however, due to a lack of staff
to unlock Ms Craig or an available room to meet. The same day, Ms Craig attended
her disciplinary hearing. She admitted that the substance that she had been
smoking was NPS which she had brought into the prison with her. She was given
five days cellular confinement.
41. A prisoner told the investigator she had been in a relationship with Ms Craig since
June. They had met in Styal. On 5 October, she deliberately got herself moved to
the CSU to see Ms Craig. She told the investigator that Ms Craig seemed different
when she returned to prison on this occasion. She appeared paranoid and said
people were following her.
42. A healthcare assistant from the primary care team assessed Ms Craig twice that
day. She noted that Ms Craig did not appear to be suffering any withdrawal
symptoms and she told her that she would not be prescribed any further medication
for the time being. She noted that Ms Craig was “bright, chatty and singing in her
cell”. A DARS worker also saw Ms Craig. They discussed the risks associated with
NPS.
43. On 6 October, a nurse assessed Ms Craig twice and noted that she had minimal
withdrawal symptoms and did not need any medication to alleviate them. A prison
GP assessed Ms Craig on 7 October and prescribed her amitriptyline (an
antidepressant).
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44. On 8 October, an officer telephoned the mental health team as staff were
concerned that Ms Craig was behaving out of character. As a result, a nurse
assessed Ms Craig around 11.00am. Ms Craig said that undercover police had
been following her in the community. She was tearful and said that, for the first
time, she did not trust staff or other prisoners and did not feel safe.
45. When the nurse told Ms Craig that the drugs she had taken might have made her
paranoid, Ms Craig did not accept this. Ms Craig told the nurse that she had
finished smoking the NPS she brought into Styal three days earlier. After around 20
minutes of discussion, the time came for Ms Craig to return to her cell so the nurse
asked whether Ms Craig would like to see her when she moved back to the wing.
Ms Craig agreed to this. The nurse said she had no concerns that Ms Craig was a
risk to herself and booked her next appointment for 14 October.
46. On 9 October, healthcare staff from the substance misuse team tried to assess Ms
Craig twice, but she was erratic and agitated so they were unable to do so. A nurse
told the investigator that she was responsible for giving prisoners in the CSU their
medication that evening. She could hear Ms Craig in her cell talking to herself,
making bizarre statements, shouting and being very erratic. She suspected Ms
Craig may have taken NPS and therefore did not give her any medication as she
was unsure whether it was safe to do so. (Ms Craig’s pupils were dilated.) She
explained this to Ms Craig through the observation panel. Ms Craig was unhappy
about this and kicked the walls of her cell.
47. On 10 October, Ms Craig’s period of cellular confinement ended and she moved to
the main residential wing. Her cell sharing risk assessment indicated that she was
a high risk to others, due to previous fights with prisoners, so she was located in a
single cell.
48. On 11 October, an officer, who had known Ms Craig from working at Styal for
several years, noted that she seemed different to normal. She recorded that Ms
Craig was paranoid, agitated, said that people were following her and was difficult
with staff. She told a nurse that she was concerned about Ms Craig and two other
prisoners. The nurse was running a mental health clinic on the wing and so could
not assess Ms Craig immediately. The officer telephoned the mental health team
and spoke to the mental health team manager. She told him that she had concerns
about three prisoners, including Ms Craig, who were acting unusually. The officer
told the investigator that after this conversation she was expecting a mental health
professional to assess these three prisoners.
49. The mental health team manager noted in Ms Craig’s medical record that he told
the officer that no one from the mental health team was available at that time. He
also noted that he had asked the officer whether DARS had been informed as he
suspected drugs might have been involved since there were three prisoners acting
unusually. The officer told the investigator that she did not remember him saying
that no one was available or suggesting that she contact DARS.
50. The mental health team manager told the clinical reviewer that he telephoned
DARS to inform them that someone would be contacting them about three
prisoners. There is no record of this occurring. The officer said that if she had been
aware that Ms Craig was not going to be assessed by the mental health team, she
would have spoken to her supervising officer. The mental health nurse later went to
see Ms Craig, who was sleeping in her cell. The nurse saw Ms Craig on the wing
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afterwards and asked how she was. Ms Craig replied that she was fine and knew
how to access mental health services if she needed them.
