A newly-published report points to ‘missed opportunities’ to assess Celeste Craig’s mental health ‘properly’
A vulnerable young woman who said she ‘felt safer in prison than in the community’ took her own life behind bars after ‘missed opportunities to assess her mental health properly’. That’s the verdict of a scathing new report into the death of Celeste Craig – just 26.
More than eight years after her death at HMP Styal, a report by the prison and probation services watchdog has now been published, saying a ‘fuller consideration of her risk of suicide’ should have taken place at the women’s prison before staff decided that suicide and self-harm prevention procedures were not necessary.
Celeste, who grew up in New Moston, Manchester, had been sent back to Styal just three weeks before her death – and events detailed in the report suggest alarm bells should have been ringing in the months before.
Nigel Newcomen, the then Prisons and Probation Ombudsman, also found ‘some weaknesses’ in the emergency response after Celeste was found in her cell. His report, dated July 2017, has been published after an inquest into Celeste’s death.
HMP Styal, in Wilmslow, Cheshire, has been at the centre of concerns over the number of deaths at the prison in recent years.
In the spring before her death, Celeste appeared in an ITV documentary called Generation Homeless. At the time she told filmmakers she had struggled with addiction since the death of her grandmother, but wanted to study at college to be a chef. Sadly her life unravelled to the point where she said she’d rather be in prison than free, according to the report.
Those who knew Celeste told the Manchester Evening News after her death that she was let down by a prison system under strain. They told of a ‘really fun person’ – a woman ‘full of life’ who was desperate for a break.
A drug user on the outside, the report suggests it was suspected she was able to access and take so-called ‘New Psychoactive Substances’ behind bars in the prison.
Celeste was found hanged in her cell on October 23, 2016.
Mr Newcomen’s report says: “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.”
Celeste, who was often homeless, had served ‘numerous’ short prison sentences at Styal since 2009, often for petty offences linked to drugs. In July, 2016, she was jailed for 20 weeks, and made threats to harm herself inside the prison just six days later.
According to the now-published report, staff began suicide and self harm monitoring procedures (ACCT), which they continued until August 2 when Celeste was no longer considered to be a risk to herself. She was released on September 16, but later recalled into custody and returned to Styal on October 4.
Staff then observed her smoking what they suspected to be possibly a Spice-like drug and Celeste was moved to a ‘care and separation unit’. She later admitted to using drugs and was given ‘five days cellular confinement as a punishment’, reveals the report. During that period, staff said they were ‘worried’ she was ‘behaving bizarrely’.
The prison’s mental health team was contacted and Celeste was assessed by a nurse. The investigation found that although the nurse said she ‘seemed paranoid’, there were ‘no concerns that she presented a risk to herself’. A further appointment, six days later, was booked in, and she was moved back to a wing on October 10.
Fellow prisoners the Prisons and Probation Ombudsman spoke with as part of the investigation said Celeste was paranoid and behaving strangely. She was also said to be withdrawing from New Psychoactive Substances.
The report says a concerned officer contacted the mental health team on October 11, ‘but no one was available to assess her at the time’. Her mood was said to have ‘improved over her time on the wing’. Celeste was said to have attended regular appointments with substance misuse workers and disclosed that she was using unprescribed subutex, which acts as a substitute for opioids like heroin.
But on the day of her death, prisoners told the investigators that she had been upset. Staff, however, are said to have had no concerns and she was locked into her cell at 5pm. At 9.30pm, a member of staff looked through the observation panel of Celeste’s cell door after another inmate had asked him to ask her to turn her music down.
On seeing Celeste, he radioed for staff assistance and CPR was carried out. An ambulance was called and nurses used a defibrillator until paramedics took over. Sadly, Celeste was pronounced dead at 10.39pm.
The report said: “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 previous behaviour when withdrawing. The investigation also found that not all staff had received ACCT training.”
Tellingly, despite Celeste saying she felt safer in prison, the report said a clinical reviewer concluded that ‘Ms Craig’s care was not equivalent to that she could have expected to receive in the community’.
“Healthcare staff missed opportunities to fully assess her mental health, despite concerns voiced by prison staff that she was behaving bizarrely and seemed paranoid,” added the report. “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.”
The Prisons and Probation Ombudsman has made a series of recommendations for Styal to follow in the aftermath.
HMP Styal holds up to 460 women, with a variety of residential units, 16 separate houses and a mother and baby unit. There’s also a wing holding up to 134 women,where Celeste was mainly located.
An inquest into her death concluded in December last year, with a coroner recording a verdict of suicide.
HMP Styal has implemented a raft of changes since the tragedy, including new staff training on suicide and self-harm and mental health team assessments for all prisoners on arrival.
A new team to manage mental health and substance misuse issues has also been created, with procedures around issuing emergency cell keys and responding to emergencies reviewed.
A HMPPS spokesperson said: “Our thoughts remain with the friends and family of Ms Craig. We accepted all of the ombudsman’s recommendations and have since completed significant improvements at HMP Styal including enhanced staff training and better support systems for prisoners.”
