Prisoner 'failed' after choking on underwear - coroner

Diana Grant was found unresponsive in her cell at HMP Bronzefield on 20 November 2021

A coroner has raised concerns over people held in prison who should be in a mental health facility after a prisoner fatally choked on a piece of underwear.

Diana Grant controlled her paranoid schizophrenia with medication but is believed to have been in a state of psychosis when she died at HMP Bronzefield, Surrey, in 2021, aged 42.

Senior coroner Richard Travers said he was concerned people were being held in prison instead of secure mental health unit estates due to limited capacity.

Sodexo UK, which runs the prison, has been approached for comment.

On 17 November 2021, Ms Grant's mother, Annette Trotman, took her daughter to see a nurse with a community mental health team, who decided Ms Grant needed to be in hospital.

Ms Grant, from Willesden in London, left the appointment before plans were finalised and subsequently attacked her mother with a kitchen knife, which the coroner said was potentially due to a state of psychosis.

She was arrested for attempted murder and taken to St Mary's Hospital in London where it was agreed she needed a mental health act assessment. This never occurred.

Mr Travers said Ms Grant probably could have started treatment for the relapse sooner, which may have reduced the risk of self-harm or even kept her away from prison altogether, had she been assessed.

HMP Bronzefield is a prison for female inmates near Ashford, Surrey

The following morning, Ms Grant was taken to Colindale Police Station, but the mental health assessment teams at Brent and Barnet were unable to see her.

Instead, Ms Grant was interviewed by police and charged with attempted murder.

She was taken to HMP Bronzefield and placed in an ordinary cell, where she spent the night screaming and unsettled, the coroner said.

The prison doctor did not see Ms Grant the next day, 20 November, because he did not have her contact details and made no attempt to find her.

Ms Grant was said to be experiencing psychotic episodes and was locked in her cell at 17:30 GMT. She was last seen alive at 19:50 that day by a prison officer.

Forensic evidence suggested that Ms Grant placed knickers in her mouth, though it is not known whether she intentionally placed them in her airway.

She was found unresponsive in cell at 21:05 and was pronounced dead at 21:47.

The coroner said that detention in prisons for people needing mental health unit admission raised a concern for a risk of death because their needs cannot be fully met.

'Forever haunted'

"The witness from whom I heard stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed," the coroner said.

Adrian Usher, from the prison and Probation Ombudsman, said Ms Grant should not have been placed in a standard prison setting, and should have seen the prison doctor and was failed by staff.

A Metropolitan Police spokesperson said: "Our thoughts and condolences remain with Diana's loved ones following the conclusion of the inquest into her death.

"After her death, the force assisted the coroner and fully cooperated throughout the process.

"The report stated that there were no concerns in relation to future deaths because actions by the police had been addressed through changes since Diana's death."

The Central and North West London NHS Foundation Trust, Med-co Secure Healthcare Services Limited, Westminster City Council, the Department of Health and Social Care, and Sodexo, which runs the prison, have been contacted for comment.

Speaking earlier this year, Ms Grant's mother said she would be forever haunted by the visit from prison staff, telling her that her daughter had died.

"I've never once felt anger towards Diana or blamed her for attacking me. That was not her, she was not in control of herself," she said.

"It was a shocking catalogue of failings by state services that failed her completely when she needed their help at a point of crisis. I am truly devastated by her passing."