51. The officer recorded some of her concerns in the wing observation book and in Ms
Craig’s computerised record. She did not, though, believe that Ms Craig was a risk
to herself. She told the investigator that later on she saw Ms Craig singing in her
cell and she seemed much more her “normal” self. Ms Craig missed two
appointments with DARS that day then, on 12 October, she walked out of her
appointment with a DARS worker.
52. The investigator spoke to several prisoners on the wing. A number of them said
that Ms Craig was very obviously paranoid when she returned to the wing and
believed that staff at Styal were conspiring against her. Most of the prisoners said
that they believed her behaviour was due to withdrawal from NPS. Some noticed
that she was sweating and aching and that her emotions were very changeable.
However, during her time on the wing, prisoners said that her mood improved and
she began to seem more cheerful and less paranoid.
53. On 14 October, Ms Craig failed to attend her appointment with a nurse. She later
attended her appointment with her DARS worker, to whom she admitted using illicit
subutex. Ms Craig said she had felt suicidal when she returned to prison but had
no thoughts of this nature at that time.
54. A prisoner, who had been released from prison, returned on 14 October. Rather
than returning to Styal, she went to HMP New Hall. She told the investigator that
she had offended so that she could be back with Ms Craig. Letters between the two
prisoners indicated that they were concerned about each other remaining faithful,
and that they loved and missed each other.
55. On 17 October, a nurse saw Ms Craig walking round the prison and asked her why
she had not attended her appointment. The nurse said she seemed happy at the
time and was singing with another prisoner. Ms Craig said she felt better and had
got her head “out of Spice mode”. She was confident that Ms Craig knew how to
refer herself to mental health services if she felt it necessary in the future.
56. On 18 October a healthcare assistant (HCA) in the substance misuse team,
assessed Ms Craig. Ms Craig said she had been using subutex for the last week
and was angry with herself because she would not be considered for a place in
rehabilitation as a result. She wanted to stop using subutex. She told Ms Craig that
she would ask the doctor to prescribe her medication to minimise her withdrawal
symptoms, which a doctor later did.
57. On 20 October around 11.30am, a HCA was working in the doctor’s room on the
wing. Ms Craig asked her for a plaster for a cut on her hand which she said had
happened when she was shredding fabric to make curtain ties. She noted that Ms
Craig had a history of making ligatures after her mood changed. She told the
investigator that although Ms Craig had seemed preoccupied, she had no concerns
that she was a risk to herself. She told a supervising officer, who asked the officer
on lunchtime patrol to check on Ms Craig. The supervising officer told the
investigator that she did not have sufficient concerns to open an ACCT. When the
officer did check, he said that Ms Craig seemed fine and was sitting on her bed
listening to music. The next day the supervising officer saw Ms Craig and asked
how she was. She replied that she was fine.
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58. The investigator spoke to three other officers, who all said that Ms Craig had
seemed her usual self when she returned to the wing. The supervising officer also
told the investigator that Ms Craig seemed to be coping with being back in prison,
and there were no obvious signs that she was withdrawing from, or using, drugs.
23 October
59. A prisoner who lived in the cell next door to Ms Craig told the investigator that, on
23 October, Ms Craig did not seem her usual self and was upset. Another prisoner
also said that Ms Craig did not seem herself and was in a “dark place”. However,
by contrast, another prisoner said that Ms Craig did seem her usual self during
exercise around 3.45pm.
60. A prisoner told the investigator that they had just come in from exercise when Ms
Craig told her that her previous partner, a fellow prisoner, had told her that she still
loved her. (They had recently been in a relationship for seven years.) Ms Craig
went into the prisoner’s cell, became angry and started shouting. The prisoner said
another prisoner was also present. (The investigator was not able to interview this
prisoner as she had been released and was of no fixed abode. Another prisoner
had also been released and did not respond to the investigator’s letter). Ms Craig
then began crying and the prisoner tried to reassure her by talking about Ms Craig’s
current relationship. Ms Craig became calmer and the prisoner told the investigator
she seemed “more than okay” when she left the cell to be locked in her own cell at
around 4.00pm.
