Miss Kirsty Walker · Prevention of Future Deaths report

The inquest into the death of Miss Kirsty Walker was opened on 7 October 2015. It was resumed on 29 October 2018 with a jury. The jury returned their conclusion on 13 November 2018.

They found the medical cause of death to have been:
1a. Hypoxic brain injury
1b. Cardiorespiratory arrest
1c. Ligature compression to the neck

They concluded with a short-form conclusion of accidental death together with a narrative conclusion.

Miss Walker died at St Peters Hospital in Surrey on 27 September 2015. At the time of her death she was 26 years old and serving a prison sentence at HMP Bronzefield. HMP Bronzefield is a private prison run by Sodexo Justice Services, which contracts out secondary mental health services to Central and North West London NHS Foundation Trust (CNWL).

Miss Walker had been diagnosed with borderline personality disorder and had a history of self-harming, both in the community and during previous periods of imprisonment. She began her final period of imprisonment at HMP Bronzefield on 24 March 2015 and from 25 March 2015 onwards she was managed under the prison’s suicide and self-harm prevention procedures (ACCT procedures).

During the period from 25 March until 25 September 2015 Miss Walker engaged in 235 acts of self-harm, with 215 of those acts involving the tying of ligatures around her neck.

On 25 September 2015 she was found unresponsive in her cell with a ligature tied around her neck. She was taken by ambulance to St Peter’s Hospital but she did not recover and she died at the hospital on 27 September 2015.

I am concerned that the average time to transfer a prisoner to a secure hospital under s.47 of the Mental Health Act 1983 is well in excess of the 14 days envisaged by the 2009 Bradley Report and presents a risk of further deaths.