"This form is opened when any member of staff considers a prisoner to be at risk. It was designed in considerable detail to manage the measures to be taken to support an individual at a time of a suicidal crisis to the point where risk was reduced and the form could be closed. The form is only intended however as a framework and following the stages of the form should not be the end in itself. Writing on the form is not what sees someone through a crisis. If the contents become clichéd and repetitive, the piece of paper becomes meaningless, and worse, staff quite wrongly feel they have done their job. This is not to argue against the role of the form, but to emphasise that it is not the most important feature of the strategy and it should not be relied on as the sole mechanism for intervention. The most important outcome of any process is that the prisoner concerned receives the help he/she needs to get through the crisis."
"The particular significance of this review is that it affects every person every time they come into custody. Death and bereavement inevitably touch us all in some way, and, when a prisoner dies in prison, his or her family and friends are bereaved in the same way as anyone else. But there is an added dimension to a death in prison. Firstly family and friends do not just lose a loved one, they lose him or her in very painful circumstances, separated from them and in conditions that they do not fully appreciate. In addition staff and prisoners, living and working with the person, are also deeply affected, and have to come to terms with their bereavement as well as that of the family. Thus the impact of a death in custody is compounded by a number of additional factors and emotions, which must be acknowledged, but are difficult to understand objectively. One suicide is one too many, but, regrettably, there will always be deaths in prison, however professional and caring the prison staff, and however efficient a reduction strategy and systems for observing prisoners."
"Those statistics sketch the profile of those who most commonly die in our prisons: they are likely to be newly in prison, often unconvicted, often so mentally ill or disturbed that they need segregation or treatment, and a disproportionate number are women, often young women. Many of them, at that stage in sentence, will be withdrawing from drugs."
"DP seems very depressed says if she goes back to prison today she will do herself in very tearful whilst in court, had to be forcibly removed from dock when remanded."
"Says she will lose her accommodation worried about her children says she has nothing left her life's a mess."
"Not suicidal or thinking of self harm. Was reacting to failure to get bail. Compos mentis. I feel she is manipulative."
"That the name is that of Sheena Dawn Lisa Nicola Marie Creamer, the injury or disease causing death was 1(a) hanging by ligature and (3) the time place and circumstances is that the deceased was a remand prisoner at Her Majesty's Prison New Hall. She was further remanded to prison by Sheffield Magistrates' Court on4 August 2000 and was admitted to the medical centre, she was moved to the residential wing cell C215 on6 August 2000 where she was discovered hanging by a ligature by a patrolling officer. An ambulance took her to Pinderfields General Hospital where she was declared dead on arrival at 0040 hours on7 August 2000 and the jury's conclusion by majority is that Sheena killed herself…"
"A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly."
"Just before I formally conclude this inquest I intend now making an announcement pursuant to rule 43 of the Coroners Rules that it is my intention to write to the prison department and inform them as to my grave concerns regarding the locum medical officer at New Hall Prison on this occasion not having a working knowledge of the form 2052SH procedures. I regard the form 2025SH as a vital tool in identifying those prisoners who are vulnerable and at risk of self harm or suicide and I take an extremely dim view of the fact that somebody in such an important position as a medical officer albeit a locum on this occasion demonstrated such a scant understanding of what is such an important provision and therefore I shall write to the Head of the Prison Service pointing out my concerns pursuant to this rule."