61. Staff unlocked prisoners to collect their evening meal at around 5.00pm. A prisoner
said that Ms Craig, two other prisoners and herself were all in a prisoner’s room,
laughing. She said that Ms Craig seemed very happy. She then went to use the
telephone and Ms Craig said good night to her on the way to her cell.
62. The investigator watched CCTV footage taken from 5.00pm onwards that evening.
An officer locked Ms Craig in her cell at 5.08pm. It appears from other sources that
CCTV timings were 30 minutes behind the correct time, so it was actually 5.38pm.
The officer said that Ms Craig said “cheers boss” as he closed the door, and he had
no concerns about her. When he returned along the landing to double check he
had locked all the doors, he looked into Ms Craig’s cell and saw her dancing and
singing.
63. Shortly after they were locked in their cells, Ms Craig shouted to two prisoners to
watch a film on television. When this had finished, they shouted to each other that
they would see each other in the morning. A prisoner estimated that this was
around 7.30-8.00pm.
64. Two Operational Support Grades (OSGs) began their night shift working on the
wing at 8.15pm. OSG A collected a sealed pouch containing a cell key for them to
share. Just before 9.00pm, the OSGs began the roll check on Y side of the wing.
(Ms Craig lived on X side.) They had nearly completed checking all the cells when
the prisoner living next door to Ms Craig pressed her cell bell. This was just before
9.30pm. OSG B went to her door within two minutes and spoke to her through her
observation panel. She asked him if he could ask Ms Craig to turn her music down,
as it was very loud. He assured her that he would, and closed her observation
panel.
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65. OSG B immediately looked through the panel in Ms Craig’s door. He saw Ms Craig
had hanged herself from the window with her feet suspended from the floor. The
investigator listened to the radio traffic of the emergency response. At 9.31pm, he
radioed for patrol staff to go to the wing “for a ligature” and OSG A reached the cell
45 seconds later. OSG B requested permission to break into OSG A’s emergency
pouch at 9.32pm, and this was granted by the custodial manager. They unlocked
Ms Craig’s door, 70 seconds after OSG B had first looked into the cell.
66. Ms Craig had hanged herself by tying a sheet to the top of an open window. OSG
B supported Ms Craig’s weight and lifted her up while OSG A used his anti-ligature
knife to cut the sheet from Ms Craig’s neck. They laid Ms Craig on the floor and
OSG A checked for a pulse. He thought he felt one, and started to put Ms Craig
into the recovery position. At 9.33pm, three officers arrived. Having confirmed
there were no signs of life, they began CPR immediately. At 9.35pm, the custodial
manager arrived at the cell and requested that control room staff telephone an
ambulance. They did so immediately.
67. A nurse and a HCA were on their way to Ms Craig’s cell. They had not heard OSG
B radioing that there was a ligature before this. The nurse arrived at Ms Craig’s cell
around 9.37pm and confirmed that Ms Craig displayed no signs of life. Staff
continued with CPR and the HCA arrived shortly afterwards with the emergency
equipment. The nurse attached the defibrillator which advised not to shock, and
staff continued CPR. Paramedics arrived at 9.54pm. They took over treatment but
resuscitation efforts were unsuccessful and they pronounced Ms Craig dead at
10.39pm.
Contact with Ms Craig’s family
68. On 24 October at 4.00am, the Governor and the Head of Operations went to Ms
Craig’s mother’s address, to inform her of her daughter’s death, and offered their
condolences and support. The prison contributed to Ms Craig’s funeral costs in line
with Prison Service Instructions.
Support for prisoners and staff
69. After Ms Craig’s death, the Governor debriefed the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team also offered support. A further debrief was held
for staff on 31 October. Most staff said they had felt well supported by the prison.
70. On the morning of 24 October, the Governor told some prisoners individually that
Ms Craig had died. The prison also posted notices informing other prisoners of Ms
Craig’s death, offering support. Staff reviewed all prisoners assessed as being at
risk of suicide or self-harm in case they had been adversely affected by Ms Craig’s
death. The prison held a memorial service for Ms Craig and arranged for balloons
to be released at the prison in her memory. All the prisoners the investigator spoke
to said that, initially, they had felt well supported by the prison. However, three of
these prisoners told the investigator that in the following weeks they would have
appreciated further support and an opportunity to talk about Ms Craig.
