What happened
Kayleigh Melhuish, known as Kay, was 36. She had autism, ADHD and complex post-traumatic stress disorder, and her autism made her acutely sensitive to noise. She arrived at HMP Eastwood Park on 15 June 2022, on remand, with a suicide and self-harm warning form completed and ACCT monitoring started.
On 21 June a neurodiversity specialist wrote a communication support plan setting out her difficulties with noise, smells, food and physical contact. Almost no staff read it.
On 4 July she cut her arms, and handed the nurse who treated her a ligature she had made. That evening she was found hiding under a table and refused to return to her cell. Six officers restrained her forcibly, about 13 minutes on her family’s solicitors’ account, and carried her upstairs. She had been headbanging, and said there was plenty in her cell to harm herself with.
She was left alone, her observations unchanged. At 7.26pm three officers found her hanging. She was cut down and taken to Southmead Hospital, where she died on 7 July 2022.
The outcome
An inquest before HM Senior Coroner M. E. Voisin concluded on 17 October 2024: suspension by a ligature, contributed to by neglect.
The jury found gross failings in her basic care, that staff shortages were no excuse, and that the prison had adequate information about her from day one. No prosecution is recorded.
The coroner issued a prevention of future deaths report, reference 2024-0672, dated 4 December 2024, to the prison, the two NHS providers and the Ministry of Justice, requiring a response by 28 January 2025.
What went wrong
Across 11 ACCT reviews in 19 days, the mandatory care plan with support actions was never completed.
The plan sat with the manager responsible for ACCT quality assurance, in a prison that already knew its ACCT processes were poor. The person who owned the gap was the person whose job was to find it.
After the restraint, constant observations were not considered, even briefly. The coroner found little understanding of her neurodiversity, and noted that neurodiversity training is not mandatory, in a prison where 75% of women have mental health or neurodiverse issues.
What it teaches
The restraint and the hours after it are one sequence. The hold ended and the risk moved into the cell with her. That is the moment to raise observations, while she is still being carried.
Neurodiversity is the reason this restraint happened. A woman who cannot tolerate noise or being moved by six officers is one whose plan should have made hands unnecessary. The plan existed, written five days before. Nobody read it.
Questions for the room
- She said there was plenty in her cell to harm herself with. What does that require in the next ten minutes?
- You are the officer who carried her to the cell. What do you do next?
- Almost nobody read her communication support plan. What would make such a plan impossible to ignore?
Evidence and limits
Confidence: confirmed. The précis records that the coroner’s prevention of future deaths report, the family’s solicitors and a Guardian report agree on the sequence, the conclusion and the concerns raised.
The six officers and the 13 minutes come from the solicitors; the coroner’s report gives neither, so they rest on the family’s account.
No member of staff is named and no finding is made about any individual. Melhuish is named because open reporting names her and her family campaigned publicly.
Proceedings concluded on 17 October 2024, so the page may be cited outward.
Our restraint reduction training covers what has to happen in the minutes after a hold ends.
Sources
- Courts and Tribunals Judiciary, prevention of future deaths report ref 2024-0672, 4 December 2024
- DPG Law, 26 October 2024
- The Guardian, 26 October 2024
Reviewed 20 October 2026.