Miss Joanna Daly · Prevention of Future Deaths report

On 4th June 2019, an investigation was commenced into the death of Miss Joanna Daly, aged 35. The investigation concluded at the end of the Inquest held before a jury on 6 July 2021.

The jury recorded that the medical cause of death was:
1a Ventricular arrhythmia leading to cardiac arrest
1b Use of illicit cocaine

A narrative conclusion was recorded by the jury as follows:

‘Joanna's death was drug related. The roll checks carried out by prison staff were adequate. The healthcare checks were not carried out adequately and this could have been a contributing factor to her death’.

On 1 June 2018 Miss Joanna Daly was admitted to HMP New Hall following a breach of licence conditions following previous sentencing. She had been released from HMP New Hall on 20 May 2018. Upon arrival, it was noted that she was experiencing withdrawal from drugs. Following nursing and medical assessment, she was taken to the First Night Centre. As with all first night prisoners, night checks were undertaken by healthcare staff. Roll checks were conducted by prison staff. On the morning of 2 June 2019, Miss Daly was found unresponsive in her cell and her death was confirmed.

During the course of the Inquest, the matter of checks undertaken by healthcare staff on prisoners resident for their first night in the prison's First Night Centre was heard in evidence. The jury found that no guidance as to how such checks were to be conducted had been provided to the staff undertaking the checks, and that it was possible that this contributed to Joanna's death.

Since Joanna's death, checks within HMP New Hall have been undertaken whereby welfare checks undertaken at the First Night Centre are now completed by prison staff. The new arrangements have been in place since October 2020.

Whilst evidence was provided of the key times at which such checks are undertaken, it became apparent that there was no specific guidance provided to prison staff to explain what was required to be undertaken during a welfare check. The particular vulnerability of prisoners resident on the First Night Centre is the reason for such checks.

I am concerned about the absence of any specific guidance, in view of the findings of the jury in relation to the night checks that were previously undertaken by the healthcare staff at the time of Joanna's death.

This could impact upon the quality of the welfare checks that are now undertaken by the prison staff, in the context of the First Night Centre where prisoners may be particularly vulnerable. I am under a duty to report this matter upon consideration of the evidence as provided to the court.