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Post-mortem report
71. We have not yet received the post-mortem report but the preliminary cause of death
was recorded as asphyxiation caused by compression of the neck due to hanging.
The police indicated that Ms Craig did not test positive for any drugs or alcohol, with
only prescribed antidepressants detected in her system.
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Findings
Assessment of Ms Craig’s risk of suicide and self-harm
72. Ms Craig had a number of risk factors for suicide. She had a history of attempted
suicide, her father had committed suicide, she suffered from depression, she had
been recalled to prison, she had a lack of social support and misused drugs from
which she may have been withdrawing at the time of her death. During her last
period in prison, she said she had no thoughts of suicide, other than on one
occasion, on 14 October, when she told a substance misuse worker that she had
felt suicidal when she had first returned to prison, ten days earlier. Ms Craig was
not managed within ACCT procedures the last time she was at Styal.
73. On at least two occasions after Ms Craig returned to Styal, prison staff told the
mental health team that they were concerned Ms Craig was behaving differently.
Prisoners told the investigator that Ms Craig seemed very paranoid which they
thought was due to her withdrawing from NPS. We are concerned about the
prevalence of NPS in prisons and the effect it has on the behaviours and health of
those taking it, including its association with suicide and self-harm. When, in July,
Ms Craig was apparently suffering withdrawal symptoms from NPS, she climbed
over the railings with a ligature tied around her neck and said she wanted to kill
herself.
74. Staff judgement is fundamental to suicide and self-harm prevention, and relies on
their using their experience and skills, as well as local and national assessment
tools, to determine risk. We are concerned that in assessing Ms Craig’s risk to
herself, staff did not consider all the risk factors involved but relied on Ms Craig’s
demeanour and her assurances that she had no thoughts of this nature. They did
not explicitly take into account her past behaviour and current drug misuse. The
clinical reviewer concluded that the mental health nurse should have opened an
ACCT on 8 October following her assessment of Ms Craig. Although we are not
convinced that staff needed to begin ACCT procedures, this is a finely balanced
decision that should take account of all the risk factors. We have not seen any
evidence that this occurred during Ms Craig’s last time in Styal. We are also
concerned that not all staff working in Styal had been trained in ACCT suicide and
self-harm prevention procedures. We therefore make the following
recommendation:
The Governor and Head of Healthcare should ensure that all staff working
with prisoners have an understanding of risk factors for suicide and self-harm
and are vigilant about any changes that might indicate an increased risk.
Clinical care
75. The clinical reviewer concluded that the clinical care Ms Craig received was not
equivalent to that she could have expected to receive in the community, although
she noted that some aspects of her care were of an acceptable standard.
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Substance misuse
76. When Ms Craig returned to prison she was not suffering any obvious withdrawal
symptoms. Staff suspected she was still using drugs at this point and so decided to
observe and monitor her regularly rather than prescribe opiate substitute
medication. This was appropriate. Ms Craig regularly met with DARS and
disclosed to them her ongoing subutex misuse. DARS staff were unable to disclose
this information to other staff due to confidentiality agreements with prisoners. Their
aim is to work with prisoners to reduce their substance misuse. We concur with the
clinical reviewer’s view that substance misuse services were delivered to a good
standard.
77. Staff suspected Ms Craig had brought NPS into prison with her. They appropriately
segregated her and, the next day, during an adjudication hearing, she admitted she
had been smoking NPS. She was given five days cellular confinement as a result.
All the prisoners we spoke to said that she had no NPS when she moved to the
wing and that she appeared to be withdrawing from the drug. We are satisfied that
the prison did all they could to reduce the supply of, and demand for, NPS while
also offering Ms Craig appropriate substance misuse treatment.
Mental health
78. The mental health team did not assess Ms Craig on the day she arrived at Styal, as
is their policy. The mental health team manager told the clinical reviewer that he
had already identified this as an issue. The clinical reviewer noted that the
reception screening identified that Ms Craig suffered from depression but failed to
include that her recent threatened suicide attempt related to her withdrawal from
NPS use.
79. A nurse assessed Ms Craig four days after she arrived at Styal, at the request of
prison staff. Ms Craig disclosed that she had been smoking NPS and she
concluded that Ms Craig was paranoid but was not a risk to herself. The nurse
seemingly did not consider her previous threat of suicide when she was under the
influence of NPS. This assessment was terminated early due to staffing issues.
She scheduled their next appointment for six days later. The clinical reviewer
concluded that, due to Ms Craig’s presentation, a further mental health assessment
should have been scheduled sooner in order to complete a full assessment.
80. On 11 October, wing staff were concerned that Ms Craig was acting differently to
normal and again contacted the mental health team. Mental health staff were not
available to assess her at that time although the officer said she was not made
aware that this was the case. Ms Craig failed to attend her mental health
appointment on 14 October.
81. The clinical reviewer concluded that there were missed opportunities to identify a
number of mental health concerns. Ms Craig had a history of attempted suicide and
threatened self-harm, was using NPS, had expressed paranoid thoughts and had
failed to attend mental health appointments. She indicated that Ms Craig’s
changeable presentation should have been discussed in multidisciplinary meetings
with the mental health and substance misuse teams working together to ensure any
drug-induced psychosis was appropriately and safely managed. To this end, she
recommended establishing a dual diagnosis team at Styal including professionals
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from psychiatry, psychology, social care and substance misuse. We make the
following recommendation:
The Governor and Head of Healthcare should ensure that:
• The mental health team assesses all prisoners on the day of their
arrival.
• A dual diagnosis team is established to ensure prisoners with related
mental health and substance misuse issues are managed
appropriately.
Emergency response
82. Prison Service Instruction (PSI) 03/2013, Medical emergency response codes,
indicates that the Governor must have a medical emergency response code
protocol that ensures that an ambulance is called automatically in a life-threatening
medical emergency. The protocol gives guidance on efficiently communicating the
nature of a medical emergency, ensuring that staff take the correct equipment to the
incident and that there are no delays in calling an ambulance. It explicitly states
that all prison staff must be made aware of, and understand, the protocol and their
responsibilities during medical emergencies. Governors are required to have a two
code medical emergency response system based on the instruction. Styal uses
code blue to indicate an emergency when a prisoner is unconscious, or having
breathing difficulties, and code red for when a prisoner is bleeding. The control
room should call an ambulance when an emergency code is used.
83. OSG B did not use an emergency code. He radioed for patrol staff to attend the
wing “for a ligature”. Prison staff responded immediately. The healthcare staff did
not hear this request but heard his request for permission to break the emergency
pouch shortly afterwards and they responded. Since the emergency code was not
used, this led to a four minute delay in an ambulance being called.
84. OSG B said that the emergency codes, code red and code blue, were not used at
Styal. He said staff were expected to radio what had happened or what they could
see. Some of the other staff the investigator interviewed were also unclear as to
whether emergency codes were used.
85. Instructions about night procedures (PSI 24/2011, Management and Security of
Nights), and about safer custody (PSI 64/2011, Management of prisoners at risk of
harm to self, to others and from other (Safer Custody) are clear that preservation of
life takes precedence over the usual arrangements for opening cells. At night,
prison staff on wings do not carry standard keys but have a cell key in a sealed
pouch for use in such an emergency. Where there appears to be immediate danger
to life, prison staff can unlock cells by themselves without the authority of the night
manager, subject to a personal risk assessment.
86. The two OSGs on the wing shared a cell key and OSG A held the key that night.
He got to Ms Craig’s cell 45 seconds after OSG B had first looked through the
observation panel. If both OSGs carried their own key there would have been no
delay. It took the OSGs another 25 seconds to unlock Ms Craig’s cell, during which
time they sought permission from the custodial manager to break the emergency
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pouch. OSG A told the investigator that staff always had to receive this permission.
We are concerned that staff are unclear about their responsibilities in an
emergency. It is evident that the Governor needs to do more to ensure that staff
understand and follow emergency procedures. We make the following
recommendation:
The Governor should ensure that all prison staff are made aware of and
understand their responsibilities during medical emergencies, including that:
• Staff efficiently communicate the nature of a medical emergency using
the appropriate code.
• All night staff carry individual emergency cell keys and enter cells as
quickly as possible in a life threatening situation.
Inquest
87. The inquest into Ms Craig’s death finished in December 2024 and concluded that
she had died due to suicide.
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